Inspection on 15/03/07 for Beech Lawn Care Home

This inspection was carried out on 15th March 2007.

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 13/03/06

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 15th March 2007 09:00 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.V333391.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 Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 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) Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th March 2006 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. The fees charged by the home were stated by the manager during the visit to range from £332.50 to £347.50. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was carried out on an unannounced basis. Some of the premises were looked at, residents were able to be spoken with, some of the records were looked at and the manager and some staff were spoken with. The registered manager of the home has now left her position and management of the home is been overseen by Melanie Ward, who intends to submit an application for registration to the Commission for Social Care Inspection in the near future. All of the accumulated evidence has been used to say how well the home is doing. What the service does well: What has improved since the last inspection? The number of care staff with a formal qualification has increased. This helps them to understand how to meet the needs of residents. Some work has been carried out to improve the toileting provision in the home. Some work has been carried out to the room, which is used for hairdressing provision to the residents. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 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.V333391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the home is made available to prospective residents and their families. An assessment is carried out and the manager confirms that needs can be met. A statement of terms particular to each resident is required to enhance the formal contract. EVIDENCE: A statement of purpose is available which meets with the requirement of the schedule. It contains information on the premises, staffing and procedures in use etc. The information relating to the registered manager of the home requires amendment as she has now left the post. A service user guide is available which contains details of present residents thoughts on the care they receive. Local authority contracts and any 3rd party agreements were seen on the files of individual residents which were looked at. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 9 Previously resident’s files have held a statement of terms and conditions, which included details of which room was to be occupied, the fees to be paid and appropriate contact details. There were no statements seen on the files viewed. A statement needs to be available for all residents of the home. The manager explained that she had visited prospective residents either at their home or in hospital to assess if the home could meet their needs. Following this assessment she said that she telephoned the resident and/or relatives to confirm that the home would be able to offer a place. Prospective service users and their relatives are able to visit the home and talk to staff and residents prior to any placement taking place. The home does not provide intermediate care and will avoid emergency placements wherever possible. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health needs of residents are identified and met. Residents are treat in as dignified manner. Personal needs of residents are known and addressed. EVIDENCE: Two residents files were looked at, a plan of care was available on each. Information relating to a resident’s healthcare, personal, and social needs was available in these plans. Some evidence was available of theses plans been updated regularly, the manager explained that once information was stored electronically the plans would be updated on a monthly basis. Staff members have a good knowledge of the needs of individual residents Healthcare needs continue to be met in a proactive manner, discussions were observed during the visit evidenced the proactive nature of staff in ensuring residents accessed the health provision they required. Risk assessments are held on resident’s files relating to falls, infection and disorientation. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 11 The medication system used in the home is the Nomad monitored dosage system. Only the manager and the three seniors administer medication and they have all attended some training. The manager explained that they are all to attend some further training shortly. Assistance is available from a pharmacy should any concerns be apparent in regard to a residents medication. The storage system was seen to be secure, and when medication was checked against recordings made it was found to a robust system. Medication is receipted into the home and any medication returned to the pharmacy is receipted. Observation of staff interaction with residents demonstrated that they treat residents with dignity and spoke to them in an appropriate manner. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities and stimulation meets the needs of residents. Contact with families and friends is encouraged. Residents can make choices on a daily basis. EVIDENCE: A range of activities continue to be undertaken in the home, music and singing continues to be popular. Planned activities include visiting entertainers, clothes parties, and a slide presentation by a visitor on the subject of how people lived in days gone by. Residents are able to choose how to spend their day and can opt in or out of any activity should they so wish. Many of the residents receive visits from friends and family. They are able to meet in private should this be required. A resident had just concluded a meeting with his social worker during the visit. One gentleman enjoyed showing me his photo album of himself, friends and family members. Another resident was intent on going out for a walk, so staff members accompanied him and then a vehicle was sent to fetch them back when he had walked far enough. Life histories of residents were held on individual files. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 13 The manager said that she was in the process of considering the setting up some resident and relative committees to ensure that everyone had a voice in how they home was been run. It is also planned to produce a newsletter containing details of events, which have taken place in the home. A previously planned residents shop does not appear to have come to fruition, however the manager said that this was something she planned to look at. A menu is available of planned meals, although alternatives can be offered if required. The cook is aware of the individual needs in regard to nutritional for some of the residents. Residents spoken with were complimentary of the food provided. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 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. 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. Information is available for staff in relation to the protection of residents from abuse. A complaints procedure is available for residents or their advocates to access. 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. Any niggles or minor issues, which are raised, are generally dealt with there and then negating the need for use of the formal complaints procedure. 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 and Pova training is undertaken as part of staff members induction training. Further training is planned to be cascaded via staff supervision sessions shortly. A whistle blowing policy is available. All staff members undertake a Criminal Records Bureau check as part of the recruitment procedures. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 15 Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 23, 24, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a safe, comfortable and clean environment for residents, which is pleasant and homely. Some attention is needed 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. There are ample communal areas fro residents and they are free to choose which area they would like to use during the day. A pleasant and appropriately furnished dining area is available. A routine maintenance programme continues to be undertaken and required maintenance is recorded. A local company visits to undertake minor maintenance on a regular basis. 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 Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 17 provided upon request again following a risk assessment. Records of the assessment following a request for a key must be held, the manager explained that this record was to be part of the electronic system of recording, which was planned to be introduced. A separate room is available for hairdressing in the home. Some improvements have been made to this area by the installation of improved lighting. Further enhancement would be made by the provision of some comfier seating, something requested by residents on a previous visit and a showerhead attachment for hair washing. 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. All of the rooms seen were tidy and clean and each resident’s bedroom was personalised to a high degree. Some of the toilets in the home have recently had the flooring replaced and the manager said that it was planned to redecorate these shortly. Some of the heating radiators in the home remain uncovered, an audit should be undertaken of these to ensure that they are either covered or are of the low surface temperature type. Any which are found to require attention must be addressed. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A robust recruitment procedure is in place. Training plans are available for staff members. EVIDENCE: The manager of the home stated that of the seventeen care staff employed, in the home, ten staff held an NVQ level 2. The three seniors have also just completed level 3 qualifications to add to the level 2’s they hold. Six staff members have recently enrolled on a level 2 course and the manager said that a further staff member planned to enrol shortly. The level of qualifications held mean that 59 of staff are qualified; this exceeds the standard which recommends that at least 50 of staff should hold a qualification. An induction and foundation training package is available which meets with the targets of the training organisation. Each staff member has his or her own individual training plan along with dedicated training days. All staff have recently been supplied with written guidance and worksheets containing quizzes etc in relation to the protection of vulnerable adults. He manager said that all staff would be supplied with some cascaded training during supervision sessions. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 19 Every staff member has now had an individual supervision session with the manager of the home and it is planned to roll out a system where senior staff members undertake further supervision. The manager said she understood the frequency of supervision, which was required. Previous visits to the home have evidenced a robust staff appointment system. The manager stated that no new staff have started employment at the home recently however one person is currently going through the recruitment procedures. She said that a CRB and Pova first check had been carried out as well as the taking of references. The referees had also been spoken to verbally to confirm their identity. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager of the home has experience of other residential facilities however is required to gain formal qualifications and register with the Commission for Social Care Inspection. Health and safety of residents is protected. EVIDENCE: The registered manager has now left the home and Melanie Ward has been in post at the home since December 2006, in the role of manager. She stated that she has enrolled on a NVQ level 4 care course along with the registered managers award. She explained that she presently holds a city & guilds 325(2), an NVQ assessor award D32/33 and a direct training certificate. She has also recently attended a POVA awareness course. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 21 An application for registration as the manager of the home should be submitted to the Commission for Social Care Inspection. The manager has experience of managing other residential establishments. Some staff members stated that they were happy with the management style of the new manager. 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. Notifications as required by regulation 37 have been sent from the home to the Commission for Social Care Inspection as required. Recent notifications received have been comprehensively completed. A local authority run quality development scheme is held by the home. A previous system used to internally audit certain areas is no longer in operation and there is no internal quality assurance programme in place, the manager said that she has identified which systems require setting up so that formal auditing can be undertaken in the home. Records are held as per requirements. Residents are informed that they are able to view any information held on them and some files contain written confirmation that they have been made aware of this. Melanie Ward explained that it was planned for the home to move to electronic recording using specific software for the task. In preparation for this staff would be undertaking training and records held were presently been weeded to ensure no unnecessary information was been held. A supervision system is in place, which enables staff supervision to take place regularly, and the manager explained that it was intended to improve the availability of support for staff. In discussion the manager said that she had identified the areas, which she felt needed attention and that she was in the process of setting up a plan of how these areas could be addressed and progressed. Only limited residents monies are dealt with by the manager and appropriate records are held of these accounts. Health and safety policies are in place and generic risk assessments have previously been carried out. All electrical and fire prevention equipment is serviced under a contract agreement. All staff have carried out some fire training in the last year. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 2 2 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 2 X 2 X 3 3 3 3 Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 23 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. Standard OP33 Regulation 24 Requirement An internal quality auditing system must be in place in the home. Following a request made by a resident to have a key to their room or a lockable provision, the risk assessment and the outcome must be recorded in their individual file. TIMESCALE OF 15/06/06 NOT MET. Timescale for action 15/05/07 2. OP24 12, 23. 15/05/07 3. OP31 9 The manager of the home must 15/06/07 commence a qualification course, which is equivalent to an NVQ level 4 in care and management. Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations The homes management should consider improvements to the room used for hairdressing purposes. The manager of the home must submit an application to be registered with the Commission for Social Care Inspection. A statement of terms and conditions should be available for each resident, which details all areas of the contract. An audit of surface temperatures of all radiators in the home should be carried out to ensure safety for residents. 2. OP31 3. 4. OP2 OP25 Beech Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Lawn Care Home DS0000060407.V333391.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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