Inspection on 16/07/07 for Beech House

This inspection was carried out on 16th July 2007.

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

The inspector 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 01/06/06

Beech House 11/12/05

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 0EA Lead Inspector Steve Chick Unannounced Inspection 16th July 2007 10:00 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.V340014.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 DS0000053654.V340014.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech House Address Yew Tree Lane Northenden Manchester M23 0EA 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 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.V340014.R01.S.doc Version 5.2 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 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). 1st June 2006 6. Date of last inspection Brief Description of the Service: Beech House 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 residents 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 and the entire home is wheelchair accessible. Shops and access to public transport is nearby and the home is within 1 mile of the M56. The home has four lounges, a conservatory, and a separate dining room. There are 35 single bedrooms and 4 double rooms, none of which have en suite facilities. Residents have access to their bedrooms at all times. The current fees for the home are £390 to £520 a week Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. For the purpose of this inspection three relatives of service users were interviewed in private as were three members of staff. Additionally discussions took place with the general manager. The inspector also undertook a tour of the building and looked at a selection of service user and staff records as well as other documentation, including staff rotas, medication records and the complaints logged. This key inspection included an unannounced site visit to the home. All key standards were assessed. This report also uses information gathered since the previous visit and information provided by the owner through an annual quality assurance assessment (AQAA). All visitors spoken to were positive about their relatives’ experience of care at Beech House. Most issues which had been identified in the previous inspection report had either been fully or partially met. What the service does well: What has improved since the last inspection? All the previous requirements had either been fully or partially addressed, although some require further work. Capital expenditure had taken place resulting in some improvements to the fabric and fittings of the building. Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beech House DS0000053654.V340014.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 DS0000053654.V340014.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 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user had their needs assessed before moving into the home to ensure their needs can be appropriately met. EVIDENCE: A selection of service users’ files was looked at. All had copies of an assessment which had been undertaken prior to admission to the home. These assessments were complemented by the home undertaking their own assessment of service users’ needs. Whilst these presented as being potentially comprehensive they were not always signed nor dated. This made it difficult to establish when the assessment had been undertaken, and consequently its current relevance. Beech House does not offer intermediate care. Beech House DS0000053654.V340014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning documentation does not provide consistently reliable information upon which to base decisions as to the manner in which an individuals care needs will be met. The home’s procedures in connection with the administration of medication are implemented to the benefit of service users who are treated with respect and have their dignity maintained. EVIDENCE: A selection of service users’ files was looked at. All had a copy of a care plan. The quality, usefulness and accuracy of the written care plans was inconsistent. Staff who were spoken to reported that they did use the written care plans, but also were informed by their personal knowledge of service users and ‘handovers’ which took place at each shift. Staff reported that they Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 10 were confident that they did have an understanding of the individual needs of each service user and were made aware of changes. An example was seen where the documentation held on a service user’s file contained confusing and contradictory instructions regarding what action to take in a certain circumstance. In spite of the staffs confidence that they were aware of each service user’s circumstances these types of anomalies would, at best, make it hard for the home to be accountable for actions to be taken. Evidence that service users’ social cultural and religious needs were systematically addressed was inconsistent. In one example seen the section on the assessment pro forma had simply been lined through. Information provided by the managing director of the home via the AQAA (annual quality assurance assessment) identified that the home employed many different races/religions etc within the staff group, but did not identify any specific strategies which would help to address service users’ social cultural and religious needs. As mentioned previously in this report, there was inconsistency in connection with the way in which recordings were signed and dated. This also presented as being indicative of a lack of rigour of managerial oversight and auditing of the documentation. Relatives who were spoken to during the site visit were positive about the care provided by the staff at the home. Relatives, who were asked, expressed the view that they were involved in decision-making around the nature of the care offered to their relative. There was documentary evidence of appropriate contact with medical and paramedical services to the benefit of service users. All staff and visitors who were asked were confident that appropriate medical support was obtained when necessary and in a timely manner. A selection of medication administration records was looked at. These presented as being appropriately maintained. Relatives and staff who were spoken to were confident that service users were treated with respect and dignity. This was also borne out by observation during the site visit. Beech House DS0000053654.V340014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social contacts and activities are facilitated within the home to give service users the opportunity for social fulfilment. The provision of food to maintain service users’ health and well-being is good and service users are able to maximise their autonomy within the context of communal living. EVIDENCE: As mentioned elsewhere in this report social, cultural and religious needs were not consistently addressed in the written care planning process. Where this was omitted service users would be less likely to benefit from any proactive planning by staff. It was reported that the home benefits from an activities coordinator. The list of activities available during the week was seen on a notice board in the home. Relatives who were spoken to, and staff who are asked, confirmed that these Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 12 activities did actually take place. It was reported that activities included games, hand massage, chair exercises, carpet skittles, occasional outings when the weather is good and occasional entertainers coming into the home. The home reported a policy of encouraging open visiting. Visitors who were spoken to confirmed that they could visit at any reasonable time. Visitors also commented that when they did visit, they were made to feel welcome by the friendly staff. Visitors and staff reported that service users were able to exercise choice and control over their lives, within the context of communal living. One meal was sampled during the visit. It was pleasantly presented, tasty and as recorded on the menu. l Visiting relatives who were talked to, expressed positive views about the provision of food, as did staff who were interviewed. Previous inspection reports have also reported positively on the provision of food. Beech House DS0000053654.V340014.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to complain about the service and are protected from abuse or exploitation by the home’s policies and practices. EVIDENCE: The home had a complaints procedure which has been found to be appropriate on previous occasions and was not looked at during this visit. There was a written reference of one complaint having been made to the home since the previous visit. The general manager indicated that this complaint had been appropriately dealt with although the documentary evidence in the complaints log was incomplete. All visitors and staff spoken to were confident that any complaint would be taken seriously by the home and responded to appropriately. All visitors spoken to expressed a high level of confidence that their relatives were safe at Beech house, and that they were protected from abuse or exploitation. Staff who were spoken to presented as understanding the need for vigilance to protect the vulnerable adults living at the home. Similarly, all staff who were Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 14 spoken to, understood the procedure for whistle blowing should that be necessary. Staff who were interviewed reported that they had received training in abuse procedures. The general manager reported that whilst courses were offered by Manchester Social Services department, it was often difficult to secure places on those courses. The written procedures at the home would be improved by including contact numbers to report any allegations of abuse or exploitation to the local authority who have the responsibility to investigate. The necessity to improve communication with other departments was acknowledged in the home’s AQAA. Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 15 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is predominantly appropriately maintained, decorated and cleaned to enable service users to live in a pleasant, safe and hygienic environment. EVIDENCE: During the visit a tour of the building was undertaken. This included communal areas and a selection of service users’ bedrooms. There were several communal areas where service users could spend their time, or they could access their rooms when they chose. The home presented as predominately clean and tidy with no unpleasant odours. This was reported as being the usual state of the home by visiting relatives and staff who were spoken to. Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 16 It was reported that several areas had benefited from new carpeting since the previous inspection visit. Some corridor carpets were looking tired, whilst others had clearly been recently renewed. Glass in the conservatory door was cracked, and the flooring in the doorway was in need of repair. It was reported that both of these had been identified as needing remedial action. Some double glazed units appeared to be misty and probably needed replacement. There was ample evidence that service users could personalise their own rooms. Several bedrooms did not have carpet flooring. In some extreme cases when other continence management strategies have proved inadequate, the use of non-carpet flooring to help minimise the smell of urine can be legitimate to aid the dignity of the service user occupying that room. It was not clear in discussion with staff that flooring reverts to carpet when the room is occupied by somebody without severe continence management problems. The home’s AQAA had identified that the quality of some rooms with better carpets and furniture was something that could be improved. It is reported that, at the time of this visit, all bedrooms were being used as single rooms, with the exception of one double room being used by a married couple. Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 17 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skills mix of staff on duty promotes the independence and well-being of service users. Recruitment and vetting procedures are usually effectively applied to minimise the risk to service users of inappropriate staff being employed. EVIDENCE: A copy of the staff rota for the week beginning Saturday the 7th of July 2007 was provided. This indicated that appropriate staffing levels were maintained throughout both day and night. Nursing staff and carers were complemented by a range of ancillary staff. It was reported that in addition to the qualified nurses two staff were enrolled on the NVQ II course. It was also reported by the general manager that several staff from Eastern Europe were employed who held nursing qualifications. These individuals were employed as carers as their nursing qualification was not recognized in the United Kingdom. The general manager indicated that she understood this to be an equivalent to an NVQ III qualification. Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 18 It was reported by the general manager that only one member of staff had been recruited since the previous visit. Inspection of the documentation relating to the vetting of that staff member indicated that most procedures had been followed appropriately. However the CRB (criminal records bureau disclosure) related to a different care home. Regulations relating to the recruitment of care staff do not allow CRB disclosures to be transferable. The general manager was unable to locate a copy of the Care Homes Regulations 2001 at the time of this visit. The absence of these regulations may make it more difficult for the home to comply with them. Staff who were interviewed reported that new staff were subject to a period of induction. A staff training file was maintained although it did not give clear evidence of what training had been undertaken by which member of staff. Staff who were interviewed during this visit expressed the view that they did have access to a range of training opportunities. Visitors who were spoken to during this visit were very complimentary about the staff. One relative described the staff as helpful and said staff cant be faulted. Another visitor, when asked what the best thing about the home was, replied - the staff, who are pleasant and very good with (service user). Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 19 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 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The absence of a registered manager undermines the homes ability to demonstrate that systems are in place and effectively managed and audited to maximise the benefit for service users and staff. EVIDENCE: At the time of this visit the home has been without a registered manager for approximately 12 months. The general manager reported that one person had been identified to be put forward for this role but had then withdrawn. The general manager also reported that steps were currently being undertaken to recruit to this post. Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 20 There was not clear evidence that the home was systematically seeking the views of service users and relatives in a structured way which resulted in an annual development plan. The general manager reported that questionnaires have been sent out to various stakeholders and, at the time of this visit, they were with the owner. At the time of writing this report information relating to an assessment of these questionnaires had not been received by the Commission for Social Care Inspection. The AQAA provided by the owner indicated that the home had no policy or procedure in connection with an annual development plan for quality assurance. The home’s AQAA indicated that there were policies and procedures in place for the handling of service users personal possessions and monies. The procedures for these were found to be adequately implemented on previous inspection visits. Previous inspection visits have identified that health and safety issues are appropriately maintained. The homes AQAA reported that the homes equipment was appropriately checked and maintained. A small selection of documentation to back this up was looked at and presented as being appropriately maintained. Staff who were interviewed, confirmed the availability of disposable gloves and aprons to minimise the likelihood of cross infection. Although appropriate action appeared to be being taken, the AQAA indicated that there was no policy or procedure in connection with communicable disease and infection control, food safety and nutrition or hygiene and food safety. Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 21 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 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 2 Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 22 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 OP29 Regulation 19 and schedule 2 Requirement All appropriate checks must be completed on employees before they commence duty. (Timescale for action of 30/06/06 not met and still applies) to minimise the risk of exposing vulnerable service users to inappropriate staff, this must include a CRB (criminal record bureau) disclosure, applied for in respect of Beech House. 2. OP31 Section 11 Care Standards Act To ensure the smooth and accountable running of the service for the benefit of the service users an individual must be registered with the Commission for Social Care Inspection as the manager of the home 30/09/07 Timescale for action 16/07/07 Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 23 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 OP3 Good Practice Recommendations The registered person should ensure that all assessments and re assessments are appropriately signed and dated to maximise their credibility and usefulness. To ensure appropriate care is offered, documentation should contain consistent information about service users and address the social cultural and spiritual aspects of an individual’s needs. To ensure that any allegation of abuse against any service user is dealt with in a timely manner, the contact telephone numbers of the Local Authorities who would undertake any investigation should be readily available. To ensure that service users benefit from an appropriate environment, there should be clear records to indicate why any bedroom does not have a carpet. To ensure service users and staff benefit from a consistently applied health and safety regime, written procedures and policies should be developed to cover all potentially vulnerable areas. 2. OP7 3. OP18 4. OP19 5. OP38 Beech House DS0000053654.V340014.R01.S.doc Version 5.2 Page 24 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 - 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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