Inspection on 11/12/05 for Beech House

This inspection was carried out on 11th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 11/08/05

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 OEA Lead Inspector Leslie Hardy Unannounced Inspection 11th December 2005 03:15 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 DS0000053654.V274449.R01.S.doc Version 5.1 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 DS0000053654.V274449.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beech House Address Yew Tree Lane Northenden Manchester M23 OEA 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) 0161 945 2083 S J Care Homes Ltd Mrs Anne Patricia Husain Care Home 43 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (42) of places Beech House DS0000053654.V274449.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. A copy of the Residential Forum Guidance on Staffing in Care Homes for Older people must be available. Staffing levels for service users who require personal care only must comply with minimum requirements of the Residential Forum guidance. 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. 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. 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). 11th August 2005 6. Date of last inspection 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 DS0000053654.V274449.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection, which was unannounced, was carried out on Sunday 11 December 2005, started at 3.15 pm and lasted for 5 hours. During the inspection, 12 residents, 3 visitors and 8 staff were spoken with. Some of the requirements from the previous inspection report had 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 report. What the service does well: What has improved since the last inspection? What they could do better: The home need to ensure that all residents have a social care assessment and plan. This along with reviewing the provision of activities will ensure that the actual needs of residents are met. The home should review how they handle eye drops to ensure safe practice. The provision of liquid soap and paper hand towels at all times in all toilets will ensure that the risk of cross infection is reduced. Beech House DS0000053654.V274449.R01.S.doc Version 5.1 Page 6 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 DS0000053654.V274449.R01.S.doc Version 5.1 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 DS0000053654.V274449.R01.S.doc Version 5.1 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 The home needs to consolidate the currently physically based pre admission assessments with social care assessments to ensure that the whole needs of each resident are identified. EVIDENCE: A requirement had been made in the last inspection report for the home to introduce and use social assessment tool because it was found that the assessment tool currently in use concentrated on areas of physical need. It was found at this inspection that this still was the case. It is important that this is addressed urgently as this home provides for residents with care only needs as well as for those who require care with nursing. The differing needs of the two groups must both be met and identifying social care needs will ensure that this objective is met. The home continues to use external assessments undertaken by perspective purchases and also funded nursing care assessments undertaken by trained NHS nurses in the case of residents receiving nursing care. Beech House DS0000053654.V274449.R01.S.doc Version 5.1 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 the following standard(s): 7,8, 9 and 10 Though the homes medication procedures were generally appropriate more attention to detail regarding policies and procedures relating to medication will ensure that residents are not put at risk. EVIDENCE: All residents had care plans but these were based on physical needs and did not look at the resident holistically or address their social care needs. However the care plans did ensure that their health needs were met. Risk assessments were undertaken and reviewed regularly as were the care plans. The daily recording for every resident was very repetitive saying usually just “good day” or “slept well” but there was separate recording against each care plan when events affecting that plan occurred. This meant that it was not possible to gain a picture of how each resident spent their days and interacted in the home. Also it meant that information on the action of others such as visitors was not recorded which again could affect the care of the individual resident. It is recommended that more rounded recording of events affecting the resident be undertaken. Beech House DS0000053654.V274449.R01.S.doc Version 5.1 Page 10 The home was undertaking appropriate procedures for the receipt, storage and distribution of medication. All containers of drops and creams/ointments were labelled on the actual container as well as the outer box apart from the smallest containers. As the Royal Pharmaceutical Society of Great Britain guidance states that the actual container be labelled in all cases the manager must ensure that this is undertaken. Eye drops and ointments with a restricted life when opened were dated although it showed in one case that the drops seemed still in use well after the appropriate date which could put the resident at risk. The dates and timescales for use of some medications must be appropriately observed. Residents were seen to be treated with courtesy and respect by staff. When staff were engaged with residents they clearly told them what they were going to do so that the resident could appropriately participate. Privacy was respected when residents were being supported by staff with physical care. Beech House DS0000053654.V274449.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14 and 15 The relaxed atmosphere in the home benefited from good resident/carer interaction, but the low availability of activities needs to be reviewed. The food available was of an appropriate standard. EVIDENCE: There was a relaxed atmosphere in the home, which was not dominated by the number of televisions and music playing, none of which conflicted with the other. No organised activities took place during the inspection, either formally or informally, residents either spending time in lounges watching Television or sat in the conservatory, (the smoking area). Residents’ did engage in conversation with each other and staff and some resident’s were engaged in individual activities. Residents’ did report that very little organised activities took place during the week, but those who were able to did go out by themselves. Residents’ were clear they were able to get up and go to bed when they wished, and indeed most residents were still up at 8pm. They had choice over where they spent their day in the home. The manager should review the availability of activities with residents to ensure that the activities programme in the home supports the expectations of the individual. Beech House DS0000053654.V274449.R01.S.doc Version 5.1 Page 12 The home has open visiting and a number of visitors were seen in the home during the inspection. Visitors spoke highly of the home, the care being delivered and how the staff treated the residents. Meals within were said to be good although one resident thought they were monotonous as there was always soup and sandwiches available as a choice to a hot main meal or hot lighter meal. There were two sittings for lunch and evening meal. The first was for residents who required no assistance and the second for the smaller number of residents needing assistance, which was seen to be given on an individual basis by staff in a discreet and sensitive manner. Beech House DS0000053654.V274449.R01.S.doc Version 5.1 Page 13 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 The home has procedures in place to enable residents to raise concerns. EVIDENCE: There was no record of any complaints being made to the home since the last inspection, which was confirmed as correct by the manager, but new procedures were confirmed as being in place by the proprietor. Beech House DS0000053654.V274449.R01.S.doc Version 5.1 Page 14 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): 26 The home was found to be generally kept clean. Some work was required to ensure the health and safety of residents. EVIDENCE: The home was found to be generally clean. It is of concern that at this inspection, as at the last one, that most of the communal toilets and bathrooms were found to be without liquid soap and paper towels. As this is not conducive to infection control, action must be taken to ensure regimes are in place to prevent this occurring. A requirement was made at the last inspection that a sluicing disinfector be installed in the sluice. This requirement has not been met and has been reiterated in this report. Beech House DS0000053654.V274449.R01.S.doc Version 5.1 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 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): 29 and 30 The home need to ensure that full pre employment checks are carried out in all cases to ensure that inappropriate staff are not appointed. Staff who trained as nurses in other countries helps to provide a good standard of one to one care. EVIDENCE: The home had employment information available for all staff, but again not all the required information was available for each employee. One member of staff had not had a Criminal Records Bureau (CRB) completed. It is a statutory requirement that all staff files require information stated in regulation 2 of the Care Home Regulations 2001. The home must ensure this is complied with. It is recommended that to make this easier each member of staff have a file that has a check sheet that can be ticked of when each piece of required information is obtained. Some carers had gained NVQ level 2 since the last inspection. This home has more carers who are qualified nurses in other countries (but with qualifications that are not automatically considered as equivalent in this country) than carers who are not. This did show in good personal interaction and observation skills. As stated in previous reports for these to be recognised as at least NVQ 2 equivalent the social care elements of the training must be shown to meet that standard. Beech House DS0000053654.V274449.R01.S.doc Version 5.1 Page 16 Staff reported on the training they had undertaken since the last inspection. Trained nurses had undertaken updating on diabetes and training on the care of the dying pathway. All care staff had undertaken training on moving and handling, and fire prevention. Beech House DS0000053654.V274449.R01.S.doc Version 5.1 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 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 and 32 The home have taken active steps to ensure that they obtain views of residents and visitors as to how they are meeting needs and this should ensure that any concerns of residents as met. EVIDENCE: The Manager was required to obtain a National Vocational Qualification in at least management by 2005. It is of concern that she had not at the time of the inspection gained this qualification. The home have reviewed how they obtain information from residents and relatives as to how the home is meeting/not meeting their needs. The proprietor described how they had just implemented regular review meetings conducted by the key worker as a means of discussing with residents and relatives needs, concerns and how the home is doing. This along with a short Beech House DS0000053654.V274449.R01.S.doc Version 5.1 Page 18 questionnaire should ensure that the home is able to monitor that they are meeting needs appropriately. Beech House DS0000053654.V274449.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X 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 X X X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X X x Beech House DS0000053654.V274449.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES 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 Standard OP3OP7 Regulation 14, 15 Requirement The home must undertake social care assessments and formulate social care plans for all residents. (Previous timescale of30/11/05 not met). All multi use eye drops must be labelled on the container. (Previous timescale of 30/10/05 not met). A sluicing disinfector must be installed in a sluice. (Previous timescale of 30/11/2005 not met). Liquid soap and paper towels must be available at all times in all toilets. (Previous timescale of 30/11/05 not met). All appropriate checks must be completed on employees before they commence duty). Timescale for action 01/03/06 2 OP9 13 01/02/06 3 OP26 23 01/04/06 4 OP26 13 01/02/06 5 OP29 19 and schedule 2 01/03/06 Beech House DS0000053654.V274449.R01.S.doc Version 5.1 Page 21 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 2 3 4 Refer to Standard OP7 OP12 OP29 OP30 Good Practice Recommendations Care plans should contain more rounded recording of events affecting the residents’. The manager should review the availability of activities with residents to ensure that the low availability of activities is what the residents want. Each staff file should be in a separate holder with a front check sheet to ensure that all required information has been obtained. The manager should obtain a NVQ level 4 or equivalent in management to meet the minimum required standard. Beech House DS0000053654.V274449.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House 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 DS0000053654.V274449.R01.S.doc Version 5.1 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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