Inspection on 02/07/07 for Beech House

This inspection was carried out on 2nd July 2007.

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 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 13/07/06

Beech House 06/01/06

Beech House 27/06/05

Beech House 19/10/04

Beech House 23/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Beech House Chapel Lane Barton upon Humber North Lincolnshire DN18 5PJ Lead Inspector Theresa Bryson Key Unannounced Inspection 2nd July 2007 09:00 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 DS0000044474.V346107.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 DS0000044474.V346107.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech House Address Chapel Lane Barton upon Humber North Lincolnshire DN18 5PJ 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) 01652 635049 beech.house@fshc.co.uk www.fshc.co.uk Tamaris Healthcare (England) Ltd Jennifer Anne Hololob Care Home 30 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (30) of places Beech House DS0000044474.V346107.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2006 Brief Description of the Service: Beech House is situated in the centre of Barton on Humber, close to local shops and amenities. It is registered to provide support and care for up to thirty older people. The home is a mixture of old and new buildings over two floors, serviced by a passenger lift and stairs. There are twenty-two single bedrooms, sixteen of which are en-suite and four double rooms, one of which is en-suite. The upper floor has a further raised level accessed via five stairs. There are two bedrooms and one unassisted bathroom in this area, which is only accessible to more ambulant service users. There are two assisted bathrooms, one of which has a bath lift and the other a parker bath for those less able. A walk in shower room with hairdressing sink is provided on the ground floor. A forth bathroom is now used as a storeroom. There are a further five single toilets throughout the home. The home has two lounges, the larger of the two having two dining tables at one end. There is also a separate dining room. Both lounges have patio doors that have access to a paved area with garden furniture. There is a quiet seating area in the entranceway. The enclosed rear garden is well maintained. Car parking space is available at the front and side of the building. According to information received from the home on 02.06.06 their weekly fees are £312 when funded by care management with a £30 top up fee for a single bedroom and £410-£420 for privately funded service users. Items not included in the fee are toiletries, hairdressing and chiropody. This is reviewed annually. Information about the services the home provides is kept in each of the service users bedrooms. Beech House DS0000044474.V346107.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit for this inspection took place over one day in July 2007. Prior to this day the home was asked to complete an AQAA document, I full for the first time, which it did well and returned promptly to the local CSCI office. Survey forms were sent out to 10 relatives and 4 were returned and to 12 staff of which 5 were returned. 6 people living in the home were spoken to on the day and 2 relatives plus 8 staff members and 2 health professionals. other records and documents were checked during the course of the visit. The manager was present during the whole of the inspection and was joined by the Area Manager for the Company for part of the site visit. What the service does well: The Company provides numerous types of records for staff to complete to ensure that the needs of people living in the home are constantly monitored and audits are completed to ensure the home is safe to live and work in. A variety were seen at the site visit and staff appeared to be following Company policies and recording accurately not only care delivered, but planning ahead for people living in the home and the home’s safety. The documented evidence showed that the needs of people living in the home were constantly under review and each person was encouraged to exercise as much independence as possible given their current situations and conditions. Their diverse needs were provided for in a variety of ways, such as how the rooms were decorated, social activities provided and outside events to attend. The home provides a varied menu, which is nutritious and takes in to consideration any cultural and specific requests and needs of people living in the home. All food is prepared in a clean and safe environment, which is closely monitored, by Company personnel and the environmental health officers. The home is clean and tidy and well maintained. All safety checks are completed on a regular basis and the views of those living in the home and working there taken into consideration when planning redecoration and renewal projects. The management team work very hard to ensure that all safety checks are completed in the home and the quality of the services provided is maintained at all times. This ensures the home is safe to live and work in and there is a Beech House DS0000044474.V346107.R01.S.doc Version 5.2 Page 6 transparent and open management way of working to allow people to express their views for the benefit of themselves and others living in the home. What has improved since the last inspection? What they could do better: There were no requirements set at this inspection visit. Only one recommendation. The Activities Organiser and the key workers need to work a little closer together to ensure that both departments are working towards a common theme for each person living in the home. This will ensure the Activities organiser is more aware of what types of social events and expectations each person has and how this can be facilitated. Beech House DS0000044474.V346107.R01.S.doc Version 5.2 Page 7 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 DS0000044474.V346107.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 DS0000044474.V346107.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each prospective service users has an holistic assessment prior to admission to the home to enable the home to see if it can meet the person’s needs. EVIDENCE: During the course of this inspection Standards 3 and 6 were checked. Prior to admission the manager or deputy manager arranges to complete a holistic assessment on each prospective service user. This was well documented in the care plans tracked. This enables staff to prepare for a person’s admission and see if the home can meet the person’s needs. Service users spoken to stated this had helped them feel at home when entering the building as staff knew a lot about them. The home does not give intermediate care so Standard 6 is not applicable. Beech House DS0000044474.V346107.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans on service users are up dated regularly to ensure current needs are being met and medication is given using safe procedures. EVIDENCE: During the course of this inspection Standards 7,8,9 and 10 were checked. Prior to the site visit 10 surveys were sent out to relatives and 3 were returned. 6 service users were spoken on the day plus 2 relatives. Also spoken to were two health professionals. 4 care plans were tracked in depth and showed that care was now being taken regarding the documentation of the delivery of care and ensuring that all current needs were being identified and the care programmes updated regularly. Beech House DS0000044474.V346107.R01.S.doc Version 5.2 Page 11 The Company provides comprehensive documentation to enable staff to keep a track of problems and needs of service users. Clear guidelines are set and appeared to be followed by staff on how to complete sections such as nutritional assessments; falls risks and how to discontinue a care plan need when completed. The key workers diary gives a general view of that person’s progress in the last month and each one seen was well written and legible. Two health care professionals spoken to at the time of the site visit both stated how cooperative staff are to them and are willing to complete assessments when required and could always give good feed back on a service user’s care needs. Service users commenting on the care they received made such statements as “I can trust all my carers to help me” and “I am happy here because I’m looked after” and “night staff attend to my requests quickly”. Of the relatives spoken to and who returned survey sheets all were positive about the care their loved ones receive, stating “Mum is well presented” and “the room is always clean and she appears happy”. Staff were observed through out the day attending to service users in a variety of tasks, including personal care and meal times. They appeared very caring in their manner and how they addressed service users and exercised a great deal of patience, especially with those having some form of memory loss. The auditing of care plans by senior staff members and Company representatives ensures that current needs of service users are being met and strategies put in place to ensure they are free from risk and are able to exercise independence as much as possible in their lives. The drug administration sheets were tracked and the senior staff member escorting the inspector appeared to have a good understanding of the processes in place and the needs of individual service users. This ensures that service users are free from risk and all medication is given using safe practise guidelines. The recording and stock control of medication has improved since the last inspection and all records appeared accurately written. Beech House DS0000044474.V346107.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A varied programme of activities is offered to ensure that service users expectations can be met. A nutritionally balanced diet is prepared in a clean and safe environment. EVIDENCE: During the course of this inspection Standards 12,13,14 and 15 were checked. Records are kept in the home of the type of activities offered to service users and how well are not these have been received. The social needs assessments seen in the care plans tracked detailed the type of events people liked before they became ill and what they would like to do now, given some limitations. The varied programme showed how well the home works to try and access as much as the service users would like to do. Daily progress diaries detail what events each person has taken part in. Beech House DS0000044474.V346107.R01.S.doc Version 5.2 Page 13 The Activities Organiser and key workers need some encouragement to ensure they liaises with others in the home so she can continue to facilitate a variety of events both inside and outside the home. One service user stated, “Through going to activities I have made some good new friends here” and another stated “I like going to the local market, which the staff help me to get to each week”. Another said, “I like some activities but not others but they let me choose with no pressure”. The cook escorted the inspector around the kitchen and storerooms. This was cleaned to a very high standard and all monitoring records were in place to show that staff keep on top of safety issues and cleaning in the kitchen area. The cook was able to explain not only about the running of the kitchen but also the needs of service users and how the kitchen can access professional outside agencies for advice about different diets. At the time of the site visit the kitchen was using a 4-week cycle of menus, which appeared nutritionally balanced and also for service users who required a diabetic diet and those on gluten free products. There was ample evidence of fresh produce being used and home baking being in place. Service users spoken to appeared to appreciate the home baking and made such comments as “excellent” and “very good”. The nutritional assessments completed in the care plans were fed back not only to the service user but also the kitchen staff, which enables the needs of service users to be met and the kitchen to be able to plan the weekly menus. Other mechanisms such as food and fluid charts for those very ill ensures that the intake of each person is carefully monitored to ensure it is part of the general care that person receives. Beech House DS0000044474.V346107.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust systems are in place to ensure concerns are dealt with promptly and service users are protected from abuse and free from harm. EVIDENCE: During the course of this inspection Standards 16 and 18 were checked. The AQAA returned by the Company showed that 2 complaints had been dealt with since the last inspection and these were checked on the site visit and found to have been dealt with appropriately. The records showed what the complaints were, a summary of investigation and action taken, where necessary and dates of response letters to the complainants. Relatives and service users spoken to stated they all had confidence in the current management team and felt concerns would be dealt with promptly and in confidence. This ensures that service users can feel relaxed about bringing concerns to the management team. Beech House DS0000044474.V346107.R01.S.doc Version 5.2 Page 15 Since the last inspection the home has ensured that the majority of staff have completed training in safe guarding adults and the policy has been updated to meet local guidelines for referral purposes. The Company now has a whistle blowing help line for staff, which can be used for all homes, which staff indicated they do know about. This is an extra line of safeguarding the Company has decided to use to protect service users from harm. Beech House DS0000044474.V346107.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are living in a clean and safe environment. EVIDENCE: During the course of this inspection Standards 19 and 26 were checked. The manager accompanied the inspector on a tour of the home, which was clean and tidy. The new cleaning schedule appeared to be working and adhered to by staff. Care had been taken to ensure the home could accommodate all service users needs and individual rooms planned to meet specific needs and risks. Beech House DS0000044474.V346107.R01.S.doc Version 5.2 Page 17 A number of areas of the home had been refurbished since the last inspection, including the dining room, some carpets and purchase of some new garden furniture. The main laundry was just out side the main building and the laundry assistant showed the inspector around and was able to explain the process of ensuring clean clothes and linen was readily available. There were good cross infection policies in place and staff were coping even though one washing machine was temporarily out of action. The home has a 3-year capital expenditure plan for replacements in the home and redecoration. This is completed alongside a yearly environmental audit for possible extra expenditure. The home had just been awarded a local authority capital grant, which they intended to be used for new dining room furniture. The home had a very comfortable and friendly atmosphere, with wellmaintained and safe surroundings for service users to live in and staff to work. Beech House DS0000044474.V346107.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment policies are in place to ensure staff are safe to work with service users prior to commencement of employment and are then trained to do their jobs. EVIDENCE: During the course of this inspection Standards 27,28,29 and 30 were checked. Since the last inspection the home has made a good improvement in the way it recruits staff and monitors them during the course of their employment. 5 personal and training records files were tracked during the site visit and 8 staff spoken to. 4 staff returned surveys (out of 12 sent), prior to the site visit. The files showed that adequate checks had been made on staff members prior to commencement of employment and they were safe to work with these service users. Staff spoken to made many positive comments about working in the home and felt supported by the current management team. Beech House DS0000044474.V346107.R01.S.doc Version 5.2 Page 19 The training files showed that all mandatory training had been completed, as well as some service specific training such as diabetes and personal care. Training needs had been identified on individual supervision records and a plan developed alongside mandatory and other service specific training through out the year. Only 36 of staff have obtained their NVQ at level 2 or above, but others were identified as working towards this award. This ensures that staff are working to the latest knowledge base to enable them to meet the needs of service users currently in the home. Service users spoken to and relatives who returned survey forms did not indicate any problems with the correct care being given when requested by them. Generally staff appeared happy with the numbers of staff on duty, but felt that more quality time with service users would be helpful. The rota was offered to the inspector to check against the dependency tool used and the numbers appeared to be correct. The manager was aware of the need to keep this under constant supervision and ensure there are sufficient staff on duty to meet service users needs. Beech House DS0000044474.V346107.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are living in a safe and comfortable environment which is constantly checked by the management team, using verifiable tools and auditing processes. EVIDENCE: During the course of this inspection Standards 31,33,35,36 and 38 were checked. The home was very prompt in returning the AQAA document sent by CSCI prior to the site visit and appeared to have given some thought in how it was completed. Beech House DS0000044474.V346107.R01.S.doc Version 5.2 Page 21 A lot of progress has been made since the last inspection in how the home views quality assurance tools and how this can benefit the monitoring of the home for the good of the service users and staff. The Company has introduced team auditing processes, which look at different aspects of the business, and running of the home on a regular basis. The scoring mechanisms determine the frequency of the process, which is highlighted in the action plans for each process covered. These are combined with other auditing methods such as accident recording, supervision of staff, induction of staff, checking of personal finances of service users, budget control and customer surveys sent out to service users on a variety of topics – recent ones have covered topics of - catering, laundry, domestic work, personal care, and social activities. Records and certificates were also seen to ensure the inspector that adequate checks are competed to ensure all equipment is safe to use, fire policies are in place and equipment is safe and that the general risk assessment of the home has been completed. Service users, relatives, staff and visitors to the home all stated they had confidence in the management team in running the home well and in concerns being dealt with promptly. This helps the service users feel at ease and the home have an open and transparent management system to ensure that everyone’s needs are currently being met and the home is running for the benefit of the service users. Beech House DS0000044474.V346107.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 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 3 X 3 Beech House DS0000044474.V346107.R01.S.doc Version 5.2 Page 23 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 OP12 Good Practice Recommendations The Activities organiser and key workers need to work in closer conjunction to ensure that they are working towards a common theme when planning activities for service users. Beech House DS0000044474.V346107.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000044474.V346107.R01.S.doc Version 5.2 Page 25 - 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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