Inspection on 27/06/05 for Beech House

This inspection was carried out on 27th June 2005.

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 02/07/07

Beech House 13/07/06

Beech House 06/01/06

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 on Humber DN18 5PJ Lead Inspector Bev Hill Unannounced 27 June 2005 9:30 th 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 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 J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Beech House Address Chapel Lane, Barton on Humber, DN18 5PJ Telephone number Fax number Email 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 Tamaris Healthcare (England) Ltd Simon Marshall (undergoing registration) CRH 30 Category(ies) of 30 OP registration, with number of places Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 19.10.04 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. A new walk in shower room with hairdressing sink has recently been provided on the ground floor. A forth bathroom is now only used as a toilet. 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. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over two days. The Inspector spoke to the manager and four of the care staff members who were on duty at the time of the inspection. Throughout the days the Inspector spoke to six people who lived in Beech House and three relatives who were visiting. The Inspector checked out the views of three other relatives by phone calls and feedback cards. The inspector looked at a range of paperwork in relation to staff recruitment, induction, supervision and training, rotas, menus, fire records, care plans, activity records, complaints and the servicing of equipment. The Inspector also checked that people who lived in the home had the opportunity to suggest changes and were listened to. The Inspector completed a tour of the building. What the service does well: The home appeared clean and tidy and had a welcoming, homely feel. The communal areas and bedrooms had recently been re-carpeted. People spoken to stated that they could choose the colour of their bedroom when redecorated. There was a core group of staff that had worked at the home for several years and knew the service users well. People who lived at the home and relatives spoken to said that the staff members were caring and kind, although busy. One person did say that one or two staff could be impatient with her at night. The manager is to talk to staff about this. People spoken to stated that the meals were very good. They had two choices at lunchtime and had plenty to eat and drink. If they didn’t like the choice on offer they could have an alternative. Catering staff visited each person daily to find out their choice for the next day. The manager completed weekly ‘resident at risk’ reports covering areas such as pressure sores, weight loss, accidents, infections, protection of adults and changes in health status. These made the manager look at issues of concern on a regular basis and, as they were forwarded to the area manager, they were also kept up to date. The home has started a newsletter to keep people who live at the home and their relatives informed of activities and changes at Beech House. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: The home must address the outstanding requirements and the new ones issued from this inspection. The care that people required was written down in care plans. They did not always reflect all the care that people needed and what staff needed to do to help people. One person did not have a care plan and they had been in the home over a month. When changes occurred in peoples care needs the staff did not always write it down in the care plan. This was important because all staff needed to know when changes occurred so they could support people fully. Staff wrote down information regarding certain risks, for example falls, but the information about how to prevent the risk needed to be more detailed. Daily records maintained by the staff did not contain all the care they had provided and were not completed after each shift. Staff did not record how they had dealt with issues that were highlighted in previous shifts. Sometimes there were gaps of a few days between entries. Staff members spoken to were confused about how often they should write things down. This could mean that important things get missed and not followed up. The home was not following regulations when recruiting staff. This is important to ensure that no one living at the home was put at risk. New staff members were not receiving a full induction. This means that senior staff members were not checking thoroughly if new staff were able to carry out care tasks in a competent way. Staff members were not receiving the full amount of supervision they should have and not all had received the training they needed. Some fire doors were wedged open which posed a fire risk. This must stop immediately. The home must provide automatic door closures on fire doors they want to remain open. The home also needed to check their emergency Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 7 lights when they do fire alarm checks. This is important because fire equipment must be checked so it remains in working order at all times. The home had a complaints procedure and some complaints had been documented and dealt with. However some people who lived at the home and also some relatives told the inspector about complaints they had made to the manager. Although they had been dealt with, they had not been recorded. The home must document all complaints to prove they are dealing with them and that people who complain are satisfied with the result. Some staff members worked double shifts, which made them tired. This may be alright for an occasional emergency when there are shortages due to sickness but not as a regular occurrence. Some staff members spoken to state that morale was a bit low at times and that things discussed in staff meetings did not always get sorted out. The home used to have meetings for people who lived there and their relatives so they can make suggestions about how the home is run. There had not been a meeting since November 2004. Meetings are important because people need to be able to put forward their views and be listened to. These meetings must be re-started. The home sends out questionnaires to people and relatives as part of the monitoring of the care provided. The same form is sent to GP’s, District Nurses and Social services but the questions need to be different on forms to the professional workers, as different information is required by the management to check that they are happy with the care provided. Questionnaires also need to be sent to the staff to find out their views. The manager must make sure that all visitors to the home sign in and out to make sure a record is readily available in case of fire evacuation or other emergencies. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and 3 The home provided information about services available to people to enable them to make a choice. This information needed slight attention to cover all the requirements. The home had not provided terms and conditions to each service user, which could affect their rights. The service users had their needs assessed prior to entering the home by the manager and the Care Management Team when funded by them. The home did not always obtain the Care Management assessment, which could mean that vital information is missed. The home was able to meet the needs of current service users. EVIDENCE: The home had produced a statement of purpose and it contained almost all the points required by Schedule 2 of the Care Homes Regulations. However it needs to be clear about the range of care needs the staff are able to care for. Staff numbers, training and qualifications needs updating and there needs to be details of the organisational structure within the home, and the number and Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 10 size of the bedrooms and communal rooms. The manager stated that a copy of the statement of purpose had been put in each of the bedrooms. The home had a brochure for their service user guide that gave a brief description of the environment and the services provided. The manager needs to ensure that it contains all the requirements of Standard 1. The manager stated that when he visited prospective service users in their home or in hospital he ensured information about the home was given to them. It was often forwarded to people who were making initial enquiries about the home. People spoken to confirmed this. The manager stated that the company was still in discussion with the Office of Fair Trading regarding the homes terms and conditions documentation. This required a swift resolution to ensure service users rights are protected. Generally there was evidence that assessments completed by Care Management were obtained by the home prior to admission. In two of the six care files examined the assessment was not in place. The assessments were important as they provided vital information for the care planning stage. However the home had obtained care plans completed by Care Management. The manager completed in-house assessments. Some of these did not always have full information about how an identified problem affected the person. This was important as it provided information for plans of care to meet identified needs. The manager formally wrote to potential service users following the assessment stating that the home was able to meet their needs. However this had not been completed consistently in all cases. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8 Care plans did not consistently include all the information staff needed to meet assessed needs. This could potentially put service users at risk. Generally health care needs were met but risk assessments were not sufficiently comprehensive and need to inform care plans. EVIDENCE: The Inspector examined six care plans and the quality and quantity of information varied. Not all care plans contained all assessed needs, for example, areas such as nutrition, pressure area management, social stimulation, promotion of continence, communication, sensory loss, emotional needs and mobility issues were missing from some of the care plans that had identified them as needs. However one care plan was quite comprehensive with needs covered. Some people spoken to had seen their care plan and had signed agreement to it, whilst others were unaware of it. Care plans did not always detail clear tasks for staff and changes in needs had not always been written down in the plans. For example a management of diabetes care plan did not detail that on certain days each week breakfast was delayed until the district nurse visited to complete a blood test. Some staff Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 12 members spoken to were unsure of the days on which this occurred although senior staff was aware. This could result in the service user not receiving the correct care and the district nurse not able to complete her test. Another care plan stated a regular toilet regime was required but did not detail what this was and how it was to be documented to ensure it was carried out. One person had had a catheter removed but a plan to promote continence had not been formulated. One person had been resident in the home for a month but did not have an individual care plan produced by the home. This time length was unacceptable as staff needed to know how to support them from the date of admission. Generally the health care needs of service users were met, however the care staff needed to be more proactive in ensuring that service users accessed GP services when health needs dictated. People spoken to felt that their health needs were met. However two relatives fed back that they had to become involved with a medication issue for one and a visit to the hospital for another. The home had a general risk assessment form, which covered walking, sitting, eating/drinks, bed and ‘other’. The section of the form that referred to how staff can reduce the risks had minimal information written down on most of the forms examined. A separate form was used to assess pressure area risks and nutritional risks. Staff members needed to be clear about the use of risk assessments and the part they played in the formulation of care plans. It was positive that the home was part of a Healthy Living Collaborative, which aimed to reduce the risk of falls and fractures and was soon to take part in an initiative that assessed the risks of all service users within the home. Daily recording was completed, however this needed attention, as it was noted staff members did not follow through issues from shift to shift. A clear picture of the care provided each day was not in evidence and in some care files there were gaps of a few days between entries. Staff members spoken to were unsure as to how often they should be recording. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 The home provided flexible daily routines and some activities were available. The staff could be more proactive in completing social needs assessments to tailor activities to meet needs, capabilities and wishes. The meals provided in the home were varied, plentiful and offered choices. EVIDENCE: Service users spoken with said daily routines were flexible. They confirmed that they were able to choose how to spend their day, what clothes to wear, which visitors to receive and there were no set times for rising or retiring. They stated that mealtimes were flexible and a good choice of food was offered. A list of arranged activities was displayed on the notice board. These included exercise to music, quizzes, sing-a-longs, visiting entertainers and trips out. A care staff member shared her role between care hours and activity coordinator hours. The latter was provided for eight hours per week. Some relatives were very enthusiastic in their support for the home and joined in planned activities and social events. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 14 The home had a corporate newsletter that was distributed to all the homes within the company detailing information of events and activities. There was a company mini-bus, which was based in Leeds, however the home did not use it, as transporting it to the home was a problem. Staff had completed social profiles in most cases but needed to look in more detail at peoples social stimulation needs in order to tailor daily activities to individual wishes, needs and capabilities. The home had a social needs assessment document but this was not completed consistently or fully. The home had four weekly rotating menus that the manager confirmed had been completed corporately and overseen by the company’s dietician to ensure they were nutritionally balanced. Service users spoken to were very happy with the meals provided stating they had choices at mealtimes and food and drinks were in plentiful supply. They confirmed a staff member visited them daily to find out their preference for the following day. Menus catered for diabetic diets and there was evidence of fresh fruit and vegetables available. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home had comprehensive complaints policies and procedures, however these need to be followed to ensure all complaints were recorded. There had been no progress noted in the home in ensuring that their adult protection policy and procedure linked to the local authority procedure with regards referral and investigation and all new staff need to receive training. The homes recruitment process is, potentially, putting service users at risk. EVIDENCE: The home had a complaints policy and procedure. A copy of the procedure was displayed in the entrance by the door. People would only notice this as they left the building and it could be more prominently displayed. A form was used to document complaint issues, however it did not indicate complainant satisfaction of how the complaint was dealt with. There was recorded evidence of the investigation of some complaints. However, via discussions with service users and some relatives it was clear that not all complaints had been recorded. They had been dealt with verbally but not recorded. All complaints should be documented to provide evidence of satisfactory resolution. Service users spoken to were able to identify whom they would complain to. The home had a comprehensive adult protection policy and procedure, however it still needed to link to the local authority multi-agency procedure with regards to referral and investigation. The area manager stated that the Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 16 company were still in discussion with the Commission for Social Care Inspection regarding the policy and procedure. There were policies and procedures regarding whistle blowing, restraint and the management of service users distressed or challenging behaviour. Not all staff had received training in restraint and challenging behaviour. Although the manager stated that all staff had received training in Adult Protection there was only documented evidence that nine staff had completed in-house training. One staff member spoken to who had started in February 2005 had not received the training. Five staff records were examined. There was evidence that staff commenced employment prior to the necessary police and vulnerable adults register checks, and in one case references, had been returned. This placed service users at risk. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 26 Service users bedrooms were found to be safe, homely and furnished with their own possessions to varying degrees. Improvements in the environment have taken place and apart from one or two areas, the home was generally clean, tidy and free from offensive odours. EVIDENCE: All bedrooms examined were generally clean and tidy and were furnished and decorated in a homely style. Bedrooms had recently been re-carpeted and redecorated. The service users spoken to stated that they were happy with their rooms. Many people had furnished their bedrooms with a range of personal items, some even bringing in their own furniture to reflect their own individual choice and taste. Locks to the doors were easily accessible by staff in emergencies although approximately four bedrooms did not have a privacy lock in place. Bedrooms were equipped with a call bell system and shared rooms had divider curtains. The majority of bedrooms had a lockable storage facility. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 18 Bathrooms, toilets and communal areas were noted to be clean, although some chairs in the main lounge were in need of cleaning. One of the bedrooms had a slight odour that needed addressing. The lounges and dining room had recently been re-carpeted. Since the last inspection the new laundry facility sited outside the main building had been completed. It had two washing machines with a high temperature sluicing/disinfecting cycle to launder soiled linen and a commercial drier. Staff members were pleased with the new facility and service users spoken to felt their clothes were laundered well. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 19 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 There was insufficient deployment of care staff at night and kitchen staff in the mornings to meet service users needs. Regular double shift patterns led to staff tiredness and will not benefit service user care. The home placed service users at risk with poor recruitment practices. Induction of new staff was insufficient to ensure they were equipped with the basic skills to complete their role and tasks. The training plan covered mandatory training although not all staff had completed the required training. EVIDENCE: The home had four care staff, including a senior carer, on duty throughout the daytime shifts and two staff during the night. Some day staff members who had completed night shifts felt that more staff were required during the night especially as some service users had become more dependent and required two people to assist them. This meant that other call bells could not be responded to quickly. This was confirmed in discussions with some relatives. Service users spoken to said that staff were kind and caring but appeared very busy. One service user felt that one or two staff could be sharp and impatient when answering call bells at night. This was discussed with the manager who will address with night staff. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 20 It was also reported that a lack of kitchen assistant staff in the morning resulted in care staff completing domestic tasks, which resulted in detracting from their care hours. It was noted that some care staff completed double shifts on a regular basis with early shifts the following day. Whilst double shifts were acceptable on a one-off emergency basis to cover staff sickness etc. the long hours were inappropriate and will cause staff tiredness when completed on a regular basis. Five staff files were examined and it was found that recruitment processes were not in line with regulation 19 of the Care Homes Regulations. Povafirst and criminal record bureau checks were not completed prior to the commencement of staff and in one case references had been applied for but not received. This process put service users at risk. The home had a training plan, which covered the basic training required. Good progress had been made with certain areas of the training programme although there was evidence that not all staff had completed the required training for their roles. Five staff had completed NVQ Level 2 in care, others were progressing through the course and five people were enrolled on NVQ Level 3 to start in August. The induction programme met TOPPS specification, however in practice the completed programmes fell short of requirements. Some had modules that had not been completed, none had any evidence regarding the testing of the inductee’s competence, one staff member had a six week induction completed in eleven days and another completed a shorter version fast track induction despite not having been in a caring role for ten years. One relatively new staff member spoken to had not received any induction at all. This lack of induction would impact on the new staffs ability to perform their role and tasks. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 21 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,37 and 38 The leadership and guidance was inconsistent at times and led to low staff morale. There was a lack of consultation with service users and their relatives. Some practices did not promote and safeguard the health and safety of service users within the home. EVIDENCE: The new manager had been in post for ten months and had commenced the Registered Managers Award. He was still settling into his role and developing his management style. Service users and relatives spoken to described him as very caring and kind. Discussions with the manager and several staff members highlighted pockets of low morale and inconsistency in resolving important issues. Full staff Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 22 meetings had been held to ensure staff make suggestions and raise issues but on occasions some staff feel they have not been followed through and this had led to disharmony amongst staff and between staff and the manager. The area manager visited the home on a monthly basis and the manager will discuss with her those staff issues highlighted during the inspection. Examination of records showed that there had not been any meetings with service users or relatives since November 2004. These meetings or small group consultation ensured that people living at the home and their relatives had a say in the way the home was managed. There had been some attempt to obtain their views via questionnaires as part of the homes quality assurance process, however the feedback response was very low. The manager had relied on having an open door policy to discuss issues with people on a daily basis. Whilst this approach was useful it provided a reactive response rather than a proactive one. Meetings and/or small group consultations must be restarted. The quality assurance system consisted of weekly and monthly audits and feedback was reported to Head Office, which ensured the area manager was kept informed. The same questionnaire about services provided, for example meals, laundry, personal care etc was distributed to service users, relatives, visiting professionals and other stakeholders such as care management who provided funding for people to live at the home. The home needed to formulate a questionnaire targeted specifically at visiting professionals and other stakeholders in order to obtain the appropriate information needed to form a judgement on their views about services. The manager needed to address the low feedback response by initiating alternative methods of obtaining views. There did not appear to be any action plans developed to meet shortfalls highlighted by questionnaires. The manager had developed a supervision plan for staff, however the times indicated did not always follow through in practice. He supervised senior care staff and they in turn supervised carers. Not all staff members had received the required six supervision sessions per year and one staff member spoken to had not received any formal supervision since they started their post six months ago. The importance of staff supervision was discussed with the manager and seen as another forum for staff to express their views and where issues can be resolved individually. The manager had not received any documented formal supervision although had monthly discussions with the area manager. Generally records were maintained and stored appropriately. Some records were in need of attention, for example the updating of the statement of purpose, service user guide and the fire risk assessment plan, terms and conditions for service users, recruitment documentation, visitors records, daily recording and care plans. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 23 It was noted that there was no visitor’s book to sign in. On previous visits this was kept in the entrance. The manager confirmed that one service user had removed the book on several occasions. The manager was unable to locate the book and relatives spoken to confirm that they had not signed in for some time. The signing in and out of visitors is an important fire safety regulation and must be complied with. The manager provided a signing in book during the inspection. Alternative means of securing it in place or alerting visitors to its existence must be maintained. Records regarding the servicing of equipment were maintained. The home received seven immediate requirements during the inspection in relation to care plans, daily records, risk assessments for people who selfmedicate, consultation with service users and relatives, fire doors wedged open and recruitment practices. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 24 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 1 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION x x x x x 2 x 2 STAFFING Standard No Score 27 2 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 1 2 x x 2 2 1 Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 25 yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4 Requirement The registered person must revise the statement of purpose to ensure all items specified in Schedule 1 of the Care Homes Regulations is included. (previous timescale of 31.12.04 not met) The registered person must revise the service user guide to ensure all items specified in standard 1.2 are included. (previous timescale of 31.12.04 not met) The registered person must revise the statement of terms and conditions to ensure it contains information relating to fees to be paid and by whom. (previous timescale of 31.12.04 not met) The registered person must improve service users care plans to include more detail and instruction to staff to ensure that service users needs are met. (previous timescale of 31.3.05 not met) The registered person must ensure that social needs assessments are completed fully to inform the daily activities Timescale for action 31st August 2005 2. 1 5 31st August 2005 3. 2 5 31st August 2005 4. 7 15 26th July 2005 Immediate requiremen t issued. 31st August 2005 5. 12 12(2)& 16(2)(m) (n) Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 26 6. 16 12(1)(a) 7. 18 13 8. 33 12(1)(a), 21&24(2) 9. 37 17 10. 3 14 11. 3 14(1)(d) 12. 7 15 13. 7 15 plan. (previous timescale of 28.2.05 not met) The registered person must ensure that all concerns and niggles are documented. (previous timescale of 31.12.04 not met) The registered person must revise the adult protection procedures to ensure they link with the local multi-agency procedures. (previous timescale of 31.12.04 not met) The registered person must ensure that the quality assurance questionnaires include the views of staff and other stakeholders. A result of the surveys must be forwarded to the CSCI. (previous timescale of end of QA year April 2005 not met) The registered person must ensure that al records required by schedule 3 and 4 are up to date. (previous timescale of 28.2.05 not met) The registered person must ensure the home obtains assessment information completed by care management and that the homes assessments contain more detailed informnation. The registered person must ensure that the home consistently writes to service users or their representatives, following assessment, formally stating their ability to meet needs. The registered person must ensure that care plans contain all assessed needs and reflect changes in need when they occur. The registered person must ensure that a specific service 28thJune 2005 31st August 2005 31st August 2005 31st August 2005 28th June 2005 28th June 2005 26th July 2005 1st July 2005 Page 27 Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 14. 7 15 15. 8 13(4) 16. 17. 8 18 12(1)(a)& 13(1) 13(6) 18. 24 12(4)(a)& 23(2)(m) 19. 26 23(2)(d) 20. 27 18(1)(a) 21. 29 19 user admitted one month ago has a care plan in place. The care plan to be forwarded to the CSCI for examination. The registered person must ensure that daily diary records detail the care provided to the service users and follow through to the next shift in order to monitor their progress. The registered person must ensure that risk assessments detail the measures to be taken to minimise risk and are linked to care plan provision. The registered person must ensure a timely request to professional support and advice. The registered person must evidence that all staff have completed or are planned to complete adult protection, challenging behaviour and restraint training. The registered person must provide lockable facilities in the remaining bedrooms and privacy locks to the remaining four doors. The registered person must address the odour in one of the bedrooms and the chairs in the main lounge. The registered person must ensure sufficient staff at night to meet the needs of service users and address the issue of regular double shifts on the rota. The registered person must ensure that recruitment of staff is in line with regulation 19 of the Care Homes Regulations. The registered person must ensure that full induction and mandatory training of new staff takes place, with updates for existing staff as required. Immediate requiremen t issued. 28th June 2005 31st August 2005 28th June 2005 31st August 2005 31st August 2005 31st August 2005 31st August 2005 22. 30 18(1)(a) 28th June 2005 Immediate requiremen t issued. 28th June 2005 Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 28 23. 32 12(2)(3) 24. 32 12(5) 25. 36 18(2) 26. 38 13(4)&23 (4) 27. 38 Schedule 4 The registered person must ensure that consultation takes place between the home and service users/relatives regarding the way the home is managed. The registered manager must address leadership and guidance skills in order to improve commincation and relationships between manager and staff, staff members themselves and between staff and one service user. The registered person must ensure that all staff receive a minimum of six formal supervision sessions per year and that new staff receive their first supervision session. The registered person must ensure that fire doors are not wedged open, the fire risk assessment plan is updated and emergency lighting is tested regularly. The registered person must ensure that all visitors to the home sign in and out of the building. 11th July 2005 Immediate requiremen t issued. 31st August 2005 31st July 2005 28th June 2005. Risk Assessmen t plan by 31st August 2005 28th June 2005 28. 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 16 Good Practice Recommendations The registered person should consider re-siting the complaints procedure in a more prominent position and identify complainant satisfaction on the current complaint form. The registered manager to continue their registered managers award. The registered manager should provide evidence on J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 29 2. 3. 31 30 Beech House induction booklets when competency of new staff members has been assessed. Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 30 Commission for Social Care Inspection Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beech House J54 S44474 Beech House 235668 27 June 2005 Stage 4.doc Version 1.40 Page 31 - 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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