Inspection on 30/01/06 for Beech House

This inspection was carried out on 30th January 2006.

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 15/10/08

Beech House 06/12/07

Beech House 07/08/07

Beech House 30/10/06

Beech House 22/06/05

Beech House 27/09/04

Beech House 02/08/04

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

CARE HOMES FOR OLDER PEOPLE Beech House 29 Great Bowden Road Market Harborough Leicestershire LE16 7DE Lead Inspector Mrs Gillian Adkin Unannounced Inspection Monday, 30th January 2006 09:30 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 DS0000001806.V280674.R01.S.doc Version 5.1 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 DS0000001806.V280674.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beech House Address 29 Great Bowden Road Market Harborough Leicestershire LE16 7DE 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) 01858 464289 Mr Keith Burrows Mrs Lesley Burrows Mrs Lesley Burrows Care Home 13 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (13) Beech House DS0000001806.V280674.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers. No one falling within categories DE (E) and MD (E) may be admitted into the home when there are 5 persons of categories/combined categories DE (E) and MD (E) already accommodated within the home. Date of last inspection 22nd June 2005 Brief Description of the Service: Beech House is a residential home, which is registered to accommodate up to thirteen older people, including five within the category of mental disorder and dementia. Beech House is situated in a residential area, close to the Market Harborough town centre. The home is accessible by car or public transport. Parking is available to the front of the home. The home provides a large lounge to the front of the property and a dining room to the rear. There is a patio area to the rear of the home, which is accessible to residents using wheelchairs and walking aids. Bedrooms are located on the ground and first floor that is accessible by the stair lift or the passenger lift. Bath/shower and toilet facilities are located close the bedrooms. Beech House DS0000001806.V280674.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over one day and commenced at 09.30 am on Monday, 30 January 2006.The inspection took 5 hours. The registered manager /registered provider facilitated the inspection The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for residents and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The primary method of inspection used was ‘case tracking’ which involved selecting two residents and tracking the care they received. This inspection report additionally addresses specific areas where requirements and/or recommendations were identified at the previous inspection. During this inspection a tour of the accommodation occupied by those case tracked took place along with other areas of the home as deemed necessary and the inspector viewed internal records, and care plans. The inspector spoke to residents, care and ancillary staff. No relatives were available during this inspection for comments. Discussion took place with the visiting hairdresser. There were 12 residents accommodated at the time of this inspection. Conversation with some of the service users tracked was limited due to communication difficulties, however other comments were received about the service which are detailed below Typical comments included: “We routinely offer choices of food to service users ” “Communication is very good in the home I would recommend the home to others” “We have a handover at the beginning of each shift” “The home is very comfortable and homely” “ I have not seen my care plan but I’m not really bothered” “Occasionally I go home with my family” Beech House DS0000001806.V280674.R01.S.doc Version 5.1 Page 6 “I am happy living here, I feel safe” “Staff give me my call bell when I go to bed” What the service does well: What has improved since the last inspection? What they could do better: The lounge and first floor could be a little warmer particularly when residents are seated for long periods of time. The registered provider should consult with service users to ensure their comfort is maintained regarding heating. Radiator guard must be fitted to radiators in the old part of the home to minimise the risk of burns to service users’ Care plans should fully describe care needs and not be reliant on staff and the registered managers knowledge. Care plans should fully detail behaviour management strategies to maintain harmonious relationships with other service users and to ensure staff are able to effectively manage this aspect of need. The registered provider should include tissue viability and adult protection (abuse) training into their existing programme, to ensure staff are fully aware of their responsibilities. Recruitment/ records must be strengthened to ensure that all documentation as detailed in Schedule 2 of the Regulations is included in staff files and available for inspection. Beech House DS0000001806.V280674.R01.S.doc Version 5.1 Page 7 The induction programme should be strengthened in order to meet the training needs of staff. The registered provider must ensure that formal fire training is provided to staff at least annually to provide a forum in which views/ concerns can be regularly expressed 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 DS0000001806.V280674.R01.S.doc Version 5.1 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 DS0000001806.V280674.R01.S.doc Version 5.1 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 the following standard(s): 1 Information supplied by the provider ensures that service users can make an informed decision about living in the home. EVIDENCE: Discussion with service users and observation of internal documentation demonstrated that service users are fully informed about the services provided in the home. It was recommended that documentation is updated to ensure that reference to the NCSC is changed to Commission for Social Care Inspection the current Regulatory Body. Beech House DS0000001806.V280674.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7.8.9. Care plans do not fully describe identified care needs; this has the potential for omissions in care occurring. Medication is suitably and safely managed this protects the safety and welfare of service users EVIDENCE: Service users needs are detailed in a plan of care. Service users’ tracked had a plan of care in place. The registered manager stated that care plans are reviewed weekly in conjunction with the daily report and a six monthly evaluation of care was seen in one care plan tracked. The last evaluation was conducted in January 2006. Inspection of care plans demonstrated that additional information was required to ensure that all care needs were appropriately met. It was apparent through discussion with staff that care needs were well known to staff however were not fully described in the corresponding care plan. One example of this was the management of difficult behaviour, which was witnessed during this inspection. Beech House DS0000001806.V280674.R01.S.doc Version 5.1 Page 11 Discussion with the registered manager indicated that no delegated nursing tasks are undertaken by the home and Community nurses provide all nursing care. Appropriate risk assessments were noted in care plans. Discussion with staff demonstrated their awareness for the need for pressure relieving equipment, and that they were suitably aware of pressure sore management. The deputy manager stated that a good rapport exists with the General Practitioner (who service users referred to) and Community nurses who visit the home to provide nursing care. Evidence of relatives input in care plans was seen and confirmed by them. One service user spoken with was not aware of the care plan being in place. The medication system was inspected and was found to be well managed and appropriately administered. Staff with responsibility for administration confirmed they had received appropriate training. The registered provider indicated that she observes staff undertaking medication round stop ensure they are fully competent. Supervision records seen included the signing off of medication competency. It was recommended that the existing medication policy is updated and includes the management of errors. One service user tracked had needs regarding pain management and it was recommended that the care plan is evaluated more often to establish how pain relief is successfully maintained. Beech House DS0000001806.V280674.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Service users are enabled to exercise choice and experience a lifestyle, which empowers them and ensures that their expectations and best interests are considered. EVIDENCE: Discussion with service users and staff indicated that choice and control is maintained. One service user tracked stated” I please myself when I get up and go to bed” another service user described how she preferred her own company and stayed in her room. Choices were offered to service users regarding their mid day meal this was observed. Inspection of service users accommodation demonstrated that they were able to bring in to the home personal possessions. Service users indicated that where possible they maintained control of their personal finances. Discussion with a staff member indicated that she had attended a course on person centred care recently; she described how she had changed her style of delivering care to be more enabling. Beech House DS0000001806.V280674.R01.S.doc Version 5.1 Page 13 Personal choices were not identified in care plans and it is strongly recommended that this is included during assessment of potential residents. Beech House DS0000001806.V280674.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16.18 Service users are confident in the system of managing complaints. Staff have a good level of understanding regarding the prevention of abuse, this would be strengthened by provision of formal training to ensure that the risk of abuse to service users is minimised. EVIDENCE: The home has a clear complaints procedure, which is included in the service user guide. The procedure however does not include the involvement of the Commission for Social Care Inspection. Service users who were able indicated that they would refer all complaints to the registered manager. The homes records were inspected and no complaints were recorded in the file. Although when questioned staff had a good working knowledge of adult protection issues and how to report incidents, some were not familiar with the whistle blowing terminology/ policy and stated that they had not had any formal training. This was confirmed when inspecting training files and no evidence was found to confirm if this training was planned for this year. The home has been issued with the Leicestershire County Council multi agency policy and the registered manager stated that this is used in discussion with staff during supervision. The registered provider must initiate adult protection training for all staff without delay. Beech House DS0000001806.V280674.R01.S.doc Version 5.1 Page 15 Service users spoken with stated that staff were respectful and kind and one service user said she “felt safe living her” Beech House DS0000001806.V280674.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23.25. The home is clean and comfortable and premises are well maintained resulting in an environment, which is homely and appropriate to meet service users’ needs. In areas where radiators are not suitably guarded this has the potential to endanger persons who are at risk. EVIDENCE: None of the rooms occupied by those persons case tracked were shared. During a brief tour of the home it was noted that all areas were well decorated and furnished, clean and tidy and well maintained. Rooms of those tracked had been personalised to accommodate personal possessions. Although overall the heating lighting and ventilation was suitable it was noted that the upper floor and lounge were relatively cool and two service users spoken with indicated they were cold one service user said the temperature was fine. The registered manager indicated that this might be due to the boiler being on a timer. It was Beech House DS0000001806.V280674.R01.S.doc Version 5.1 Page 17 suggested that discussion takes place with service users to ensure they are suitably comfortable and warm. It was noted that radiator guards had not been fitted in the old part of the building and risk assessments had not been undertaken to identify /minimise any risk. Three service users are able to wander at will in this area including one who was tracked it is therefore essential that this work be undertaken. The registered provider indicated that the downstairs bathroom /toilet was due to be refurbished in the next month. There are no separate visitor toilets provided in the home. Beech House DS0000001806.V280674.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27.29.30 Recruitment processes are not thorough. Staffing numbers allocated ensure that service users needs are met. EVIDENCE: The inspector undertook a calculation of staffing hours the calculation demonstrated that the home were meeting the recommended hours as in the Department of Health Residential Forum guidance. The calculation of hours includes the registered managers rostered hours, the registered manager undertakes managerial duties after care hours are completed. Adequate numbers of hours are supplied for ancillary staff. Service users spoken with all stated that the home is always adequately staffed and service users needs are attended to in a timely manner. Staff confirmed this. The registered manager stated that she never uses agency staff preferring to either fill gaps with permanent staff or working the shift herself. Two staff files were inspected and one file contained an out of date CRB and no written references as detailed in Schedule 2 of the Regulations. The registered manager was unable to account for this; Beech House DS0000001806.V280674.R01.S.doc Version 5.1 Page 19 The second file although containing all relevant documentation contained unsatisfactory references; the registered manager stated this had been explored at interview and reasons given which were considered satisfactory. This exploration had not been formally documented in interview records. Staff files contained evidence of recent training including Dementia Care, Continence and NVQ level2. Discussion with the registered manager and observation of records indicated that the staff handbook is used as an induction handbook for new staff. Although containing relevant information regarding the home the handbook was not considered to be adequate to provide sufficient information required by new staff in relation to care practises and a requirement has been made to update the induction programme to meet the National Training Organisation Standards. Staff when questioned had not received any formal training in relation to tissue viability or adult protection. Beech House DS0000001806.V280674.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33.36.38 The health, safety and welfare of service users are protected by systems and procedures being in place. Provision of fire training will improve the overall outcomes for service users regarding fire safety. EVIDENCE: Inspection of fire records took place and it was noted that regular fire drills take place. Fire systems are routinely inspected; this was well evidenced in files. Staff training records inspected indicated that fire training had not been undertaken since 2004.This must be arranged and repeated at least annually. Beech House DS0000001806.V280674.R01.S.doc Version 5.1 Page 21 Evidence was seen in the home of fire safety notices, which service users and the hairdresser were aware of. The home has a fire alarm test each week; two service users indicated that they knew when it was performed. Discussion with staff indicated that they were regularly supervised; this was evidenced in internal records inspected. The registered provider responsible for supervision stated that a day-to-day supervision of staff takes place and therefore considered that six monthly supervision and an annual appraisal was sufficient, this does not however allow time for personal issues to be explored in between and it was recommended that the frequency be increased. A formal Quality Assurance policy /system is in place, this was evidenced through discussion with staff, and service users (where practicable). A survey had recently been completed with 70 of service users responding positively about the service provided. Beech House DS0000001806.V280674.R01.S.doc Version 5.1 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 3 X X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 X X X 2 X 3 2 X STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 3 X 2 Beech House DS0000001806.V280674.R01.S.doc Version 5.1 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. 1 Standard OP25 Regulation 13 Timescale for action Radiator guards must be fitted to 28/02/06 radiators in the old part of the home to minimise the risk of burns to service users’. Care plans must fully detail all 28/02/06 care needs as identified at assessment. Care plans should fully detail behaviour management strategies to ensure staff are able to effectively manage this aspect of need. Recruitment/ records must be 28/02/06 strengthened to ensure that all documentation as detailed in Schedule 2 of the Regulations is included in staff files and available for inspection. The induction programme must 28/02/06 be strengthened and should meet with the National Training Organisation Standards. The Registered Provider must 28/02/06 ensure that formal fire training is provided to staff at least annually. Requirement 2 OP7 15 3 OP29 19 Schedule 2 4 OP30 18 5 OP38 13 Beech House DS0000001806.V280674.R01.S.doc Version 5.1 Page 24 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 OP16 Good Practice Recommendations The Registered Provider should ensure that the correct contact details for the Commission for Social Care Inspection are displayed on documentation. The Registered Provider should ensure that the lounge and individual bedrooms are suitably heated particularly when residents are seated for long periods of time. The registered provider should consult with service users to ensure their comfort is maintained regarding heating. The Registered Provider should include tissue viability and adult protection (abuse) training into their existing programme. The Registered Provider should provide formal supervision to staff at least six times per year. 2 OP25 3 OP30 4 OP36 Beech House DS0000001806.V280674.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 DS0000001806.V280674.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!