Inspection on 16/12/08 for Beech House

This inspection was carried out on 16th December 2008.

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 06/12/07

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/02/2009.

CARE HOMES FOR OLDER PEOPLE Beech House Radcliffe Park Crescent Salford Gtr Manchester M6 7WQ Lead Inspector Adele Berriman Unannounced Inspection 16th December 2008 11:10 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 DS0000071064.V372963.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 DS0000071064.V372963.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech House Address Radcliffe Park Crescent Salford Gtr Manchester M6 7WQ 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 745 8373 beechhouse@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross BC OpCo Ltd Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (32), Physical disability (1) of places Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only- Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 32 2. Physical Disability - Code PD, maximum number of places 1 The maximum number of service users who can be accommodated is: 33 6th December 2007 Date of last inspection Brief Description of the Service: Beech House is a purpose built home offering residential care to a maximum of 33 older people. The home is situated in a residential area of Salford and has a pleasant garden area. Car parking is available at the front of the building. The cost of the service in December 2008 was between £325.87 and £440.00. Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means that people who use the service experience adequate outcomes. We made an unannounced visit the Beech House on the 16th December 2008. The visit formed part of a key inspection of the service. During the visit we looked at a selection of records, policies and procedures including care plans and staff files. We also had a look around some areas of the home. During the visit we spoke to several residents, three staff and representatives from Southern Cross Ltd. Prior to our visit the manager of the service completed an Annual Quality Assurance Assessment (AQAA). The AQAA gave the opportunity for them to tell us what they do well, how they have improved and their plans for improvement in the next 12 months. The information in the AQAA told us some of the information we asked for. What the service does well: What has improved since the last inspection? They had developed an action plan on how they were going to make improvements to the service. Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 6 Improvements had been made to when they tell us about accidents around the home. They had improved the testing of fire detection systems. 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. The summary of this inspection report can be made available in other formats on request. Beech House DS0000071064.V372963.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 DS0000071064.V372963.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A process of assessment was in place to record people’s identified needs and ensure that their needs could be met at Beech House. EVIDENCE: We saw that there was a process in place for assessing what care people required to ensure that Beech House had the facilities to meet their needs. They told us that the assessments were generally carried out by the manager of the home who would visit people either in their home or at hospital to assess their needs. People’s needs were recorded on a format that gave the opportunity to record people’s daily living needs. Individual risk assessment relating to falls, continence and nutrition were included in the assessment process. We saw the needs assessments of three people who had recently moved into the service. Not all of the information had been fully completed in the Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 9 assessment. All known information should be recorded to ensure that people receive the support they require. Beech House does not provide intermediate care facilities. Beech House DS0000071064.V372963.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information contained in individual’s care plans did not fully reflect people’s needs or demonstrate that people’s rights and wishes had been considered. EVIDENCE: We looked at the care plans of four people, including those people who had recently moved to Beech House. We saw that people’s needs had been identified in their care plans, however, there was little information about the actual support that was needed to ensure that people’s needs were fully met. For example, care plans included the following statements, “is doubly incontinent, wears aid”, “needs assistance with washing and dressing” and “requires a lot of prompting at meal times.” There was no further information available to tell us how these needs were to be met. Detailed information should be available to the staff team to ensure that people’s needs are fully met at all times. Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 11 We saw information on care plans that was inconsistent with the person’s actual needs. For example, one person’s pressure ulcer and eating and drinking assessments stated that the person had no problems with nutrition and that they never refused a meal. However, staff stated that the person often refused a meal and that they had developed a way of encouraging them to have a meal. None of this information was recorded. The ways in which people’s needs are met should be recorded in full to ensure that staff aware of what actions they need to take to ensure that individual’s needs are met at all times. It was of concern that no care plan had been created for one person living at the home. The person’s social worker had requested that staff monitor a certain area of the person’s day to day life to ascertain how their need could be met. There was no evidence that this monitoring was taking place. To ensure that people receive the care and support they require, their needs must be monitored and recorded on a regular basis. We saw that care plans contained individual risk assessments relating to continence management and nutrition. We saw information in three care plans relating to not resuscitating individuals. The term DNR (do not resuscitate) had been used. This information was not appropriate. There was no information to demonstrate that appropriate protocols and procedures had been adhered to in ascertaining whether a person wished to be resuscitated. For example, the service failed to demonstrate that people’s rights and wishes under the Mental Capacity Act had been sought. People living at Beech House told us that they were able to see their GP when they needed to. Visits from healthcare professionals including district nurses and opticians were recorded in people’s care plans. Policies and procedures were available for the receipt, recording, storage, handling, administration and disposal of medication. The deputy manager demonstrated a good awareness of how to manage medication safety. All medication administered was recorded on Medication Administration Records (MAR). We looked at several of these records and all had been completed appropriately. Medication was stored in a safe secure place. During our visit we saw staff supporting people in a positive respectful manner. Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Practices within the home do not fully promote people to have choice and control over their lives. EVIDENCE: A part time activities co-ordinator was employed at the home. Outside entertainers visit the service on occasions. On the day that we visited members of the local Brownie group visited to sing carols. They told us in their Annual Quality Assessment (AQAA) that they intended to improve on the number of outings available to people and also create more involvement with local schools and clubs over the next twelve months. People told us that they could receive visitors at any time. During the visit we saw several relatives and friends arriving at the service. People had no choice in whether they wished to lock their bedroom door. They told us that there was no a facility available for people to have a lock and key for their bedrooms. People should have the option to lock/unlock their bedroom doors to promote privacy and security. Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 13 Meals were served in a pleasantly decorated dining area of the lounge. We saw that tables were set with table cloths and condiments. At 11.45 we observed twelve residents sat at the dining tables waiting for their lunch with support of the staff team. The lunch was served at 12.30. We saw that two people were becoming anxious whilst waiting for their meal. The service should ensure people are able to join the dining table at a time of their choice. The home has a detailed menu planning system that promotes a nutritionally balanced diet throughout the day. The menu also stated that fresh fruit would be offered in between meals. We saw no evidence of any fresh fruit being offered. We saw that a meal of meatballs, potatoes and vegetables followed by sponge and custard was served at lunchtime which people appeared to enjoy. However, the food served for lunch did not correspond with the menu. The menu also gave a choice of foods at all mealtimes. However, they told us that there was no choice of meals offered at mealtimes. Staff said that if a person was vegetarian or needed an alternative diet their needs would be met. They should review how people are made aware of what is on the menu and ensure people are offered a choice of meal. Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were protected by policies and procedures within the home. EVIDENCE: A complaints policy was available along with a system for recording complaints and their outcomes. They told us that they had received seven complaints about the service since we last visited. The complaints related to privacy and dignity and changes made to the lounge. Records of how these complaints had been investigated were available. People living at Beech House told us that they knew who to speak to if they had a concern about the service. The service had a policy and procedure relating to the protection of vulnerable people. A copy of Salford Services safeguarding adults procedure was also available. We saw training records that demonstrated that no current members of staff had received training in safeguarding procedures. All staff should have access to awareness training relating to safeguarding to ensure that they are aware of what action to take if they felt that a person had been abused or was at risk from abuse. Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 15 Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Beech House provides residents with a clean and comfortable place to live. EVIDENCE: A part time maintenance person was employed by the service to carry out general maintenance and minor repairs. They told us that they had identified areas of improvements needed around the home and that they were in the process of implementing an action plan. These improvements included revising the call bell system and replacing carpets and curtains. We looked around several areas of the home including the communal area, kitchen, bathrooms and several bedrooms. We saw that bedrooms were personalised with individuals’ personal effects. Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 17 The communal lounge and dining area were furnished to provide a comfortable environment for people to sit. Where locks were provided on bedroom doors they did not enable staff to have immediate access to the rooms in the event of an emergency if the locks were activated by residents. They must contact Greater Manchester Fire and Rescue Service for advice about appropriate locks for bedroom doors that would enable to door to be opened with ease in an emergency. The home was clean and tidy. Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. To ensure that people receive the care and support they require at all times the service must ensure that staff participate in the training opportunities available. EVIDENCE: We saw that three carers, a cook, a domestic worker and the assistant manager were on duty to meet the needs of the 29 people in residence. People living at Beech House told us that they liked the staff and that they were supportive. Southern Cross Ltd have clear recruitment policies and procedures. We looked at the recruitment files of the most recently recruited staff. We saw that they contained completed application forms and references. There was evidence that the service had completed POVA register (Protection of Vulnerable Adults) checks. We saw evidence that CRB (Criminal Record Bureau) checks had been applied for but had not been returned. No records were available to demonstrate how recently recruited staff were being supervised whilst awaiting the return of their Criminal Record Bureau check. They should consider people’s skills and experience when making arrangements for the deployment of staff around the home to meet the needs of the service. Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 19 Southern Cross Ltd have a set induction programme for newly recruited staff. We saw no evidence that staff had had the opportunity to have a formal induction into their role when they started their employment. We spoke to two staff who told us that they had not received a formal induction into their role. However, the staff had previous experience working in a social care environment and were able to demonstrate a good knowledge of peoples’ needs. Southern Cross Ltd had a comprehensive programme of training which included mandatory training in areas of health and safety and protection. We saw a staff training matrix that demonstrated that very few staff had received training for their role. The matrix demonstrated that staff had not received training in fire drills, COSHH, health and safety and Abuse/POVA. It is essential that people living at Beech House are supported by a team of staff who have received appropriate training for their role. Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed to management procedures to promote the best interests of the people living at the home. EVIDENCE: Beech House has not had a manager registered with the Commission since Southern Cross took over the ownership of the service. At the time of the visit the service was being managed by a project manager from Southern Cross Ltd. They told us that an action plan had been developed to make improvements to the service. Improvements to care planning to ensure that people’s rights are adhered to were needed and the service also should take into account the staff’s knowledge of the service and individuals’ needs. Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 21 They told us that they had a quality assurance system to gain the thoughts and opinions of people with an interest in the service. This included resident, relative and staff meetings. A system was in place for the safe management and recording of individual’s finances. Southern Cross Ltd have a computerised management system for the recording of and monitoring of resident’s monies. The system provides monthly (or when required) statements for individual residents. We saw that accidents were being recorded. The service has corporate health and safety policies and procedures that are reviewed and updated nationally on a regular basis. Risk assessments were available for safe working practices. They told us that regular servicing of utilities and equipment around the home took place. Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 22 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 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 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 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 12 Requirement To ensure that people’s needs and wishes are provided for, any decision making process for or on behalf of people must consider their rights and wishes under current legislation including the Mental Capacity Act. To promote people’s safety, the service must seek advice from Greater Manchester Fire service regarding appropriate locking devices on people’s doors. An application must be submitted by a person to become the registered manager of the service. Timescale for action 25/01/09 2. OP19 13 20/01/09 3. OP31 9 25/01/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 24 1. 2. OP3 OP7 All known information about a person should be recorded and considered in their needs assessment to ensure that their needs are identified. Care plan records should be completed in full to demonstrate what care and support the person has been offered/received to ensure that people’s needs are met. To promote individual’s privacy and security people should have the opportunity to lock and unlock their bedroom doors at a time of their choice. People should have the opportunity to sit down for their meal at a time of their choice. They should review how people are made aware of what is on the menu and ensure people are offered a choice of meals. They should consider people’s skills and experience when making arrangements for the deployment of staff around the home to meet the needs of the service. People should be supported by staff who are appropriately supervised and that have had an induction into their role. This would help to ensure that people’s needs can be met at all times. 3. OP14 4. OP15 OP27 5. 6. OP29 Beech House DS0000071064.V372963.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000071064.V372963.R01.S.doc Version 5.2 Page 26 - 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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