Inspection on 01/08/06 for Beech House

This inspection was carried out on 1st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beech House 09/07/07

Beech House 29/11/05

Beech House 10/03/05

Beech House 02/09/04

Beech House 23/10/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Beech House Beech Close Halesworth Suffolk IP19 8BQ Lead Inspector Julie Small Unannounced Inspection 1st August 2006 10:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech House Address Beech Close Halesworth Suffolk IP19 8BQ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01986 872197 01986 874638 tpic.access@virgin.net The Partnership in Care Limited Sonia Sherwood Care Home 39 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (39) of places Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 The home may also, within the total of 39 service users, accommodate up to 10 older people with dementia - DE(E) 29th November 2005 Date of last inspection Brief Description of the Service: Beech House, owned by The Partnership in Care Limited, provides care for up to 39 people aged 65 years and over. The home can care for up to 10 older people who have a diagnosis of dementia. The homes manager is Miss Sonia Sherwood. The purpose built home, is set within a residential area, within walking distance of Halesworth town centre. There is a footpath, which leads straight to the town’s market place, where there is a range of amenities. These include shops, church, banks, post office, eating and drinking establishments. Public transport links include railway and bus services. The home consists of 2 floors, which can be accessed via a lift or stairs. The 38 single bedrooms (located on both floors) all have wash hand basin, and 6 also have an en-suite toilet. A further single bedroom cannot be used until the renovations have been completed. For residents that do not have their own toilet, there are communal bathrooms and toilets located close to the bedrooms and lounges on each floor. The home is separated into 2 areas, 1 part known as the main home, has a large dining room. The second part of the home is the special needs unit, which supports people with dementia, and has it’s own dining room, lounge and enclosed garden. This is a non-smoking home. At the time of the inspection, the inspector was informed that the fees for the home were £331 for social care customers and £385 for private customers. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection which took place on Tuesday 1st August 2006 from 10.15 to 19.30. The inspection was undertaken by regulatory inspector Julie Small and was assisted in the process by the home manager and deputy manager. All information requested was provided promptly and openly. A tour of the building and observation of work practice was undertaken. Records were viewed which included residents records, fire safety records, risk assessments, staff recruitment records and training records, quality assurance surveys and health and safety records. One visitor to the home, nine residents and four staff members were spoken with during the inspection. Prior to the inspection resident ‘you’re your say about…’ questionnaires and staff and relatives/visitors comment cards were sent to the home. Ten relatives/visitors comment cards, seventeen staff comment cards and thirteen resident ‘have your say about…’ questionnaires were returned to the inspector. What the service does well: What has improved since the last inspection? There have been improvements in the medication procedure, which included a record of checks of medicines received into the home from the pharmacy service. There was an activity programme provided for residents who had dementia, which included reminiscence activities. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 6 The home was clean and no unpleasant odours were detected. There was maintenance work undertaken on the outside of the home. A programme of planned maintenance work was displayed in the entrance hall to the home for visitors and residents information. The manager and staff had worked to address requirements from the last inspection, which included fire safety of the home, and the work was ongoing at the time of the inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5, 6 The quality in this outcome area is good. Residents can expect that they have their needs assessed and be assured that they will be met prior to moving into the home and that residents assessed and referred for intermediate care are helped to maximise their independence. Prospective residents and their relatives and friends can expect to have an opportunity to visit the home prior to moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Resident’s records were viewed and included pre admission assessments undertaken by the management team of Beech House. The assessments were thorough and identified day to day care needs that prospective residents have. There were assessments present from placing authorities where applicable. Each resident had a detailed care plan which identified how the resident’s day to day needs would be met at the home. One resident was spoken with who had recently moved into the home for a trial visit. They said that their family had visited the home before they had Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 9 moved in and that it was too early to make comments on the home but they said that they liked being there so far. The manager confirmed that the resident was staying at the home on a two week trial to provide the opportunity to consider the service they received at the home. The resident’s records contained a detailed care plan which identified their day to day needs and preferences. One staff member confirmed that they had been involved in undertaking the assessment. They had taken a lead role in introducing the resident to the home. This included welcoming them, showing them around the building and introducing them to others in the home. This provided a familiar person that the resident could refer to if they had any problems. One resident was spoken with who said that they had visited the home four times before they decided to move in, they said that they had made their decision based on the attitude of the staff and that they had known several residents also living at the home. One resident spoken with said that they had stayed at the home on a one month trial basis, before they had decided to remain at the home and if the home could meet their needs. They said that they were happy at the home. One question in the residents ‘have your say about…’ questionnaire was ‘did you receive enough information about this home before you moved in so you could decide if it was the right place for you?’ eight answered yes, four answered no and one answered don’t know. The home provided intermediate care for residents, the manager was spoken with and confirmed that the residents were encouraged to maintain their independence as much as possible and were supported in improving their independence skills where their had been circumstances which had affected them, such as illness. One resident was spoken with who had received intermediate care, they said that their needs had changed when they were in the home and had decided to remain at the home because they liked it there Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 The quality outcome for this area is good. The health and personal care, which a resident receives is based on their individual needs. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four residents records were viewed which included detailed care plans that identified the day to day care and support that residents should receive. Care plans were stored in resident’s bedrooms, which allows care staff, residents and their families to refer to. There were care plans stored in the homes computer system, which also included resident’s health information, next of kin information, risk assessments, dependency assessments and daily records. One staff member was spoken with and said that security of the system was robust and that there was a password to enter the system. The management team were provided with access to some areas which was not permitted to all staff, such as with changing residents essential information. The member of staff said that there were plans to provide fingerprint recognition access to the system. All Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 11 information held on computer could be cross-referenced to paper based information, which was stored securely in the home. There was evidence that care plans were updated on a monthly basis to meet with residents changing needs. The home held a record of when care plans where amended which included the date, what was changed, reasons for the change, and signatures of the staff member involved in the change and of the resident and/or their representative where appropriate. There was clear health information in resident’s records, including a summary of their medical history, information regarding their continence, dietary needs and appointments they had attended, including medical, dental, optical and hearing. During the morning of the inspection residents were undertaking an exercise activity. One resident was spoken to following the activity and they said that they had enjoyed the exercise. There was an activity programme on display in the home which evidenced that there was regular exercise sessions, information regarding participation in activities was also recorded in an activity book. One staff member was spoken with and showed a stand aid, which had been provided for a resident to strengthen their limbs following a stroke. The home had a private chiropodist who regularly visited, which residents could choose to use, for which they would pay. One staff member explained that diabetic residents were provided with chiropody service to meet their health needs. One resident was spoken with and said that the staff help them to put their hearing aids on white paper at night, on the right or left side, which assists the resident in putting their hearing aids on each morning. They said that they were registered blind and the white paper allows them to identify where their hearing aids were. A staff member explained work they had undertaken in obtaining support for residents who have sight loss. One resident was awaiting a magnifying tool to assist them in seeing the television screen. In the resident ‘have your say about…’ questionnaire they were asked if they received the medical support they needed, nine said always, 1 said usually, two said sometimes and one said mostly. The home provided a policy and procedure for the administration of medication and for residents self administration of medicines. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 12 The manager informed the inspector that they had recently obtained a medication trolley from another home, which was viewed. Medication storage in the home was observed to be appropriate. The administration of medication was observed during lunchtime. The staff member administering the medication was spoken with and confirmed that they had received Boots medication training and were undertaking a safe handling of medicines certificated distance training course. The medicines were observed to be secured during their administration. Medicines were administered using a nomad system. Records evidenced that medicines were checked upon arrival to the home, including the amount of medication received. There was a notice of principles of care displayed in the entrance hall of the home, which included statements that residents would be called by their preferred form of address, that they be treated with respect at all times and that they have access to make private telephone calls. The laundry was viewed during a tour of the building, which had named boxes for each resident, and residents clothing was labelled. One staff member said that resident’s belongings were kept on an inventory upon admission into the home. One resident was spoken with and said that the staff at the home were respectful to them and that they never entered their bedroom without knocking and being invited in. One resident said that they were treated with respect at the home and that their visitors were welcomed into the home. They said that they enjoyed having a joke with the staff, and that they were still respectful when joking. During the inspection staff were observed to knock bedroom, bathroom and toilet doors before entering. Interaction between staff and residents was observed to be positive and respectful. Residents records viewed included their wishes when they die, such as burial or cremation, their choice of religious service, funeral directors and if they had made a will. The resident’s next of kin details were maintained on their records. One staff member explained how they undertake care of the dying and how they work with the resident and their family when they have died, which was found to be sensitive and caring. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 13 Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 The quality in this outcome area is good. Residents are able to choose their lifestyle, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: There was a timetable of activities displayed in the home which residents could participate in if they wished. Activities included bingo, reminiscence activities, exercise, shopping and board games. The home had an activities staff member who organised and undertook activities with the residents. Nine residents were spoken with and confirmed the following; • they had been out in the mini bus to Beccles the week before. They said that they had also been to Southwold. • they were provided with lots of things to do in the home and they participated when they wanted to. • they had participated in the exercise session during the morning of the inspection, which they had enjoyed. • they have a newspaper delivered to the home. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 15 There were a good collection of books, board games, videos and music, which were situated in the communal areas of the home, which residents could use. One staff member said that the local library provides a service to the home and the ‘book man’ delivers a selection of books to the home which residents can buy if they choose to. The home had a shop trolley, which sold items such as sweets and items of toiletries which residents could purchase. One resident said that they enjoyed gardening. They had created a raised flower bed in the homes grounds. The flower bed was viewed and a staff member confirmed that the resident had worked on this. It was positive that they were encouraging this persons interest in enabling them to enjoy working in the garden. Staff reported that a previous resident had grown vegetables which they had maintained. One resident was observed working with a staff member on a word search puzzle book. A resident was observed watching a video about a local steam train which had been bought into the home by a staff member after the resident had said they were interested in watching it. There was a separate activities programme for service users who have dementia which included increased reminiscence work. There was a good selection of music tapes, such as brass band music and older style films which residents could use in their communal area. The activities staff in the home told the inspector that they had made a large collage and that they had bought some wheat into the home, which had generated lots of discussion with the residents. There were reminiscence cards in the home which the activities staff said that residents look at and talk about. One staff member said that there had been contact made with a team who support individuals with sensory loss who visited the home and were providing a magnifying item for one resident who could not see the television well and that they were visiting one resident who remained in their bedroom and were unable to undertake communal activities. Residents were asked if there were activities arranged by the home which they could take part in, in the ‘have your say about…’ questionnaire, seven said always, three said usually, four said sometimes and one said mostly. One relatives/visitors comment card stated ‘the staff make every effort to provide activities, things to motivate the residents’. It was observed that several residents enjoyed visitors throughout the day. One resident had been taken out by a family member, who telephoned the home to cancel their evening meal and ensure that they would be provided with supper, the staff member answering the call was polite and ensured that they acted upon the request. A visitor said that they visited often and were welcomed into the home. One resident said that their family often visited and Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 16 they could visit in their bedroom or in the communal areas in the home, they said that their family were always made welcome. There was a notice board in the entrance hall of the home which provided information to visitors to the home including, the last inspection report, complaints procedure, complaints forms, the plans for decoration to the exterior of the home, the days menu, activity programme, an invitation to residents and visitors meeting, the homes statement of purpose, CSCI (Commission for Social Care) contact details, No Secrets, Association of Counselling and homes procedures such as whistle blowing, equal opportunities, visitors charter, quality statement. The manager said that they were working to improve relations with the community, residents had attended the local carnival and were hoping to have a float at the next one and they were aiming to work with a local school to design a sensory garden for the home. Residents spoken with confirmed that they were provided with choices in their day to day living. One staff member said that some residents maintained their own finances and were supported in doing so. One staff member said that there had recently been new menus introduced at the home. The homes residents meeting minutes were viewed and showed that residents had stated their views and offered suggestions regarding the homes menus. The menus were nutritious and balanced. All residents spoken with said that the food was good at the home and they were provided with enough food, two residents said that sometimes they could not eat all that was on their plate. One resident was spoken to who was diabetic; they confirmed that their needs were met with regards to food. One resident said that they were asked what they wanted to eat and that there were three or four choices at each meal. One staff member said that there were two vegetarians in the home and there was always a vegetarian option on the menu. Lunch time was observed, which was the main meal of the day, the meal looked and smelled appetising and was attractively served. Residents could choose to eat in the large airy dining room or in their room. In the area of the home where residents with dementia live, there were colourful pictures of food in the hall, with arrows pointing the way to the dining room. Residents were observed to be provided with hot and cold drinks throughout the day. Residents were asked if they liked the meals at the home in the ‘have your say about…’ questionnaires six said always, four said usually, two said sometimes and one said ok. Comments received in relatives/visitors comment cards were ‘(resident)always comments on how good the food is’, ‘the home should make (resident) eat more – ignore that (resident) wants just a yogurt for afters every day!’ Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 17 Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The quality in this outcome area is good. Residents can expect that their complaints will be listened to, acted upon and taken seriously and that they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a robust complaints procedure, which was displayed on a notice board in the entrance hall to the home. There were also complaints forms available on the notice board for residents and visitors to take when they chose to. The homes complaints procedure was included in the welcome pack provided to newly admitted residents and their family and in the resident’s handbook. There had been no complaints received since the last inspection. However, the manager explained that there had been some concerns, which were dealt with amicably prior to a complaint being made. One concern raised in a relatives/visitors comment card was that there had been an issue with the reporting to a next of kin regarding a resident who had fallen. The family were concerned that they had not been informed on the day of the accident. Records were viewed in the residents records, which identified the problem and amendments had been made to the residents risk assessment, the meeting record and risk assessment had been signed by the manager and the resident’s next of kin. It is recommended that the home maintain a record of concerns received and actions taken in a central log in the home. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 19 Staff records were viewed and evidenced that staff had read and understood the homes policies and procedures including the complaints procedure and procedures related to the protection of vulnerable adults, including whistle blowing. Staff had signed and dated when the procedures were read. Residents ‘have your say about…’ questionnaires asked if they knew how to make a complaint six said always, one said usually, three said never, one said no and one did not answer. The questionnaires also asked if residents knew who to speak to if they were not happy, eight said always, one said usually, two said sometimes and two said no. Seven relatives/visitors comment cards received stated that they were aware of how to make a complaint, three said they did not. One stated that they had raised a concern regarding food which had been dealt with promptly. Sixteen staff comment cards stated that they were aware of the homes complaints procedure and one said that they were not. Three residents spoken with said that they knew what to do if they were not happy about the care they received at the home. One resident shared an example of when they had a concern and had spoken to the homes manager, they said that they were listened to and had been offered to make a complaint, which they said they did not pursue because they were happy with the response received from the manager. Two residents said that they felt safe at the home. There was information regarding No Secrets and procedures on the protection of vulnerable adults displayed in the entrance hall of the home. There had been no allegations received by the home since the last inspection. Staff training records were viewed and evidenced that staff had received POVA (protection of vulnerable adults) training. Fourteen staff comment cards said that they had received training on the homes abuse policy and one said that they had not. All residents were provided a lockable drawer in their room for the storage of their valuables, or they were provided with the option to store them in the safe. There were robust procedures in place to ensure that the resident’s finances were safe and secure. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 26 Quality in this outcome area is good. Residents can expect that they live in a safe well maintained environment which is clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Upon arrival to the home it was observed that the external woodwork on the ground floor was being painted and there was work being undertaken in the gardens of the home. One staff member said that the gardens at the front of the house had been cleaned up and they had planted shrubs and plants, the work being undertaken was to fill the former pond and create a raised flower bed. There had been a smaller raised flower bed planted with flowers which had been worked on by a resident at the home, who said that they liked gardening. There were various vegetables growing in the gardens, which included an abundance of tomatoes. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 21 There was a programme for work which had been and was planned for the maintenance of the exterior of the home which was displayed on a notice board in the entrance hall to the home for the information of visitors to the home. There were two residents and a visitor sitting on attractive garden furniture at the front of the home, which was underneath a shelter. They said that they liked sitting there and one resident explained the best places to sit if it was raining or if the weather was very hot and where they could get the best breeze. During a tour of the building it was noted that there were sufficient toilets and bathrooms for the use of residents, staff and visitors to the home. All bathrooms and toilets were provided with hand wash gel and disposable paper towels. There were baths and showers available which provided the choice of bathing methods to residents. Bathrooms were accessible and provided assistance aids such as grab rails and bath seats. There was a sluice area on the ground floor and on the first floor, these also provided hand washing facilities. There was a good stock of disposable aprons and gloves. The inside of the home was clean and well maintained. There were pretty artificial flowers placed around the home including on the dining tables. There were no unpleasant odours detected in the home. The laundry was viewed during a tour of the building and was noted to be appropriate to meet the needs of the home. One staff member was spoken with and explained appropriate methods of laundering soiled bedding and clothing. Relatives/visitors comment cards received stated ‘I always find the home clean and well cared for, a very friendly atmosphere’ and ‘(residents) room could do with redecorating, carpet has been changed which is good’. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 The quality in this outcome area is good. Staff in the home are trained, skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes rotas were viewed and provided sufficient care, domestic, senior and kitchen staffing throughout the day to meet the needs of residents living in the home. The manager explained that there had been an advertisement for relief staff, they said that recruitment was often a slow process due to the rural location of the home. Ten relative/visitors comment cards were received, four stated that in their opinion there were sufficient staff on duty and six said there were not. One stated that they had concerns regarding the staffing of the home during staff handover. The manager was aware of meeting the diverse needs of staff and residents and shared an example of how they ensured that a staff member was not subject to discriminatory behaviour displayed by a resident. A staff member said that they were working on their NVQ (National Vocational Qualification) level 2 in care at the home, which they were happy about. During the inspection the NVQ assessor was observed to arrive for an appointment to meet with a staff member. Another staff member said that Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 23 they were undertaking their NVQ award and that the homes manager was assessing them. The manager confirmed that they were a qualified NVQ assessor and discussed the commitment to the training, development and qualification of the staff team. An administration staff member said that they had achieved their NVQ whilst working at the home. A training matrix was displayed in the office, which identified staff who had achieved their NVQ qualification. There were thirty six care staff at the home, twenty one had achieved the minimum of NVQ level 2 and four were working on their award. The home had met the target of 50 of care staff to have achieved a minimum of NVQ level 2. The homes deputy manager confirmed that they were working on their RMA (registered manager award). Four staff recruitment records were viewed and were found to be appropriate, providing information such as two written references, an application form, CRB (criminal records bureau) check, photograph and identification. The manager of the home was be committed to the development of the staff team and equal opportunities of development, ensuring that support was provided to those who had specific learning needs and to all staff members including night staff and domestic staff. The manager confirmed that some staff were attending a certificated literacy course, which was improving competence and confidence. Training records were viewed, which included a list of training staff had attended and certificates of achievement and/or attendance. Training courses included first aid, protection of vulnerable adults, manual handling, care planning, food hygiene, safe handling of medicines, fire safety, promoting continence, occupational health and safety, MRSA and infection control and caring for people affected by strokes. Staff had attended ‘getting started in care’ and TOPSS (now Skills for Care) induction. All staff working with residents with dementia had received dementia training and the manager said that three staff had recently undergone a train the trainer course in dementia and would be providing training for the staff team. The home also had one staff member who could train in manual handling. One staff member said that all the domestic staff had attended COSHH (control of substances hazardous to health) training. A staff member said that they were provided with a good training programme at the home. In the staff comment cards staff were asked if they felt that the home had a good training and development programme, to support staff, there were seventeen received all answered yes. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is good. Residents can expect to live in a home which is run and managed by a person who is fit to be in charge, that is run in the best interests of service users, their financial interests are safeguarded and that their health and safety is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes manager said that they had completed their RMA (registered manager award) and were awaiting verification to confirm this. The manager had recently undergone a fit person application with CSCI and was found to be competent and experienced to run the home. The homes manager was not responsible for the running of any other home. The manager clearly understood their roles and responsibilities and lines of accountability and received support through supervision. One staff member Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 25 said that the manager had implemented many improvements since they had been working at the home. The homes quality assurance monitoring records were viewed, which included questionnaires regarding the running of the home and the provision of care to staff, residents and to residents families, visitors to the home, and other professionals. The responses to questionnaires had been collated and the manager said that they were a useful monitoring tool to identify aspects of the home which individuals were happy of not happy with. The manager was receptive to any comments made by the inspector during the inspection process and was keen to receive any suggestions which would improve the service they provided. The manager and staff at the home had worked hard to meet the previous requirements made through inspection and there were no outstanding requirements during this inspection. There were CSCI relative/visitors comment cards with return envelopes placed in the entrance hall to the home, for relatives and visitors to help themselves to. The previous inspection report was displayed in the entrance hall to the home. One staff member was spoken with, who had responsibility for ensuring that residents finances were securely maintained. They provided good detailed records of any transactions and what finances were kept in safe keeping for residents. Receipts were provided for any transactions made. There was a secure facility in the home where valuables could be kept, and residents were provided with a lockable drawer in their bedroom where they could keep their valuables if they chose to. Staff spoken with confirmed that they received regular supervision. Records were viewed which evidence that staff receive regular supervision and appraisal. The manager said that they were undertaking the yearly appraisals for the staff team. One staff member said that there was support available in the home and that they could approach the manager if they had any concerns. The manager confirmed that they have an ‘open door’ approach and encourage staff to speak to them if they need support. Records were viewed which evidenced that regular fire equipment checks, fire drills and checks of water temperatures were undertaken. Records of accidents were kept in a central log and were also kept on resident’s records. The home had appropriate procedures and policies regarding health and safety in the home. COSHH materials were kept locked in a secure place in the home, there was a COSHH handbook for staff information. The homes risk assessments were viewed which included legionnaires disease, manual handling, lifting equipment, food preparation and food hygiene, laundry, bathing, bed rails, electrical items, work equipment, first aid, COSHH and work related stress. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 26 The homes certificate of liability insurance was displayed in the entrance hall to the home. The manager said that there was a recent visit from the fire service, which they had not yet received the report. There had been improvements since the last inspection at the home with regards to fire safety. The manager said that they had received guidance from the fire service. There were fire doors for bedrooms which were due to be delivered to the home on 3rd July 2006, which would provide a self closing mechanism if the fire alarm was sounded. During a tour of the building it was noted that the mechanisms for the doors had been installed. Fire doors were not locked with keys, there had been sliding locks installed on fire doors; this included the homes front door. Signs on fire doors were present. There was a requirement from the last inspection which stated that an upstairs fire exit door and escape platform must be made good, to ensure the door can be freely open. One staff member spoken with said that this had been actioned and that there was a fire door on the first floor which had been condemned following advise from the fire service and that there were sufficient fire exits provided in the area. Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP16 Good Practice Recommendations It is recommended that the home maintains a central log of concerns raised by service users and their families in addition to the records maintained on residents records, which includes the nature of the concern and the actions taken Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beech House DS0000029245.V306512.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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