Inspection on 11/08/05 for Beech House

This inspection was carried out on 11th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 06/04/09

Beech House 10/06/08

Beech House 16/07/07

Beech House 01/06/06

Beech House 11/12/05

Beech House 04/12/04

Beech House 08/07/04

Beech House 08/01/04

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

CARE HOMES FOR OLDER PEOPLE Beech House Yew Tree Lane Northenden Manchester M23 0EA Lead Inspector Les Hardy Unannounced 11 August 2005 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 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 F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Beech House Address Yew Tree Lane Northenden Manchester M23 0EA 0161 945 2083 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) S.J.Care Homes Limited Responsible Individual - Mr S.S.Jobanputra Mrs Anne Hussain Care home with nursing (N) 43 Category(ies) of Old age, not falling within any other category registration, with number (OP) (42) of places Learning disability (LD) (1) Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of 43 service users can be accommodated at any one time. Of this number a maximum of 28 service users will require nursing care and a maximum of 15 service users will require personal care only. 2. One service user is currently accommodated who is under 65 years years of age and requires nursing care and also care by reason of learning disability (LD). Should this place no longer be required then the category will revert to old age (OP). 3. Staffing levels for service users who require personal care only must comply with minimum requirements of the Residential Forum guidance. 4. Staffing levels for service users who require nursing care must comply with the minimum requirements of the staffing notice, served on 15 July 2004, under Section 13 of the Care Standards Act. 5. A copy of the Residenital Forum Guidance on Staffing in Care Homes for Older people must be available. 6. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 4 December 2004 Brief Description of the Service: Beech House Residential and Nursing home is located in the Northenden area of South Manchester, close to local amenities. The home is registered with the Commission for Social Care Inspection to accommodate 43 service users over the age of 65. The large extended detached house is set in its own grounds and has ample car parking spaces. Residents living accommodation is available on the ground and first floor, access to which is facilitated by a passenger lift. The building is accessible to wheelchair users via a ramp. Shops and access to public transport is nearby and the home is within 1 mile of the M56. The home has ample communal space and residents have access to their bedrooms at all times. Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection, which was unannounced, was carried out on a Thursday, started at 6.15 pm and lasted for 7 hours. During the inspection, 11 residents, 2 visitors and 9 staff were spoken with. Some of the requirements from the previous inspection report had been actioned. The 3 of the 4 recommendations from the previous report had also been actioned. During this inspection only a selection of key National Minimum Standards were assessed. Therefore to gain the full picture of how the home meets the needs of residents, this report should be read with the previous and any future reports. What the service does well: What has improved since the last inspection? Overall management of medication has improved since the last inspection and the regimes in place ensure that residents get prescribed medications in a safe manner. Action has been taken to ensure that radiators are protected and the water from hot taps is at a safe temperature to ensure that residents cannot be accidentally burned or scalded. The home have a full time handy man to ensure that minor problems in the building are quickly dealt with. Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 6 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 F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 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 standard(s) 3 Though the home uses external assessments as well as its own basic pre admission assessment, the emphasis on physical needs meant that social needs were not assessed. EVIDENCE: Prior to admission to the home residents were seen by a senior member of staff from the home and a short assessment form completed. This was very basic and tended to concentrate on areas of physical need. It covered areas needing attention but only gave a very brief view of the residents’ potential needs. The emphasis on physical needs could lead to the non-identification of social care needs. The home also used assessments undertaken by Social Workers, including in the case of residents admitted for care with nursing, the funded nursing assessment. However, the Manager must review the assessment form to ensure it gives a full picture of need, including social needs. Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 9 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 standard(s) 7, 8 and 9 The home was fully meeting residents identified health needs but were failing to identify social care needs. Medicines were safely handled in the home and were no longer putting residents at risk. EVIDENCE: Residents had care plans that were formulated using the assessments mentioned at standard 3 and also appropriate risk assessments undertaken by the home following admission. These plans gave details of the care that was needed by the resident and were regularly reviewed. Residents were seen to have only 2 or 3 plans that reflected identified needs. These concentrated on physical health needs. The same documentation was used for both care and care with nursing residents. This could mean that the social care needs of all residents but particularly those not requiring nursing were not being identified so they could not be met. The home must look at identifying social care needs. The daily records of residents included information on how they had been but also gave a picture of how there identified needs were changing. The home used appropriate recording tools for residents with wounds and sores and involved the Tissue Viability Nurse from the local NHS Primary Care Trust for specialist advice. Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 10 The home had reviewed its procedures for the administration of drugs. The procedures now in place were much more robust and ensured that prescriptions were ordered from the GP’s by the home, copied and signed before being sent for dispensing. When the drugs were received the amounts were recorded on the Medicine Administration Record (MAR) as was the giving or omission of a medication. All eye drops and creams were appropriately labelled on the actual container rather than the packet apart from very small containers. The manager must ensure that these are also appropriately labelled by the pharmacy as required by the Royal Pharmaceutical Society of Great Britain. The Manager should ensure that the trolley is secured to a wall when not in use, as it is currently is not during the day. Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 11 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 standard(s) None of these standards were assessed at this inspection. EVIDENCE: Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 16 and 18 The home complaints recording procedure needs to be further developed, as the investigation a. Staff members were aware of action to take in the event of seeing physical abuse. EVIDENCE: The home had had 3 complaints since the last inspection and these had been recorded appropriately, but the action taken and the outcome, though an improvement on the previous practice still needs to be further developed. This was a requirement in the last report and is reiterated. One visitor stated that in the three years her mother had been in the home she had not made any complaints. She said she was confident that if she had a concern she could raise this with staff and it would be dealt with. Staff spoken to where aware of the action they would take if they observed adult abuse. Senior staff in the home had undertaken training on the matter 4 years ago, it is recommended that further training is undertaken for all grades of care staff at the home so that staff were confident in identifying and reporting abuse. Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19,25 and 26 The home was clean and free from offensive odours. It was reasonably maintained but the current refurbishment of the ground floor communal areas was needed. EVIDENCE: The downstairs communal areas and corridors were being redecorated at the time of the inspection. This was much needed, as the areas were becoming quite drab and worn. The carpets were also going to be replaced; again this was needed as they were becoming quite marked and dirty, and needed either deep cleaning or replacement though the cleaning techniques currently in use were noted to have a positive effect. The home now has a full time handyperson and it was seen that he is having a positive effect on ensuring the environment is generally well maintained. Since the last inspection radiators that were unprotected have been and the temperature to all the baths and hand basins is now appropriately regulated so Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 14 that hot water is delivered at a safe temperature. This will prevent residents being accidentally burnt or scalded. A requirement had been made in the previous inspection for the home to purchase a sluicing disinfector machine to disinfect bedpans. This must be purchased to ensure that these are appropriately dealt with after use to prevent cross infection between residents by this means. The home was kept clean by an enthusiastic cleaning team who were observed to be thorough in their regime. Some toilets had no liquid soap or towels. These must be available. Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 28 and 29 The home met minimum staffing requirements but must ensure that minimum numbers of qualified carers are available to provide the level of support to residents and to ensure that the quality of care provided is improved. The home must ensure that information available in staff files reflects a robust recruitment practice that ensures the protection of residents. EVIDENCE: The home was staffed to at least the minimum requirements of the current staffing notice dated the 15th July 2004. The home had 4 carers with NVQ level 2, and need to progress to increase this number to 50 of carers by December 2005. The home employ as care assistants a number of registered nurses from Eastern Europe. As stated in previous inspection reports, if these staff are to be included in the numbers of staff with as a minimum NVQ level 2, the home must demonstrate in writing that the Social Care elements of that training are NVQ equivalent by comparing the 2 curriculum. The home maintained required information on new staff, apart from references, which in one instance was stated, to have been taken up but was not on file. Where staff from Eastern Europe were recruited via an agency it was stated that references were seen although again these were not on file. Files must contain all the items required by Schedule 2 of the Care Home Regulations 2001. This will ensure evidence is available to demonstrate that Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 16 the home took all the actions required when recruiting staff to ensure that residents are safeguarded. Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33 and 38 The home has not introduced formal methods of obtaining views from residents and visitors, which would enable them to benchmark the service. Regular servicing and maintenance of equipment ensures residents safety. EVIDENCE: The home has a homely caring ethos, with the availability of the manager appreciated by residents and visitors. One resident did comment that they did not see the proprietor as much as they used to as she felt his availability was a good thing. As required in previous inspection reports the home must develop a formal audit tool with the results feed back to residents and visitors. This is a positive way of ensuring that the views of residents are heard and acted upon. This requirement is reiterated. Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 18 The home collects and manages money for a number of residents. The accounts were reviewed and found to reconcile. The home undertakes appropriate servicing and maintenance of equipment. A recent environmental health inspection was satisfactory. Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x 3 2 x x x x 3 Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 20 Are there any outstanding requirements from the last inspection? 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. 1. 2. 3. 4. Standard 3, 7 9 9 16 Regulation 14, 15 13 13 17 Requirement The home must undertake social care assessments and formulate social care plans for all residents. All multi use eye drops must be labeled on the container. The medicine trolley myst be securely attached to a wall when not in use. The home must fully document the action taken following a complaint being made, to include details of the investigation, findings and any action taken as a result, response to the complainant and date this happened. (Previous timescale of 31/03/2005 not met). A sluicing disinfector must be installed in a sluice. (Previous timescale of 31/03/2005 not met). Liquid soap and paper towels must be available at all times in all toilets. All staff files must contain all the information required by Schedule 2 of the Care Homes regulations 2001. Timescale for action 30/11/05 30/10/05 30/10/05 30/11/05 5. 26 23 30/11/05 6. 7. 26 29 13 19 30/11/05 30/11/05 Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 21 8. 32 24 The provider must develop ways of seeking the views of residents, relatives and others involved into how the home could develop. 30/11/05 9. 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 18 Good Practice Recommendations Provide training on the recogntion and reporting of adult abuse for all staff. Beech House F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 9th Floor, Oakland Hose Talbot Road Manchester M16 0PQ 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 F55 F05 s53654 Beech House V242941 D110805 Stage 4.doc Version 1.40 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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