Inspection on 13/03/06 for Beech Lawn Care Home

This inspection was carried out on 13th March 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beech Lawn Care Home 15/03/07

Beech Lawn Care Home 14/12/05

Beech Lawn Care Home 18/01/05

Beech Lawn Care Home 28/07/04

Similar services:

Snydale Care Home

Abbey The

Whiteley House

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Beech Lawn Care Home 48 College Street Sutton Hull East Yorkshire HU7 4UP Lead Inspector Malcolm Stannard Unannounced Inspection 13th March 2006 01:30p 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 Lawn Care Home DS0000060407.V287932.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 Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beech Lawn Care Home Address 48 College Street Sutton Hull East Yorkshire HU7 4UP 01482 375165 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) Beech Lawn Care Home Limited Ms Nora Rosina Saxby Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (28), Old age, not falling within any other category (28), Terminally ill over 65 years of age (28) Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 2005 Brief Description of the Service: Beechlawn is a large house set in private gardens; a recent extension has enabled the home to increase the numbers of residents to be able to be cared for to 28. Car parking is available to the front of the home. The home is situated in the village of Sutton, which provides easy access to shops, a post office, churches and health care. Public transport is available close to the home. The home is registered to care for a range of needs. A summary of these is available on page 4 of this report. Beech Lawn Care Home DS0000060407.V287932.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 on an unannounced basis. Some records were viewed, discussion was held with the manager, a number of residents were chatted with and some areas of the premises were viewed. Any key standards not assessed on this occasion were addressed at the last inspection. This report should therefore be read in conjunction with the report produced following the previous inspection. What the service does well: What has improved since the last inspection? What they could do better: The completion of the managers and staff member’s qualifications will help to ensure that the care offered to residents can fully meet their needs. Work is required to be completed to protect hot surfaces of radiators and adjacent pipe work. Recording of decisions taken in regard to lockable provision and door keys been made available to residents must be recorded on their individual files. Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 Page 6 Consideration should be given to upgrading the provision in the room used for hairdressing purposes. 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 Lawn Care Home DS0000060407.V287932.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 Lawn Care Home DS0000060407.V287932.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, 2, 3 & 6. A statement of purpose and resident guide is available to ensure prospective users of the service have information, which enables them to make an informed choice. A comprehensive statement of terms and conditions protects residents. Residents know that the home can meet their needs prior to assessment. EVIDENCE: The homes statement of purpose has now been amended to include details of the homes physical environment; staff qualifications and arrangements for the review of residents care plans. A statement of terms and conditions available for residents includes details of the room, which is to be occupied, details of the fees to be paid and by whom and contact details for the registration authority. An assessment is carried out prior to any admission. This is completed by the manager at the prospective residents home or in hospital. The assessment is Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 Page 9 used in conjunction with any local authority information to ensure that the home can meet the resident’s needs, and contributes to the plan of care. The home does not provide intermediate care and will avoid emergency placements wherever possible. Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 & 8. Plans of care are available for all residents. Health care needs are addressed thoroughly. EVIDENCE: An individual plan of care is available for all residents, this contains all details in relation to a residents healthcare, personal, and social needs. Healthcare professionals contact details can be found on the individual’s files. The plan of care is reviewed on a monthly basis by the responsible staff member. staff members had a good knowledge of each individual, in relation to their families and background. Healthcare needs of the residents are viewed as an important and integral part of life at Beechlawn. Health needs are met in a proactive manner and examples of appropriate appointments been made were available. One resident explained how he was able to regularly visit his wife, who was presently in hospital. A local G.P. was also present during the visit; he had been called to see one of the residents who felt a little unwell. Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 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 the following standard(s): 12 & 15. Residents have choice, diversity and experience good quality in the meals provided. EVIDENCE: The home have, recently, following a comment made at a review, made questionnaires available to all residents. From the results of these an eightweek menu was produced which aimed to satisfy all requests. This was then reduced to a four weekly menu, which includes the majority of resident’s wishes. The manager explained that the cook is extremely aware of healthy options and the specialist diets, which may be required. The manager said that she in conjunction with the cook, carries out a stock requirement check and the necessary supplies are then ordered online. The manager during discussion, stated that serious consideration was been given to alterations to the room used for the weekly hairdressing visits; this had been identified as an area in need of some attention by the hairdresser and residents on a previous visit. A proposed residents shop is to be set up shortly. Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 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 the following standard(s): 16 & 18. The home has a complaints procedure, which meets the needs of residents, and relatives who feel their views are listened to. A vulnerable adults procedure and policy is available and staff are formally supervised and trained in order to protect residents from abuse. EVIDENCE: A complaints procedure is available in the home and this is displayed prominently as well as been made available in information available to residents and relatives etc. A log is held of all complaints received, which contains outcomes of the complaint and a note as to whether the complainant was satisfied with this. The home experiences minimal complaints and the manager explained that any concerns are usually able to be sorted out in the initial stages. There is one outstanding complaint at the present time. Appropriate policies and procedures are available in relation to the protection of vulnerable adults and the local adult protection procedures are also available. Staff members are given guidance on these matters internally via the manager and POVA training is is undertaken as part of staff members induction training. All staff are checked via the Criminal Records Bureau including a POVA 1st check. Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 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 the following standard(s): 19, 24, 25 & 26. The home provides a safe, comfortable and clean environment for residents, which is pleasant and homely. Work is required to ensure protection to residents in regard to heating radiators. EVIDENCE: The home continues to be suitable for it’s stated purpose and provides a safe and well maintained environment. A routine maintenance programme continues to be undertaken and required maintenance is recorded. Service users following an assessment of risk are provided with a key for a lockable provision in their room, which can be used to store medication, money and valuables. All bedroom doors are capable of been locked and keys can be provided upon request again following a risk assessment. The manager said that recording of the actions carried out in relation to each resident has begun. The management of the home must ensure that any request, the risk Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 Page 14 assessment carried out and the subsequent result is recorded in the individuals care plan. The premises are clean, hygienic and well presented. There are no malodours present in the home. Domestic support staff are available to ensure cleanliness in the home is kept to a high standard. Some heating radiators in the home remain uncovered; the manager explained that as the radiators were differing sizes there had been problems with measurements. It is essential that this work be completed as soon as possible as it has now been outstanding for some time. Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 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 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 & 28. Formal qualification training programmes for staff require to be continued. Resident’s needs are met by the numbers and skill mix of staff. EVIDENCE: There are presently 17 care staff employed, of whom just under half hold a qualification which is equivalent to an NVQ level 2 in care, this is just below the required level of 50 of staff to hold such a qualification. The manager explained that further staff members have enrolled on the course and so is confident that the target of 50 will be met soon. She stated that it is proposed that three staff members will move onto a NVQ 34 qualification following the gaining of level 2. The home has a care team of 17 staff and 3 ancillary staff members with a mix of male and female staff. The staff group have a wide range of experience and backgrounds. Observation of staff going about their duties demonstrated that they do so with as smile on their face and are attentive to resident’s individual needs. There are no staff employed in the home under 18 years of age. Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 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 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): 31,32 & 33. The home is led by an experienced manager who is registered with the Commission for Social Care Inspection. Residents are able to make contributions to the running of the home. Quality checks are carried out by the proprietor. EVIDENCE: The manager is experienced in residential care working in the care sector for over 19 years and having been the manager of the home for the last eleven years. The manager has recently completed an NVQ level 4 qualification in management and care; she explained that this was just waiting for verification. There is an open management style in which the views of residents and staff are taken into account. The registered provider conducts visits as required by regulation 26 and copies of the report written following these visits are held in the home with further copies been sent to the Commission for Social Care Inspection. Internal quality checks and audits are also undertaken. Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 Page 17 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 3 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 2 3 STAFFING Standard No Score 27 3 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X X Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? YES 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. 2. Standard OP25 OP28 Regulation 16, 23. 31. Requirement Radiators must be guarded or have low temperature surfaces. 50 of the care staff must be qualified to NVQ level 2 or equivalent. Any request made for a resident to have a lockable provision in their room; the risk assessment and the outcome must be recorded in their individual file. Timescale for action 15/06/06 15/06/06 3. OP24 12, 23. 15/06/06 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 OP12 Good Practice Recommendations The homes management should consider improvements to the room used for hairdressing purposes. Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beech Lawn Care Home DS0000060407.V287932.R01.S.doc Version 5.1 Page 20 - 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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