Inspection on 14/08/09 for Beech House

This inspection was carried out on 14th August 2009.

CQC 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 CQC 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 03/02/09

Beech House 18/08/08

Beech House 20/02/08

Beech House 20/09/07

Beech House 07/06/07

Beech House 25/09/06

Beech House 10/01/06

Beech House 05/07/05

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 25/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Beech House Wollerton Market Drayton Shropshire TF9 3NB Lead Inspector Karen Powell Key Unannounced Inspection 14th August 2009 09:30 DS0000064947.V377112.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech House Address Wollerton Market Drayton Shropshire TF9 3NB 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) 01630 685813 01630 685014 Ash Paddock Homes Limited Manager post vacant Care Home 54 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (54) of places Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care with nursing to service users of both sexes whose primary care needs on admission to the home are within the following categories:Old age not falling within any other category - (OP) 54 Dementia - over 65 years of age, DE(E) 10 The maximum number of service users to be accommodated is 54. 2. Date of last inspection 28th April 2009 Brief Description of the Service: Beech House is registered to provide nursing and personal care for a total of 54 older people, of whom ten may have dementia related illness. The home is owned by Springcare Ltd, (Ash Paddock Homes) the Managing Director being Mr Lee Cox. The home is located in a rural setting within a large extended country house in the village of Wollerton near Market Drayton. It is set in its own grounds, which are well maintained, and all bedrooms have lovely views of the surrounding countryside. Due to its location, there is limited public transport to and from this home. Accommodation is offered in either single or double bedrooms, some of which have en suite facilities. Some bedrooms are provided on the ground floor, and the remainder are accessed by a passenger lift onto the first floor. The home does not have a separate unit for people with dementia related illness. These individuals share their living accommodation and access the communal areas alongside the rest of the residents in the home. Springcare Ltd makes the services of Beech House known to prospective residents in their statement of purpose, and its brochure/service user guide. Weekly fees range from a minimum of £450.00 to £650.00. Additional charges to service users are for hairdressing, toiletries, and newspapers. The reader may wish to obtain more up to date information from the care service about this matter. Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the service was unannounced and took place on 14th August 2009 by two inspectors over a period of approximately five hours. A range of evidence was used to make judgements about this service to include discussions with people using the service, visitors, the manager, staff and relatives. We also examined a number of records to include care records of people living at the home, staff training, staff recruitment and health and safety records. Three people who live in the home were ‘case tracked this involves establishing individual’s experience of living in the care home by meeting them, discussing their care with staff, looking at care files and focusing on outcomes. Tracking people’s care helps us understand the experiences of people who use the service. An Annual Quality Assurance Assessment (AQAA) document was posted to Beech House for completion. The AQAA is a self-assessment and a dataset that is filled in once a year by all providers. It informs us about how providers are meeting outcomes for people using their service and is an opportunity for them to share with us areas that they believe they are doing well. By law they must complete this and return it to us within a given timescale. The area manager and manager completed this, and some of the information is included in the report. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Care Homes for older people and any further standards necessary and to follow up the requirements and recommendations made at the last key inspection undertaken on 3rd February 2009. We carried out random inspections on 28th April 2009 and 5th May 2009 to review the environment maintenance processes and to follow up the remedial guidance the home had been offered by the Health and Safety Executive following their inspection in October 2008. We also looked at actions undertaken to improve safety for people living in the home since our last key inspection to the service in February 2009. Following this visit the Care Quality Commission issued a statutory requirement notice with regard to the home being in breach of regulation 13(4) of The Care Homes Regulations 2001 in relation to the safety of people living at the home. We returned to the home on 25th June to carry out a compliance visit to check that the home had complied with the statutory notices issued with regard to the safety people living at the home. We found that the home had fully Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 6 complied with the notice served and it was not necessary to take any further action. Information to produce this report was gathered from the findings on the day and also by review of information received by CQC prior to the inspection date. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. Fees are published in information given to prospective clients. The weekly fee range is 450.00 to 650.00 per week. Readers wishing to know more about this information should contact the service directly. What the service does well: Peoples health needs are well monitored and we saw evidence of the home engaging the support of health care professionals where necessary. Training for all members of staff is being actively encouraged. More than half of the care workers have National Vocational Qualifications in health and social care at level 2 or above. Beech House provides people with a clean and comfortable place to live with the opportunity to personalise their own bedrooms. People who use the service were treated with respect and personal care was carried in private. One person said, Staff are very kind. What has improved since the last inspection? Most of the requirements made at the last key inspection of 3rd February had been addressed by the time of the compliance visit on 25th June 2009. The following action has been taken to comply with the requirements made at the last key inspection: Care plans have all been reviewed and re written and are detailed and written in a personalised way. The management of medication is much improved and there are now systems in place to ensure that people receive medication as prescribed for them. Improvements to the meal provision at the home means that people’s dietary needs are monitored and well maintained. Systems and resources to promote residents’ safety and well being are also much improved with better approaches to keeping people safe, for instance, whilst in bed or while being assisted to move. Better accident and incident Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 7 recording is in place with clear cross reference to risk assessments and care plans to guide staff as to how anything unsafe or which lead to an accident can be avoided in future. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 8 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 DS0000064947.V377112.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are provided with information and encouraged to make informed decisions about the home before moving in. Pre-placement assessments ensure that individual needs are met. EVIDENCE: It was stated on the completed AQAA that “We have a Statement of Purpose and Service User guide which are regularly updated and freely available. Copies are included in our information pack together with sample menus and Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 10 an activities diary for the coming month. The Service User guide is in large type to aid those with sight difficulties.” The completed AQAA also told us “Each Service User has a comprehensive and individualised pre-admission assessment carried out by a senior staff member before coming into the home in order to ensure that we can meet all the assessed needs. If it was felt that assessed needs could not be met then a clear explanation would be given to the prospective service user. Prospective service users are encouraged to view the home, and, if desired, are welcome to spend the day with us, come for lunch and participate in events or activities which are going on. New residents are given a six week “settling-in” period to ensure that they have selected the correct placement.” We saw a copy of the service user guide and statement of purpose which are detailed brochures with information about the home and what people can expect if they choose to move in. We looked at the records and spoke to one individual who was admitted to the home from hospital. The records for this person contained a completed pre admission assessment carried out by the home which was detailed. We talked to them about their experience of the admission; they told us that their next of kin had assisted them with finding a place at Beech House and that a member of the staff from the home had visited them in hospital to discuss their needs before they moved in. The person said that they were happy with these arrangements and that “they wouldn’t have a bad word said about the home, its a marvellous place and the staff are very kind.” “They look after me very well here.” The home told us that two people had agreed to be resident representatives and would attend meetings on behalf of the other people living at Beech House and would be proactive in welcoming new people into the home. We met one of the representatives. They had already attended a resident meeting with the other representative and told us the meeting went well. We also saw minutes of the meeting held this month; some valuable suggestions were made which people are hoping will be put into practice. The home does not provide intermediate care. Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have the information they need and have a clear understanding of how to offer care to each person, which ensures peoples health and personal care needs are met in a way that they prefer. There are now systems in place to ensure that people receive medication as prescribed for them. EVIDENCE: Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 12 The completed AQAA told us “we have care plans and risk assessments in place to identify those at risk of pressure damage or injury by the use of bed rails and action is taken to reduce to the lowest point possible.” We looked at the care plans of three people who use the service. These plans identified the health and social care needs of each person and provided clear directions for staff to follow to ensure their individual needs were met the way they preferred. Appropriate risk assessments including ones for falls, nutrition and the development of pressure sores were in place. Guidance for staff to follow about how to manage identified risks was also included in the care plans. A written report about the care given to each person using the service was written during each shift. This ensures that all staff have up to date information about the condition of each person to ensure continuity of their care. A verbal handover at the start of each shift ensures that staff are provided with up to date information about the people living at the home. Care plans and risk assessments are reviewed monthly and usually updated when the needs of the person changed. We saw evidence in one person’s records that their condition had deteriorated and a decision to move them from an upstairs room to a ground floor room had been made. Relatives had been contacted about this and a record of the communication between the home and the family was seen. We also saw evidence recorded regarding the use of bed rails and the necessary risk assessment and bed rail safety checks that had been put into practice. This change had also been communicated to the family involved with this individual. Where possible the person using the service or their relatives were involved in care planning and signed the care plan to indicate their agreement with the care provided. There were records of the involvement of GPs and other healthcare professionals including the chiropodist, optician, physiotherapist and tissue viability nurse involved in the care of people who use the service. It was stated on the completed AQAA that “we ensure the privacy of service users is respected by knocking on doors before entering their room, having an area of the home available for private discussions and by delivering their mail promptly and unopened.” On the day of the inspection we saw carers knocking on doors before entering. Personal care was given in the privacy of the persons own room or the bathroom. One person told us that any mail they receive is always given to them unopened. The provision of medication for three people was examined in detail and records for a number of other residents were inspected. None of the current residents are able to manage their own medication so people are totally reliant Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 13 on the nursing staff to ensure that they receive the medication they need. Records were found to be well maintained, with clear directions for staff when dosages varied from day to day, for instance for anti-coagulant medication. Documentation is in place to ensure that short course medication such as antibiotics is given as prescribed. Medicines which need to be dated on opening were found to be so. All records were found to be signed off appropriately. The organisation undertakes regular audits to ensure that staff are working effectively in this area and that any errors are addressed promptly. Receipt, storage and disposal of medication are managed well and storage facilities are tidy, well organised and maintained to correct temperatures. All but one of the nursing staff has undertaken medicines management training and the remaining nurse is booked to attend training in September 2009. It was confirmed by the manager as stated in the completed AQAA that she has attended a full days training on the Management of Medicines within a care setting. It was evident that staff identify changes in the health needs of people living at the home, engage with healthcare professionals as and when needed, and explore alternative means of medication administration, for instance, when people’s health and ability to swallow are deteriorating. One health and social care professional who completed a survey and returned it to CQC as part of the inspection process stated that usually peoples’ social and health care needs are properly monitored, reviewed and met by the home. It also stated that the service usually seeks advice and acts on it to meet peoples’ health and social care needs and improve their well being. It continued to tell us that they felt people living at the home are usually supported to administer medication, or manage it correctly when this is not possible, and that peoples’ privacy and dignity is usually upheld and that the service supports people to live the life they choose. Beech House DS0000064947.V377112.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Beech House are provided with opportunities to experience a meaningful lifestyle that ensures self esteem and well being. People are provided with healthy, well presented meals according to their dietary requirements and choice. EVIDENCE: It was stated on the completed AQAA that “We have very strong links in the local community so that service users can access local activities and the community can be involved in activities held within the Home. We have a mini-bus, suitable for wheelchair use, available for outings outside of the Home and we use this for individual as well as for group outings.” Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 15 Discussion with people using the service and members of staff confirmed that a variety of activities were organised in the home. These included trips out, a summer garden fete, church services, hairdresser, baking and bingo. A forthcoming trip to a garden centre was advertised on the activity notice board, along with the August activity plan. There were lots of photographs showing people enjoying activities provided including the recent ‘exotic animals’ who visited the home. People using the service and a relative said that visitors were welcomed into the home at any time. The meal served at lunchtime looked wholesome and appetising and a choice was offered. Blended meals were served with each item of food blended separately so people could identify the food and experience the individual flavours. Members of staff were observed to be assisting people with feeding in a patient manner. All the people asked said the meals were good. One person told us that sometimes dirty cutlery had been in use and this had to be sent back to the kitchen on more than one occasion and sometimes the meals could be served warmer. This information was given to the manager during our feedback. Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 16 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that, if they made a complaint, it would be investigated and responded to fully. People are protected from abuse by the home’s policies and procedures and a well trained workforce. EVIDENCE: The completed AQAA told us “We have a clear complaints procedure which is prominently displayed together with stated time-scale for responding to complaints and contact names and addresses.” The complaints procedure is on display at various points around the home and is contained in the organisation’s resident information folder. The service states that it responds quickly to complaints, admits its own failings and makes every effort to rectify these failings. Two complaints have been received recently and both were seen to have been well documented and responded to appropriately. Recent quality questionnaires and residents/relatives meetings have also allowed people to comment on the service and make suggestions for Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 17 improvements, which have been listened to and are influencing further work to drive up the quality of the service. Training records showed that all the staff have undertaken abuse awareness training and the home has policies and procedures in place should an issue arise. The majority of staff have undertaken training in dementia care and a small number have attended training about working with behaviours which might be verbally or physically difficult to deal with. Assessments by the local authority to ensure that people are not deprived of their liberty did not identify any problems, and recommendations for further improvements to care management have been acted upon. Managers and staff within the organisation have co-operated fully with any adult protection procedures which have been necessary. Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at Beech House are provided with a clean and homely place to live which is equipped to meet their individual needs and makes them feel safe and secure. EVIDENCE: Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 19 We took a tour of the home with the manager and found it to be clean and tidy. Ongoing renewal and maintenance of the home ensures that the service provides an environment that is well maintained for people who live at the home. All exposed pipe work had now been covered. We looked at the bedrooms of the three people we met. These were personalised with their own belongings and were suitably equipped where specialist equipment had been identified as necessary to assist with their care. The home is set in pleasant grounds and in nice weather can be accessed by people if they wish to sit and walk around the garden. Staff were observed to follow good practice with regard to infection control systems in order to minimise the risk of spreading infection within the home. Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are sufficient staff on duty during the day and night to meet the needs of people living at the home. The organisation has a thorough recruitment procedure to ensure that people are in safe hands. Staff are provided with induction and training to promote their skills and the provision of good care for the people living at Beech House. EVIDENCE: The numbers and skill mix of staff working at the home are sufficient for the current reduced level of occupancy. In addition to nursing and care staff, an activities co-ordinator is provided plus a member of staff dedicated to promoting good dietary uptake. It was reported that the home’s ongoing recruitment drive has succeeded in that additional nursing and care staff will be available and will reduce the longstanding reliance on agency staff, which has not helped the home achieve stability or best practice. Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 21 The home’s own analysis of its staff group states that over 70 of carers have undertaken training to a level accredited to a national vocational qualification (NVQ) at Level 2, and almost half have undertaken further work to be accredited at NVQ3. All care staff are provided with access to this type of training. The organisation’s own trainers provide induction training, training in care skills and mandatory training such as moving and handling, fire safety, food hygiene and infection control. Nursing staff are also trained first aiders. Records show good levels of training being maintained within the staff group. The organisation has a thorough recruitment procedure which ensures that staff are checked prior to them starting work, through obtaining criminal records disclosures and by taking up references. A reference should always be obtained from a person’s current or most recent employer in order to get the most up to date and relevant information about their work – this was not the case in one file examined during this inspection. Staff meetings and individual supervision sessions are becoming established, and staff spoken to reported feeling well supported through the current management arrangements. One person told us “the staff are very kind.” “They look after me very well here.” Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Although the manager has been in post only a short time, she and the staff team are working well together to promote residents’ best interests. A more open approach has been adopted and communication within the home, with relatives and with outside agencies has improved. Policies and procedures are being followed, and monitored, to ensure that people are kept safe. EVIDENCE: Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 23 The organisation is known to have good policies and procedures which have been put into good effect in other homes. However, Beech House has been without stable or consistent management since the organisation took on the running of the home and outcomes for both people living there and the business have not been good. The current acting manager has only been in place for a short time, having previously worked elsewhere for the organisation. She is well qualified and experienced for the post. The organisation is now hopeful that a stable environment can be created in which the service can grow and develop. Detailed questionnaires sent to residents and/or their relatives in July 2009 show good levels of satisfaction with the service, with most people rating standards to be either “as expected” or “better than expected”. The areas which showed room for improvement – communication and involvement with care planning/provision in particular – are being worked on. Residents/relatives meetings have taken place and there is a commitment to make the home work in the best interests of the people living there. Quality assurance audits and checks continue to provide self monitoring tools and feedback for the home’s manager and senior management. These, plus staff meetings and supervision sessions provide opportunities for everyone to influence the running of the home. Efforts have been made to make documentation used to plan and record care for people more “person centred” – that is, that the care provided is geared to the person’s individual needs and preferences. Our findings are that this area of work is much improved. Systems and resources to promote residents’ safety and well being are also much improved with better approaches to keeping people safe, for instance, whilst in bed or while being assisted to move. Better accident and incident recording is in place with clear cross reference to risk assessments and care plans to guide staff as to how anything unsafe or which lead to an accident can be avoided in future. The home has worked with external agencies to implement the requirements of the Mental Capacity Act and to ensure that nobody at the home is deprived of their liberty. Inevitably some residents are restricted in their movements due to disability or the need to keep them safe; these measures have been approved and efforts are being made to ensure that people can still make choices, go outside with assistance and engage with activities even if there are limits to what they can and can’t do. Management of medication has been a key area where shortfalls have been found in the past; this again is much improved. A small amount of residents’ money is held and accounted for by the home; these records are maintained jointly by the manager and the home’s administrator. Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 24 Processes to keep residents and staff safe, for instance, checks on the fire alarm, passenger lift and hoists, electrical and gas safety are in place and records are well maintained. Staff receive training in health and safety and how to undertake their everyday tasks in a way that doesn’t put them or the residents at risk. Reports and recommendations from external bodies such as the Health and Safety Executive and the Environmental Health Officer have been complied with. Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 25 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 26 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 OP29 Good Practice Recommendations References should be obtained from current or most recent employer. This is to ensure the most up to date and relevant information about a potential employee is obtained about their work. Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 27 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Beech House DS0000064947.V377112.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!