Inspection on 09/07/07 for Beech House

This inspection was carried out on 9th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 01/08/06

Beech House 29/11/05

Beech House 10/03/05

Beech House 02/09/04

Beech House 23/10/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Beech House Beech Close Halesworth Suffolk IP19 8BQ Lead Inspector Julie Small Unannounced Inspection 9th July 2007 09:50 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 DS0000029245.V345284.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech House Address Beech Close Halesworth Suffolk IP19 8BQ 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) 01986 872197 01986 874638 tpic.access@virgin.net The Partnership in Care Limited Sonia Sherwood Care Home 39 Category(ies) of Dementia - over 65 years of age (20), Old age, registration, with number not falling within any other category (39) of places Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may also, within the total of 39 service users, accommodate up to 20 older people with dementia (DE(E)) 1st August 2006 Date of last inspection Brief Description of the Service: Beech House, owned by The Partnership in Care Limited, provides care for up to 39 people aged 65 years and over. The home can care for up to 20 older people who have a diagnosis of dementia. The homes manager is Miss Sonia Sherwood. The purpose built home, is set within a residential area, within walking distance of Halesworth town centre. There is a footpath, which leads straight to the town’s market place, where there is a range of amenities. These include shops, church, banks, post office, eating and drinking establishments. Public transport links include railway and bus services. The home consists of 2 floors, which can be accessed via a lift or stairs. The 38 single bedrooms (located on both floors) all have wash hand basin, and 6 also have an en-suite toilet. There was a further bedroom which was to be renovated. For residents that do not have their own toilet, there are communal bathrooms and toilets located close to the bedrooms and lounges on each floor. The home is separated into 2 areas, 1 part known as the main home, has a large dining room. The second part of the home is the special needs unit, which supports people with dementia, and has it’s own dining room, lounge and enclosed garden. This is a non-smoking home. At the time of the inspection, the inspector viewed the service user’s guide which identified that the fees at the home ranged from £340 to £495 per week, dependant on if residents were private customers or social care customers and the type of care they received. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on Monday 9th July 2007 from 09.50 to 16.00. The inspection was a key inspection which focused on the core standards relating to older people and was undertaken by regulatory inspector Julie Small. The report has been written using accumulated evidence gained prior to and during the inspection. The home’s manager Sonia Sherwood was present during the inspection and provided the requested information promptly and in an open manner. The manager said that service users were referred to as residents and this term will be used throughout this report. During the inspection a tour of the building and observation of work practice was undertaken. Three residents, a resident’s family member, a visiting medical professional and three staff members were spoken with. Records viewed included three resident, three staff recruitment, training, fire safety and accident records. Further records viewed are detailed in the main body of this report. Since the last inspection there had been two applications received to increase the numbers of residents who had dementia. This had been increased from 10 to 15 and then to 20. There was no evidence identified during the inspection that the increase in dementia beds adversely affected the existing residents in the home. Prior to the inspection an annual quality assurance assessment (AQAA) questionnaire and staff, visitors and residents surveys were sent to the home. The AQAA was returned to CSCI (Commission for Social Care Inspection) and twelve staff surveys, four relative/visitor surveys and fifteen resident surveys were returned. What the service does well: The home was clean and maintained. There had been efforts to ensure that the environment was homely, which included paintings on the walls and flowers and plants in the communal areas. There was a good training programme for staff and high NVQ (National Vocational Qualification) achievements for staff. There was opportunity for care staff to gain the experience of ‘acting up’ in senior roles. It was evident that the manager was committed to staff development. The interaction between staff and residents was observed to be friendly and professional. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 6 There was a good programme of activities which residents could participate in if they wished. There were individual activities plans in resident’s bedrooms, which provided information about what they had said they wanted to participate in on a daily basis. There were lots of board games, videos and books in the home, which residents could use. The care plans were detailed and clearly explained what support each resident requires to meet their needs. They were regularly updated with residents changing needs and preferences. Residents and their representatives were included in the care planning and there were copies of residents care plans in their bedrooms. Records viewed and discussion with a health care professional evidenced that the home ensured that residents health care needs were met. There was evidence that the home worked in partnership with health care professional and sought advice where necessary. What has improved since the last inspection? What they could do better: There was a recording format for the pre-admission assessments, which were undertaken by the home’s management prior to residents moving into the home. It is recommended that the document be provided with a section which asks for the date of the completing of the assessment and the name of the person completing the assessment. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can expect to be provided with the information they need to make a decision about living at the home and that they have their needs assessed prior to moving into the home. Prospective residents have the opportunity to visit the home prior to deciding if they wish to move in. The home does not provide intermediate care. EVIDENCE: The home provided intermediate care at the time of the last inspection. The home no longer provided the service. The home’s Statement of Purpose was viewed during the application for the first increase in numbers of dementia residents. The document was updated to meet the requirements during the application. The Statement of Purpose Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 10 clearly identified information about the home, the numbers of places provided and information about how the home met the specific needs of residents. The AQAA confirmed that the Statement of Purpose had been reviewed and revised since the last inspection. The Service User’s Guide was viewed and included information about the residents and staff at the home, the complaints procedure, terms and conditions and fees for the home. The AQAA stated that the Service User’s Guide was reviewed at regular intervals and that it was available to prospective residents. An introductory pack was viewed, which the manager said was provided to prospective residents and their family. The pack included the Service User’s Guide, the CSCI inspection report, outcomes for the satisfaction questionnaires and details of how the home met the needs of residents. A resident’s family member was spoken with and said that they had been provided with good documentary information about the home, which clearly identified the care that their family member would be provided with. They had heard about the positive service the home provided from a family of a previous resident. They said that the resident and their family members were provided with the opportunity to visit the home before they made a decision. They said that they were welcomed into the home during the visits and staff answered any questions they had. The family member said that they were involved in providing information during the completion of the needs assessment. A resident spoken with said that they had visited the home before they decided that they wanted to live there. They said that they met the staff and looked around the home. The AQAA confirmed that each individual was provided with the opportunity to visit the home before they moved in to help them make their decision. The AQAA said that the home offered a six week settling in period before those involved could reassess the placement, a longer settling in period could be provided if required. The relative/visitor survey asked if they received enough information about the home to help them to make decisions and four answered yes. The resident survey asked if they received enough information about the home before they moved in, so they could decide if it was the right place for them. Eleven answered yes, one answered no and three said that they could not remember. Fourteen resident surveys said that they had received a contract and one said that they had not. Three resident’s records were viewed and all three held detailed needs assessments completed by the manager or the deputy manager of the home Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 11 and one also held a local authority needs assessment. The home’s preadmission needs assessments included details of the name, address, reasons for admission, medical and health needs and wellbeing, abilities and interests. The home’s pre-admission assessments were completed on a set format, however, there was no section provided for the date of the assessment and the name of the individual completing the assessment. The manager provided dates of the assessments, which they obtained from the home’s diary. The manager said that prior to moving into the home, prospective residents were visited where they lived and the assessment was undertaken. They said that they were due to complete two assessments for prospective residents who had shown an interest in the home, the day after the inspection. They said that social care customers were also provided with needs assessments, which had been undertaken by the local authority. The AQAA stated that each resident had an individualised pre-admission assessment to check if the home could meet their needs. If the home could not meet their needs an explanation would be provided. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are provided with an individual plan of care, that their health needs are fully met, that they are protected by the homes medication procedures and that they are treated with respect. EVIDENCE: During the last inspection the home were working on the development of computer based care planning records. The staff were in the process of inputting information onto the computerised system from the paper documentation. During this inspection it was noted that the work had been completed. Staff were provided with a password to enable them to access the documents. Staff were observed recording daily notes on the system. The AQAA confirmed that staff had been provided with training on the record keeping system. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 13 Three resident’s care plans were viewed and they provided good detail regarding their needs and actions staff should take to meet their needs. The care plan included details regarding their mobility, personal hygiene, their likes and dislikes, preferences and their psychological, spiritual, emotional and social well being. There was reference in a care plan viewed, which stated that the resident prefers to wear a vest underneath their sweater and the type of perfume they choose to wear and when they prefer to use it, which evidenced that residents preferences were listened to and identified in their care plans. Resident’s records viewed included dependency, manual handling and risk assessments. There were entries to the action plan which provided actions to minimise risks if the assessments identified that there were risks. The computerised records identified when they had been updated with changing needs and preferences. Records identified that each resident was weighed on a monthly basis and there were actions identified if there were issues noted regarding their weight. The manager spoke about the possibility of not weighing each resident on a monthly basis, there were some residents who had no issues with their weight and that they could weight them less frequently. They had a clear understanding of issues that could arise and how they would minimise risks. There was clear reference to risks that they faced in their daily living and methods of minimising the risks were clearly identified. There were specific risk assessments completed for identified risks, such as a hygiene risk assessment for one resident who goes into the kitchen area and for those who had dementia. The records detailed residents’ medical history and there was a reference to their personal history, which was undertaken by staff talking to the residents about their history. A resident’s family member was spoken with and confirmed that they and the resident had participated in the completion of the care plan. They said that a copy of their care plan was kept in their bedroom. The manager confirmed that the care plans were printed and stored in resident’s bedrooms to provide information to the residents and was accessible to staff if they needed to refer to it while they were supporting the resident. The AQAA stated that the residents were supported to make their own decisions regarding their care, which was evaluated at regular intervals. With the resident’s permission they worked with the resident, their relatives and carers to provide the best support for the individual. The resident survey asked if they received the care and support they needed. Seven answered always, five answered usually and two answered sometimes. One comment was ‘would like a bath more regularly’. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 14 The relative/visitor survey asked if the care home met the needs of their relative or friend. Three answered always and one answered usually. The staff survey asked if they were given up to date information about the needs of the people they supported. Eleven answered yes and one answered sometimes. The resident’s records viewed provided clear information of health care visits and treatments, including dental, medical, chiropody and optical. A district nurse professional was spoken with and said that the home worked in partnership with them. They said that they worked together to ensure the best health outcomes were achieved for residents, staff followed advice and worked closely with the district nurse. They attended the home on a regular basis to provide support to residents with specific health care needs. They said that they were always welcomed into the home and they were provided with a room where they could complete their records. They said that residents could choose if they wished to see them in the treatment room or in their own bedroom. They were complimentary about the staff and support provided at the home. The district nurse said that they provided a community care fund charity, which provided support for obtaining equipment. They said that the home could access equipment if it was needed for individual residents. The resident survey asked if they received the medical support they needed. Thirteen answered always, one answered usually and one answered sometimes. The manager said that they had been provided with support from the Arts Council and that there had been a dance professional who visited the home. The manager said that the residents enjoyed the dance sessions which they undertook, which provided an opportunity to do gentle exercise while they were dancing. The home’s medication storage and lunchtime medication administration was observed. The staff member said that the pharmacy had changed the way that medication was provided to the home. The previous provision was in ‘cassettes’ and had been changed to be MDS (monitored dosage system) blister packs. They said that the system was preferred. Medication was in a secured trolley, which was stored in a lockable treatment room when not in use. The medication records were viewed and clearly identified medication prescribed for each resident and there was a photograph of each resident. There were no gaps identified in the records viewed. A staff member clearly explained the procedure for ordering and disposing of medication. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 15 There was secure storage available for controlled medication. The controlled medicines records were maintained in a bound book and there was a clear audit system in place. The home had a detailed medication procedure which was viewed. Medication training had been provided to staff who were responsible for the administration of medication and there had been an update provided by the pharmacy on the new system. During a tour of the building, the manager was observed knocking on bedroom doors before entering and they asked for the resident’s permission for the inspector to look at their bedroom. They introduced the inspector to residents and explained why they were in the building. There was lockable storage space provided in each resident’s room. Interaction between residents and staff was observed to be friendly, respectful and professional. Residents spoken with said that the staff treated them with respect and they confirmed that their privacy was respected. A resident’s family member said that the staff always polite and friendly and treated them and the resident with respect. They said that they were always clean and smart. Staff spoken with said that resident’s clothing was labelled to ensure that they were provided with their own clothing when it had been laundered. A resident’s record viewed identified what they preferred to be called, their preferred form of address was different to their first name. The AQAA stated that staff were trained to enable residents to make choices, for example what they chose to wear. The resident survey asked if the staff listened and acted on what they said. Twelve answered yes, one answered no and two did not answer. A comment was ‘staff are pleasant’. Comments in the relative/visitor surveys were ‘the staff are a friendly and happy team and this reflects in the way they interact with the residents and their relations or visitors’, ‘the most important thing is the caring and friendly attitude of the staff’. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 16 Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 17 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can expect that they are provided with the opportunity to participate in activities, that they are supported to maintain contacts, that they exercise choice and control over their lives and that they are provided with a balanced diet. EVIDENCE: The resident’s care plans viewed identified their interests, hobbies and any religious worship, which they participated in. There were clear records of activities which they had participated in at the home. The home employed an activities co-ordinator who devised the activities programmes. There were individual activities programmes provided for residents with dementia displayed in their bedrooms to ensure that they knew what they were doing each day. Activities included seasonal work, reminiscence activities provided both in a group and individual basis, day trips, eating out, films, cooking, bingo and various games. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 18 During a tour of the building it was noted that there was a large range of entertainment available such as videos, books and games. There were art work, literary work and painted plant pots, which had been made by residents. The manager explained that the home had been provided with support from the Arts Council and three professionals had provided residents with the opportunity to participate in dance, visual arts and creative writing. Training had been provided to staff to continue with the activities. In the dining room there was a ‘bunting’ style decoration, residents had written memories, such as where they bought milk from when they were younger, on each flag. In the entrance hall to the home there was a resident’s notice board. On the board were photographs and newspaper articles about the local carnival which the residents and staff had participated in. The residents were dressed as school children, and all pictures showed the residents laughing and having fun. The manager explained that they had intended to do a float, but decided to walk as the float would not be accessible to wheel chair users. The residents had chosen their theme and what they wished to wear. A resident had made a pointed hat with a D on the front to wear. The home had won a prize and one resident had entered themself into a fancy dress competition and also won a prize. Residents spoken with confirmed that they had a wonderful time at the carnival and laughed when they told the inspector about the day. The manager said that the home provided Holy Communion on a monthly basis and the residents enjoyed singing. They said that the home organised for a further activity of hymn singing, which was led by a staff member who played the organ. There was work being undertaken to provide a sensory garden, where residents could participate in gardening if they wished to. The manager said that they had accessed support for the creation of the gardening from a local community organisation and a local school had been involved in the design of the garden. The manager said that one resident’s family member had bought in the resident’s Wellington boots so they could advise them on how they wanted the garden done. They said that the resident had been a keen gardener prior to moving into the home. During the inspection residents were observed to be watching the television and sitting in the garden areas of the home, three residents were sitting in the summer house. There were several residents enjoying visits from their families and friends. Residents spoken with said that there were plenty of activities available in the home. They said that their relatives could visit them at any time and were made welcome. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 19 The AQAA stated that a resident was reminiscing about their time as a ‘land girl’ with the activities co-ordinator. There had been an outing arranged for a local war museum which other residents participated in. Comments in the relative/visitor surveys included ‘there is always activities for the residents if they wish to participate’ and ‘(relative) has gained confidence and will attempt things (relative) never would before’. A resident’s family member said that they visited their relative on a regular basis. They said that they were always welcomed into the home, could make themselves drinks when they visited and likened the home to being ‘like one big family’. They said that staff were always willing to spend time with them if they requested information about their relative’s well being. The AQAA stated that visitors were welcomed into the home, that they could enjoy a meal if they wished to and that there were several communal areas they could use if they wished to. The manager said that one resident’s family member lived overseas and they were supported in sending and receiving e-mail communication, the resident had also shown an interest in accessing an Open University course. They said that they were planning an ‘internet café’ for the use of residents, where they would have a computer for their own use which provided internet access to maintain contact and could access further education if they wished to. The relative/visitor survey asked if the home helped their relative/friend to keep in touch with them. Two answered always, one answered N/A and one commented ‘as I visit my (relative) every day the question does not apply’. The survey asked if they were kept up to date with important issues and four answered always. Residents spoken with said that they could bring their personal possessions into the home if they wanted to. They said that they chose what they wanted to do in their daily lives. Resident’s records viewed evidenced that residents made choices about their daily living including what they wanted to eat and what activities they wished to participate in. The AQAA stated that there were regular resident’s meetings and identified how the home had actioned requests raised. For example a resident with sensory loss had asked that a lounge be available to assist them to access television and radio with minimal distractions, others with sensory issues supported the request. An existing lounge was changed to a quiet room and this was found to have been a popular change. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 20 The menu for the day was displayed on the resident’s notice board. The choices provided for lunch were cheese salad or cold meat, mash and pickles or vegetable lasagne and there was a choice of two deserts. The menu was viewed and there was a choice of meals, including a vegetarian option. Lunch was observed during the inspection and the meals looked appetising. Residents spoken with said that the food was of good quality and they were provided with enough to eat. Residents were observed to be provided with choices of hot and cold drinks throughout the day of the inspection. The kitchen was viewed and there was a range of drinks available. Food such as cereals, sauces and canned goods were branded varieties. Resident’s specific dietary requirements were identified in their care plans. The District Nurse spoken with said that they provided support to residents with diabetes and that staff asked questions about the best support they could provide to the residents. The resident survey asked if they liked the meals at the home. Ten answered always, two answered usually, three answered sometimes and comments included ‘excellent’ and ‘food good’. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 21 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that their complaints are listened to and acted upon and that they are protected from abuse. EVIDENCE: The home had a complaints procedure, which included CSCI (Commission for Social Care Inspection) contact details. The complaints procedure was provided to prospective residents, in the Service User’s Guide and was displayed in the entrance hall to the home. Residents and a resident’s family member spoken with said that they knew how to make a complaint if they were unhappy about anything in the home. Staff spoken with were aware of how they could support resident or visitors to the home if they wished to make a complaint. A range of ‘thank you’ letters and cards were viewed. They had been sent to the home by resident’s family members, thanking the home for the support they had provided. The homes complaints records were viewed and clearly identified any complaints received, actions taken and how they had remedied the situations. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 22 A recommendation from the previous inspection was that the home maintain central records of concerns, which were not formal complaints. This had been actioned and there was a book which identified any concerns or requests made by residents and visitors to the home and actions taken. Twelve resident surveys and four relative/visitor surveys said that they knew how to make a complaint. Twelve staff surveys said that they knew what to do if a resident or relative had concerns about the service. Records of complaints made by the manager regarding the health care support provided by other professionals to residents were viewed. The records evidenced that the manager sought to act in the best interest of residents if they were not receiving the standards of support they should do. Staff spoken with confirmed that they had received POVA (Protection of Vulnerable Adults) training and were aware of the procedure for reporting and recording any concerns or allegations of abuse. The home had clear POVA procedures. The training schedule viewed evidenced that all staff were provided with POVA training. The AQAA stated that POVA training was mandatory and that all staff were provided with it. It stated that the home had recently purchased a new shredding machine, which enabled the home to protect residents from ‘identity theft’. The manager said that the home did not restrain residents and that their admission criteria to the home included that they did not offer placements to those who display behaviours which warranted restraint. The AQAA listed the homes procedures, which had been updated March 2007 and included aggression toward staff, bullying, concerns and complaints, dealing with violence and aggression, whistle blowing, gifts to staff, management of service users money, valuables and financial affairs, missing service users, physical intervention and restraint and POVA. A record, where staff had signed and dated that they had read the procedures were viewed. There were records where staff had signed that they had read the updated versions of the procedures. Twelve staff surveys said that they knew about the procedure for safeguarding adults, which was sometimes called POVA (protection of vulnerable adults). Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 23 Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 24 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that they live in a safe, hygienic and well maintained environment. EVIDENCE: The home was clean, well maintained and homely. There had been efforts made to ensure that the home was homely which included paintings on the walls and flowers in the communal areas. There had been some decoration in the home, which included new carpets, redecoration in some bedrooms and lounges. The ground floor lounge had new furniture. The exterior of the home had been painted. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 25 There was a programme of redecoration and there were plans to the building showing areas that were to be refurbished displayed in the notice board in the entrance hall to the home. The manager discussed how bedrooms were being decorated and residents were provided with the choice of how they wished their bedrooms to be redecorated. All rooms were decorated when they were vacated. During the last inspection there were plans to replace the ‘sliding’ type of bedroom doors to fire doors. It was noted that this work had been undertaken during a tour of the building. The doors were fitted with a self closing device. Areas in the back garden were being made into a sensory garden. There were areas in the garden where residents could sit and there was a summer house, which residents were sitting in during the inspection. The front garden area had been landscaped. There was a large dining area, where residents were observed to be enjoying their lunch during the inspection. The manager said that this area would be redecorated. There were several lounges, which residents could choose to use. The AQAA stated that one lounge was adapted to a quiet room, where those with sensory loss could watch television or listen to the radio without distraction. This had been actioned following a resident’s suggestion during a residents meeting. The home was accessible to wheel chair users. The special needs unit had pictures of, for example a toilet and a bathroom outside the rooms to show the residents where the toilets and bathrooms were. There were pictures of food, such as fruit and vegetables on the hall walls leading to the dining area, which showed residents where they could eat their food. Bedrooms viewed were clean and well maintained. Each bedroom had the resident’s personal memorabilia in them and reflected their choice and personality. There was a lockable cupboard in each room where residents could store items in if they wished to. During a tour of the building it was noted that the home was well ventilated and lighting was sufficient to meet the needs of residents. Radiators had safety covers, which fitted with the décor of the home. Records of regular water temperature checks were viewed. The laundry was viewed and it was clean and tidy. There was hand washing facilities provided in the laundry. Washing machines provided adequate programmes to ensure that soiled laundry was laundered appropriately. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 26 There were no unpleasant odours in the home during the inspection. Fifteen resident surveys said that the home was always fresh and clean. The home had procedures regarding infection control and clinical waste. Staff spoken with said that they were aware of infection control and had received training. The training schedules and individual staff records viewed evidenced that staff were provided with infection control training. The AQAA stated that infection control training is provided to enhance the awareness of the importance of prevention. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 27 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can expect that the numbers and skill mix of staff meet their needs, and that staff are trained and competent to do their jobs. They can expect that they are protected by the home’s recruitment procedures. EVIDENCE: The staffing rota was viewed and showed that there were care staff on duty twenty four hours each day, with domestic and catering staff providing support. Staff spoken with said that there was sufficient staff on duty at all times and said that if there were instances of sickness, the shift would be covered straight away. The manager said that the home was fully staffed apart from a senior carer role and a domestic assistant, which was being covered by relief staff at the time of the inspection. The manager said that the posts had been advertised in the local press, along with an advert for relief staff. Discussions with the manager and records viewed clearly evidence that the manager was committed to the training and development of the staff working Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 28 at the home. The manager explained that care staff were provided the opportunity to ‘act up’ in a senior role for a period of time. The staff were provided with in house training and assisted them in their career and personal development. A staff member spoken with confirmed that they were acting up in a senior position and were enjoying the increased responsibilities. A staff member said that the manager had asked them if they wished to take part in acting up, they said that they did not feel that they were confident enough, but may reconsider at a later time. It was noted that there were good level of staff qualification. The home had exceeded the target of 50 staff to have achieved a minimum of NVQ level 2 by 2005. The AQAA stated that 75 had achieved their awards. The manager said that only four care staff had not yet achieved their award. They said that staff were also offered the opportunity to undertake the NVQ level 3. Staff spoken with confirmed that they had undertaken an NVQ level 3 when they had completed their level 2 awards. The deputy manager had recently achieved an NVQ level 4 combination care and management Registered Manager award. Staff said that they were given opportunities to participate in training and development activities and listed training which they had attended, which included POVA, first aid, infection control, manual handling, fire safety, dementia and safe handling of medication. They had received training on how to work with residents who may be aggressive in the POVA training. Training records viewed confirmed that the staff team were provided with a good training programme. Staff were also provided with literacy training. The staff survey asked if they were given training which is a) relevant to their role, twelve answered yes. b) helps them to understand and meet the individual needs of residents, nine answered yes, two answered no and one did not answer. c) keeps them up to date with new ways of working, nine answered yes, two answered sometimes and one did not answer. New staff were provided with Skills for Care (formerly TOPSS) induction. During the previous inspection standard 30 was exceeded. The manager said that if newly recruited staff had a minimum of two years care experience they would be provided with the opportunity to work towards their NVQ award upon commencement of their role, rather than the Skills for Care induction. The staff survey asked if the induction covered everything they needed to know when they started. Eight answered yes and four answered mostly. Three staff recruitment records were viewed and included the required information, including two written references, evidence of CRB (Criminal Records Bureau) checks, application form, identification and a photograph. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 29 Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 30 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect that the home is managed by a person who is fit to be in charge, that the home is run in their best interests, that their financial interests are safeguarded and that their health, safety and welfare is promoted and protected. They can expect staff are appropriately supervised. EVIDENCE: The manager had been successful in the registered manager application process. The manager and the deputy manager had achieved NVQ level 4 registered manager awards, which was a combination of care and management. The manager said that they had recently attended Mental Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 31 Capacity Act training and explained how they would incorporate information into the running of the home. The AQAA stated that the manager had an open style of communication and held regular meetings with residents and staff. A comment in a staff survey was ‘manager is approachable, caring to residents and staff and fair’. The manager was receptive to the inspection process and was keen to discuss methods of continually improving the care provided to residents and how to develop the staff team. There were regular quality assurance satisfaction questionnaires undertaken by staff, residents and professionals. The results of the questionnaires were displayed on a notice board in the entrance hall of the home. The results were provided, and were viewed, in the information pack, which was provided to prospective residents. The manager said that the results of the questionnaires were used in the monitoring of quality of the home’s care provision. The Regulation 26 visit reports were viewed and evidenced that the visits were undertaken on a regular basis and areas for improvement were identified and actioned. The AQAA stated that the company’s senior management team regularly audited the home and company management team meetings were held. The management at the home were working on resident’s care plan audits, the documentation which evidenced this was viewed. The manager said that they would be audited on a regular basis to check that they were all up to date and provided the information which should be provided. Residents, who wished for their personal allowances to be kept in a secure place in the home, were provided with the facility. The records of their personal allowances were viewed. The staff member responsible for the safekeeping of the finances explained the procedure. There were clear records maintained which showed all transactions of money and receipts for spending could be clearly cross referenced into the records. During a tour of the building it was noted that residents had a lockable cupboard in their bedroom, in which they could store items if they wished to. Staff spoken with confirmed that they were provided with regular one to one supervision meetings, which were recorded. They said that they felt that they were supported in their work role. The supervision schedule was viewed and evidenced that each staff member were provided with regular supervision. Staff records viewed included supervision notes and records of an annual performance review. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 32 The staff survey asked if the manager gave enough support and met with them to discuss how they were working. Eight answered yes and four answered sometimes. The kitchen was viewed and it was noted that it looked clean. All foodstuffs which had been opened were labelled for the opening and use by dates. The records for water, fridge and freezer temperature checks were viewed. There were risk assessments regarding cleaning and food preparation stored in the kitchen. They identified possible risks and ways of minimising the risks. Kitchen staff were viewed to wear clean aprons and head wear. The cook confirmed that they had attended food and hygiene training. Accident records were viewed and they were appropriately recorded and reported. The home had a fire risk assessment and fire procedure. There was evidence viewed of regular fire safety checks and evacuation. Health and safety related records were viewed and there was documentary evidence which included maintenance undertaken, electrical appliance testing, bed rail monthly checks, water temperature checks and a monthly maintenance record where items such as the hoists and call bells were checked to be in working order. There were records that evidenced that the hoists were regularly serviced. The homes environmental risk assessments were viewed and included legionella, security of the building and safe surface temperatures. The home had a valid certificate of liability. Staff training records evidenced that staff were provided with health and safety related training such as manual handling, fire safety and infection control. There were detailed policies and procedures which identified how the health and safety of the home and resident’s was promoted and protected and included emergencies and crises, moving and handling and infection control. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 33 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 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 34 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations It is recommended that the template document for preadmission assessments include a space for the date of the assessment and the name of the person completing the assessment. Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 35 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beech House DS0000029245.V345284.R01.S.doc Version 5.2 Page 36 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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