CARE HOMES FOR OLDER PEOPLE
Beech House Wollerton Market Drayton Shropshire TF9 3DB Lead Inspector
Mike Highfield Announced 5 July 2005 10:00
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 E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Beech House Address Wollerton Market Drayton Shropshire TF9 3DB 01630 685813 01630 685905 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) Spring Care Limited Managing Director Mr Lee Cox Area Manager Helen Whitehouse Mrs Wendy Raichura Care Home with Nursing 54 (46) (8) Category(ies) of Old Age registration, with number Dementia of places Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home must comply with the Staffing Notice as issued by Shropshire Health Authority dated 23rd August 1995. 2. The maximum number of Service Users must not exceed 54 Older People who require Nursing Care. This number may include a maximum of 8 Service Users who suffer from Dementia. Date of last inspection 11th January 2005 Brief Description of the Service: Beech House is a large country house in the village of Wollerton near Market Drayton. It is set in its own grounds, which are well maintained, colourful and have all round views of the surrounding countryside. Beech House is owned by Spring Care Ltd the Managing Director being Mr Lee Cox, the Area Manager is Helen Whitehouse, Mrs Wendy Riachura continues to manage the home and a competent and experienced workforce in turn supports her. The home is registered for a maximum of 54 older people who need both nursing and residential care. The home offers a mix of single and double accommodation and the service users are encouraged to bring personal items into their rooms. The Hodnet medical practice provides medical cover for the home. Staff employed within the home arrange activities and external entertainers are frequent visitors to the home. Visitors are made welcome into the home and the staff extend the same courtesy to them as to the service users. This inspection was undertaken by Michael Highfield, Inspector for the Commission for Social Care on 4th July 2005.
Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over a period of six hours it was announced and formed part of the two routine inspections per year undertaken by the Commission for Social Care Inspection. During the inspection a tour of the premises took place, discussions with management, residents, and staff occurred. The care records of residents were perused together with the medicines administration system. The residents records indicated that the home continues to have the capacity to meet the needs of current users of the service in a commendable manner. What the service does well: What has improved since the last inspection?
There have been some developments since the last inspection which took place in January 2005 under the direction of the “new” owners. 1. Redecoration in the home, and some refurbishment. 2. Continued training of Care Staff to NVQ Level 2 to meet the national minimum standard by April of this year. 3. Staff felt that team work had improved. 4. Since the last inspection an extra extraction fan and tumble had been installed in the laundry room to provide improved facilities for staff and residents. Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1-6 The homes statement of how they operate and the Residents User Guide provide the present and prospective residents with very detailed information which does and would assist them in their residency in the home. EVIDENCE: There is a well laid out Service Users Guide which makes it clear to residents, and their relatives, the homes philosophy of care, facilities and services offered, admissions criteria, visiting policy, who the care team are, how they are dressed and what their respective roles are. The Homes Policies and Procedures are clearly outlined. Prospective residents are only admitted to the home following a care needs assessment by the Registered Manager, or senior member of staff. The documented assessment, care planning and reporting of care delivery indicated the homes capacity to provide care to meet the assessed need. The home has a good working relationship with visiting professionals to the home. At the time of the inspection the number and skill mix of the staff on duty and their deployment was consistent to meet the overall care task.
Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 9 The personal records of the residents in the home were very detailed indicating that the home continues to have the capacity to meet their needs in a commendable manner. Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 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 standard(s) 7-11 The health needs of the residents were well met. The Residents Care records were well written, and the system of medicine administration was now well managed. EVIDENCE: An initial care plan, based on the preadmission assessment, is drawn up on the day of admission for each resident, this was evidenced in the case records reviewed. The inspector viewed the care plans, and was assured they were clearly set out, well written and contained all the elements required in the standard. The care plans indicated that the residents have access to the services of visiting clinical professionals and they have a named nurse who is responsible who is responsible for planning their care and reviewing the plan. Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12-15 Systems for residents consultation are well organised, being in both verbal and written form. Residents are involved in the daily routines and social activities in the home, Routines are flexible and the home has good links with the local community. EVIDENCE: The home employs an Activities Co-ordinator who leads the planning of outings and activities. Religious Services are held weekly for those residents who wish to become involved. There was evidence seen in the residents rooms that they are encouraged to bring personal possessions into the home, and they are able to entertain visitors when and where they wish. The food menu for the residents showed a good range of “traditional meals” and the residents engaged in conversation told the inspector they enjoyed the meals that were served and that it was adequately proportioned to suite their appetites. On admission to the home the Catering Manager has access to the assessment reports so that dislikes in foods can be recorded and she is able to meet the residents needs. Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 12 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) 16-18 The home has an effective complaints procedure, and there is evidence that residents feel that their views are listened to and acted upon. EVIDENCE: The Homes Complaints Procedure was displayed throughout the home, and the residents and their families are encouraged to make suggestions at any time to improve their quality of life in the home. Residents and family meetings are held on a regular basis. The residents engaged in conversation with the inspector had no complaints about the home, and could not foresee any circumstances in which they may need to do so. There is an Adult Protection Policy and Procedure in place, with which staff are fully conversant. Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 13 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) 19-26 The standard of the environment is good providing residents with a safe well maintained home to live in. The standard of cleanliness in the home indicated that the home has a dedicated team of staff who have the good name of the home uppermost in their standards. EVIDENCE: The layout, function and general décor in the home is unchanged since previous inspection and meets the requirements of the standards. The décor in the corridors and some rooms has been renewed. The provision of toilet, washing and bathing facilities was found to be well planned and maintained. All parts of the building are accessible, the upper floor via a shaft lift. All bedrooms are comfortable, furnished and equipped to a high standard they are all personalised with the residents own possessions. The home on the day of the inspection was found to be very clean and tidy. The building is compliant with the requirements of the local fire service and environmental health department.
Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 14 A variety of aids, hoists and specialist beds are available to meet the needs of the residents presently living in the home. Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 15 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) 27-30 There is a stable staffing group in the home who were working positively and enthusiastically to provide the residents with a quality of life that meets their individual requirements and aspirations. EVIDENCE: At the time of the inspection Pat Amos the Manager was on duty supported by Velma Groom a very experienced RGN. Eighteen care staff at the home are now trained to NVQ level 2 which equates to 70 of the workforce. There is an on-going staff training programme, which addresses relevant training needs on a comprehensive front, including NVQ, Fire, Moving and Handling, Food Hygiene, Wound Care, COSHH, Nutrition and Needs Assessment. It was identified by the “new” Management Team that recruitment to increase Registered Mental Illness Trained Nurses into the group when the next vacancy occurs would be beneficial to support the home in its care of Elderly Mentally Ill residents. Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 16 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) 31-33, 35-38 The home is managed by a competent team of senior staff who work in the best interests of the residents, and protect their health, safety, and welfare at all times. EVIDENCE: The home has had a change in ownership in the last two months, as part of the team building process all staff are undergoing performance review and regular staff meetings are occurring. The “new” management team are meeting on a quarterly basis and reviews of the homes Procedures are undertaken at that time taking into account any changes in legislation. There are a range of approaches which contribute in developing a good quality service in the home being both verbal and written. Daily discussions with residents occurs and written questionnaires are circulated annually.
Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 17 Health and safety records were well written and all necessary certificates were available for inspection. Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 18 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 3 3 3 4 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4
COMPLAINTS AND PROTECTION 4 4 4 4 3 4 4 4 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 Standard No 16 17 18 Score 3 3 4 3 3 3 N/A 3 3 4 4 Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 19 None 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 Regulation Requirement None made at the Inspection. 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 Good Practice Recommendations None made at the inspection. Beech House E56 S64947 Beech House V234777 AAI 050705 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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