Inspection on 24/04/06 for Beech Hurst Nursing Home

This inspection was carried out on 24th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Hurst Nursing Home 02/11/05

Beech Hurst Nursing Home 08/06/05

Beech Hurst Nursing Home 08/11/04

Beech Hurst Nursing Home 08/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Beech Hurst Nursing Home Butlers Green Road Haywards Heath West Sussex RH16 4DA Lead Inspector Mrs S Gawley Unannounced Inspection 24th April 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 Hurst Nursing Home DS0000024114.V288899.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 Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beech Hurst Nursing Home Address Butlers Green Road Haywards Heath West Sussex RH16 4DA 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) 01444 412208 01444 412091 manager.burroughs@careuk.com Care UK Community Partnerships Limited Miss Wilhelmina Aletta Ackermann Care Home 60 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24), Mental disorder, excluding learning of places disability or dementia (12), Mental Disorder, excluding learning disability or dementia - over 65 years of age (12), Old age, not falling within any other category (24), Physical disability (4), Physical disability over 65 years of age (4) Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Accommodation is provided in three units each with its own categories of registration. One unit is for up to 24 service users male and female in the category (OP) of whom 4 persons maybe in the category physical disability age 50 years and over Additionally 4 persons maybe in the category physical disability elderly PD(E) One unit is for up to 24 service users male and female in the categories dementia over the age of 45 years (DE) and dementia over the age of 65 Years (DE(E)) One unit is for up to 12 service users male and female in categories mental disorder over the age of 45 years (MD) and mental disorder over the age of 65 years (MD(E)) A maximum of 60 service users male and female may be accommodated 2nd November 2005 2. Date of last inspection Brief Description of the Service: Beech Hurst is a care home providing nursing care and accommodation for up to 60 residents in the categories listed above. The accommodation is laid out in three units to care for the categories of residents separately. The home is located in Haywards Heath a short drive away from shops and other amenities. It consists of a two-storey building with kitchen and laundry facilities. The majority of the homes bedrooms are single and all of the rooms have en-suite facilities. The home has well-maintained and accessible gardens. Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over two days by the lead inspector Mrs S Gawley and a second inspector Mr E McLeod. The information held on file at the commission was reviewed to prepare for the inspection as was previous inspection reports and any requirements. The home, its facilities and documentation within the three units were inspected against the National Minimum Standards, the building was toured and staff, residents and relatives were spoken to. The home on this occasion was found to meet the majority of the national minimum standards. Evidence to support this is cited in the body of the report. What the service does well: What has improved since the last inspection? The home has worked well to meet the requirements from the last inspection. The building is maintained to a good standard, training and supervision are now in place and the kitchen has been inspected by environmental health and has a good standard of hygiene. Residents and relatives speak highly of the home. Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 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 Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 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 the following standard(s): 1, Prospective residents do not have the information they need to make an informed choice about where to live. 3, No resident moves into the home without having had his/her needs assessed and been assured that these will be met. 4, residents and their representatives know that the home they enter will meet their needs. 5, prospective resident service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. EVIDENCE: The Statement of Purpose dated 24.2.06 seen - did not include all information specified in Schedule 1 of the Care Home Regulations 2001. There was not any information on staff qualifications, training, communal accommodation, and residents’ views. The description of services provided does not include service information on the individual units on which prospective residents or relatives could make an informed choice about whether the service was appropriate for them or their relative. Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 9 One relative spoken to however felt she and her relative had received all of the information they required to make a decision about the home and were happy with the admission process Evidence of pre-assessment was seen in the care plans not all of the assessments were totally completed. Care plans inspected showed evidence of pre assessment. Standard 6 does not apply. Documentation needs to be improved but the outcome for residents, from discussion is not adversely affected. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Beech Hurst Nursing Home DS0000024114.V288899.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, The residents health, personal and social care needs are not all set out in an individual plan of care. 8, Residents health care needs are mostly met. 9, Residents, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. 10, Residents feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Resident’s health, personal and social care needs were not all set out in an individual plan of care. In particular the adult mental unit had little evidence of ongoing mental health needs and therapeutic interventions required was seen. This was discussed with the nurse in charge. Social needs were not recorded, this was evident in all of the units with one resident saying she loved to dance but never had the opportunity and another saying she enjoyed music and singing but it was rarely provided. These residents may need to have advocates involved to assess and implement their needs Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 11 The issue of fluid provision and recording has been addressed with evidence of fluid being given, recorded where necessary and the residents stated they were frequently offered drinks. New procedure in place for the assessment of fluid needs on admission. This was tested on the Elderly Frail Unit. All residents and visitors spoken to stated that the home is very welcoming and residents are treated with respect and dignity. Policies and procedures are in place for the safe receipt, storage, administration and disposal of medicines. Medicine Administration Charts inspected were up to date. The disposal of medicines was not however signed for on the AMI unit, the nurse in charge stating that he was informed that this was not necessary since the new system of disposal was introduced. This was discussed with the deputy manager who investigated immediately and confirmed there had been a miscommunication between two staff and this has been rectified. There have been improvements to the provision of most health care needs and the recording of this. Further improvement is need in the provision and recording of mental health and social needs. Medicines are administered safely. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Beech Hurst Nursing Home DS0000024114.V288899.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): 12, Resident find the lifestyle experienced in the home matches expectations and preferences, and satisfies their social, cultural, 13, religious and recreational interests and needs. 13, Residents maintain contact with family/ friends/ representatives and the local community as they wish. 14, Residents are helped to exercise choice and control over their lives. 15, Residents receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: The last inspection report stated that a second activities coordinator was being employed, this has not occurred. There is an activities programme in place but the planned activity for that morning was not occurring in the adult mental health unit. More clarity is required on the activities rota to show time spent on each unit. On the second day of the inspection the activities coordinator was observed doing one to one work with the residents on the EFU. Staff were seen appropriately interacting with and encouraging residents and Residents help where appropriate with day-to-day activities. One resident spoken to stated that she loved dancing but never had the opportunity to do so since admission. This information was not recorded in any of her documentation, neither were Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 13 her remarks that the hospital bed supplied was very hard with its plastic cover and that she would prefer an ordinary divan bed. Another saying she enjoyed music and singing but it was rarely provided. A shared room still occupied by one resident, with limiter capacity to express her opinion, is being decorated despite the misgivings of the maintenance man and nurse in charge. This shows a disregard of her autonomy. The trafalgar project was spoken about by staff, activities coordinator and it is a system of one to one interaction with residents at all interventions rather that general group work. The need to meet individual preferances was discussed with the deputy manager. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Beech Hurst Nursing Home DS0000024114.V288899.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, will 17, 18, Residents and their relatives and friends are confident that their complaints be listened to, taken seriously and acted upon. Resident’s legal rights are protected. Residents are protected from abuse EVIDENCE: There is a complaints procedure in place but it is not included in the Statement of Purpose. It is on display. A separate welcome pack incorporating the Service User Guide does include this information. A visitor spoken to stated that she felt any complaint or concern was dealt with efficiently as did some residents spoken to. Staff in charge on the Emi and AMI units were not able to evidence that staff had had training in Adult protection and could not locate an adult protection policy. The nurse in charge of the EFU stated that all staff attended a threeday update in mandatory training. This includes adult protection. Such a training session was occurring at the time of the inspection (second day). The nurse in charge was also able to provide documentation of this training and a policy. During discussion she demonstrated clearly an understanding of adult protection procedures including, recognition and reporting issues. She also demonstrated knowledge of POVA and the implications for staff. These different responses were discussed with the deputy manager. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 15 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): 19, Residents live in a safe, well-maintained environment. 20, Residents have access to safe and comfortable indoor and outdoor communal facilities. 21, Residents have sufficient and suitable lavatories and washing facilities. 22, Residents have the specialist equipment they require to maximise their independence. 23, Service users’ own rooms suit their needs. 24, Residents live in safe, comfortable bedrooms with their own possessions around them. 25, Residents mostly in safe, comfortable surroundings. 26, the home is clean, pleasant and hygienic EVIDENCE: A programme of maintenance has been ongoing and the home is generally well maintained. Rooms are personalised where possible and residents spoken to stated that they were happy with their surroundings, one resident stated that she would prefer an ordinary bed rather than the hard plastic covered hospital bed that she had. This was discussed with the nurse in charge. The smoking room was somewhat improved and the problems with keeping this room clean Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 16 were discussed with the deputy manager. He stated that he would ensure that it was on the domestic’s rota. The grounds are well maintained and accessible. Room 47 in the EFU was being decorated. This is a shared room and one resident is still accommodated. This was discussed with the maintenance man who stated that he had expressed his displeasure at decorating while resident still accommodated due to paint fumes and had been told to continue. This was discussed with the nurse in charge who also stated that she was not happy and had discussed this with the deputy manager who had asked them to go ahead. She stated that the resident is unable to express an opinion. Suitable aids to lifting and mobility were seen and were observed in use. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 17 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. The numbers and skill mix of staff meets resident’s needs. 28, Residents are in safe hands at all times. 29. Residents are supported and protected by the home’s recruitment policy and practices. 30. Staff are trained and competent to do their jobs. EVIDENCE: The nurse in charge of the adult mental health unit stated that he felt one Registered Nurse and one carer for the twelve residents is insufficient. This he says has been discussed with management. The activities coordinator also stated that she did not feel the hours on offer could fully meet the social needs of these residents. The staffing levels in the elderly mentally frail unit and the elderly physically frail unit were deemed satisfactory by the staff in these units. Recruitment file inspected were complete with the exception of one, which was awaiting the renewal of a work permit. The deputy manager confirmed that supervision was in place although there is discussion on a corporate level as to the best method for recording this. Training records were seen and all staff receive mandatory training in the form of a there day workshop annually. Staff spoken to felt their training needs were met. The majority of staff on the two days of the inspection did not wear name badges this was discussed with the deputy manager. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 18 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): 31. Residents 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. 32. Residents benefit from the ethos, leadership and management approach of the home. 33. The home is run in the best interests of residents. 34. Residents are safeguarded by the accounting and financial procedures of the home. 35. Residents’ financial interests are safeguarded. 36. Staff are appropriately supervised. 37. Residents’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. 38. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 19 The manager, not present for this inspection met all the requirements for registration with the Commission for Social Care Inspection and has worked with the commission in meeting requirements. Bank accounts are not held by the home for residents. Small allowances are held securely and records kept. A deputy has been appointed and he has implemented supervision. Recruitment records and other documentation are mostly up to date. The health, safety and welfare of residents and staff are ensured by the provision of training in moving and handling, fire safety, first aid and food hygiene and infection control. Adult protection training is also undertaken annually. Staffing does not however appear equitable in all three units Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 20 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 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 21 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 OP7 Regulation 15 Requirement Timescale for action 30/06/06 2 OP12 A service user plan of care to be generated from a comprehensive assessment and is drawn up with each service user and provides a basis for the care to be delivered. 16(20(m)( The routines of daily living and 30/06/06 n) activities made available are flexible and varied to suit service users’ expectations, preferences and capacities. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beech Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Hurst Nursing Home DS0000024114.V288899.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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