Inspection on 21/05/07 for Beech Tree House

This inspection was carried out on 21st May 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 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 Tree House 29/06/06

Beech Tree House 25/10/05

Beech Tree House 12/07/05

Beech Tree House 20/01/05

Beech Tree House 02/09/04

Beech Tree House 24/02/04

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

CARE HOMES FOR OLDER PEOPLE Beech Tree House 240 Boothferry Road Goole East Riding Of Yorks DN14 6AJ Lead Inspector Mr M. A. Tomlinson Unannounced Inspection 21st May 2007 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 Tree House DS0000019646.V335554.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 Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Tree House Address 240 Boothferry Road Goole East Riding Of Yorks DN14 6AJ 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) 01405 720044 01405 763824 beechtree.house@fshc.co.uk None provided County Healthcare Ltd, a wholly owned subsidiary of Four Seasons Health Care Ltd Mrs Margaret Roe Care Home 31 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (31), of places Physical disability (1) Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Category (PD) applies to one named service user. Date of last inspection 11th January 2007 Brief Description of the Service: Beech Tree House is registered to provide residential personal and social care to 31 people over 65 years of age, some of whom may have dementia. Nursing care is not provided except through the Community Nursing Services. The home is a large detached house set in its own grounds not far from Goole town centre and with good access to the town’s services and amenities including the public transport network. Accommodation is provided in a range of single and shared rooms some of which have en suite facilities. There is a lift to provide access between the floors and large well maintained gardens and outdoor areas for the residents to enjoy. There is private parking for several vehicles. The fees range from £315-£420. Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit formed an integral part of the annual ‘key inspection’ process for Beech Tree House undertaken by the Commission for Social Care Inspection (CSCI). Information contained in this report was obtained through discussions with the home’s manager, who had been registered with the CSCI since the previous inspection visit, the staff on duty at the time of the visit, several service users and the relatives of four of the service users. A discussion was also held with a District Nurse who was visiting clients at the home. Reliance was also placed on observation of the staff and the support provided for the service users. The report incorporates information provided by the manager in the pre-inspection questionnaire and survey comment forms completed by visitors to the home. Six of the home’s staff also submitted survey comment forms. In addition, the report includes relevant information obtained by the CSCI prior to, and subsequent to, the inspection visit. A number of statutory records kept by the home were also examined and a partial inspection of the premises carried out. Feedback was provided for the registered manager on the completion of the inspection visit. What the service does well: Beech Tree House presents as an informal and friendly environment that provides the residents with a homely and pleasant place in which to live. It is evident that the staff have established an open but professional relationship with the residents and their families and in doing so have enabled the residents and their relatives to voice and discuss any problems or concerns they may have. Good standards of recording and record keeping ensures that issues relating to the welfare and safety of the residents are fully documented and provides confirmation that their needs have been identified and met. The process of recording is also an integral part of the lines of communication within the home. The home continues to provide the residents with good standards of meals that are varied and nutritious. A sound quality assurance process and associated action plan ensures that any weaknesses in the service will be quickly identified and improved. Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? Since the registered manager had taken up her post at Beech Tree House she had made a considerable number of changes considered to be beneficial for the residents. Amongst the most important of these were: • The employment of an Activity Organiser who has consequently provided the residents with a greater range of social activities leading to improved levels of stimulation. This improvement in the staffing level has also provided the care staff with the opportunity to spend more time with the residents on one-to-one basis. Greater involvement of the staff, particularly the residents’ Key Workers, in the development of the residents’ care plans. This has provided the staff with increased responsibility and accountability for the standard of care provided for the residents. A more detailed admission process thereby enabling the manager to make a more considered decision as to whether the home was capable of meeting a prospective resident’s assessed needs. The introduction of cleaning staff at weekends thereby ensuring that the required standard of cleanliness is maintained in the home over this period. Improved staff support particularly through formal supervision and encouragement to undertake training courses. The Requirements made during the previous key inspection visit had been addressed. • • • • • What they could do better: The home needs to continue to look at ways of providing social stimulation and emotional support for the residents. This should, if possible, include more contact with the local community, including trips out. In order to further improve and promote the residents’ right to privacy and dignity, consideration should be given to increasing the number of rooms with en-suite facilities, particularly a toilet. The care staff should be further encouraged to undertake a National Vocational Qualification to further their knowledge and to provide the home with greater professional credibility. Beech Tree House DS0000019646.V335554.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 Tree House DS0000019646.V335554.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 Tree House DS0000019646.V335554.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): 2, 3 and 6 Prospective residents are provided with a comprehensive pre-admission assessment that enables the registered manager to make a considered decision as to whether the home can meet the needs of the resident concerned. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care records of the three most recently admitted residents were examined. They contained evidence that these residents had been fully assessed by the registered manager or her deputy prior to the residents being admitted into the home. The assessments undertaken by the home were in addition and supplementary to any assessment provided by placing authority. Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 10 The assessments were comprehensive and provided sufficient information in order for the registered manager to decide whether the home could meet the prospective residents’ needs. The manager also provided documented evidence that a Care Management Assessment had been obtained for a resident who had been admitted on an emergency basis. The assessment records had been revised and updated by Four Seasons Health Care Limited and a new admission record had recently been introduced. Following a decision to admit a prospective resident they were sent a letter of welcome which was written in user friendly terms. This letter did not, however, clearly state that the home was able to meet the needs of the resident concerned. Some of the residents had been admitted on a permanent basis following a period of day-care. The care records examined contained copies of the terms and conditions of residence issued to, and agreed by, the residents. The conditions of residence clearly indicated the room to be occupied. The residents presented as having a range of needs including the early stages of dementia. One resident had been assessed as having specific mental health needs and the services of a Community Mental Health Nurse had been obtained. From discussions with the registered manager and the staff, it was evident that the staff had the skills and knowledge to meet the residents’ diverse range of needs. Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 11 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 and 10 The use of comprehensive and detailed care plans provided the staff with good standards of information by which they could meet the needs of the residents. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care records examined contained the care plan of the respective resident. The residents’ needs and abilities were clearly identified in the care plans along with the actions to be taken by the staff in order to meet those needs. The care plans were reasonably holistic insofar as they addressed the residents’ physical, emotional and social needs. The care plans were broken down into elements of care with short/medium term goals linked to each element. The residents’ social needs had been assessed by their Key Worker following the resident’s admission into the home. By this approach the registered manager Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 12 had endeavoured to gain greater involvement of the care staff and obtain a more accurate picture of the resident. It was apparent that the care plans had been regularly reviewed. This had been undertaken monthly by the care staff (Key Workers) and annually by the placing authority. Some of the reviews were, however, slightly overdue. The relatives of the residents spoken to confirmed that they had been invited to attend these reviews. Some of the care plans had been signed in agreement by the resident or their representative. The manager stated that the direct involvement of the residents was difficult as many were not interested in their care plans. A member of the care staff stated in the questionnaire, ‘There is ample input from the residents as we cannot complete a care plan without some input from them’. In addition to the admission record the care plans were also in the process of being reviewed and amended to be more ‘person centred’. In addition to the basic care plan, which had been regularly audited by the registered manager, the care records also contained a range of risk assessments on the respective resident in order to minimise the possibility of a resident’s safety being compromised. These risk assessments had been regularly reviewed and updated. A photograph in the residents’ bedrooms identified the residents’ Key Worker. Those residents spoken to were aware of the name of their Key Worker, understood their role and commended the respective member of staff’s attitude and support. The care records contained recorded evidence when the residents had a bath or shower in order to monitor their personal hygiene standards. Where a resident had refused a bath this had also been recorded. In two cases, however, there were extensive periods of time (e.g. three weeks) between recorded baths. There was no explanation recorded for this. The registered manager could only assume that it was a recording error although she was also of the view that ‘if it was not recorded then it was not done’. She was intending to speak with the care staff on this issue. It was evident from the records that there was a good level of input from health care professionals. A District Nurse commented, “I have no problems with the home. The staff are cooperative and accommodating. They follow my advice and do not hesitate to get in touch”. The nursing records were readily available in the home. At the time of the inspection visit one resident had a bedsore. The District Nurse was treating this. This particular resident had been provided with appropriate equipment to alleviate the bedsore. Advice had also been provided for the staff on the management of incontinence. There was no physical Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 13 evidence of this problem even though the many of the residents were incontinent. The home continued to use a Monitored Dosage System for the administration of the bulk of the residents’ medication. Some medication was, by necessity, retained in their original containers. The records confirmed that the system had been regularly checked by the local pharmacist and audited by the registered manager. The medication in use was secured in a dedicated drugs trolley. This was locked to the wall when not in use. The medical stock was secured in a drugs cupboard. All medication was kept in a locked medication room. Only nominated staff, who had been appropriately trained in the safe handling of medication, had access to it. No controlled drugs were in use at the time of the inspection visit although proper arrangements were in place, including the use of a controlled drugs record and dedicated storage facilities. The medication records were complete and up to date. From the description of the medication administration process provided by the deputy manager it was apparent that it was efficient and safe. With the exception of some creams/ointments and inhalers the residents did not self-administer their medication. The residents had lockable facilities in their rooms in which they could secure their medication. It was evident from discussions with the residents and observation of the staff that the residents were generally treated with respect and spoken to in an appropriate and mature manner. One resident, however, voiced their disquiet at being ‘made’ to join in social activities. They said, “The staff want me to go to the lounge but I don’t always want to. It’s not my choice. I like to be on my own. I’m a private and shy person and I don’t like mixing especially when you can’t have a conversation”. The resident acknowledged that the staff took this approach to encourage them to participate in social activities but felt that it was going against their wishes. Only seven of the twenty-eight bedrooms had en-suite facilities. (See Environment) The residents in the remaining rooms had to use a communal toilet and/or a commode. This had a direct effect on the dignity of those residents who did not have en-suite facilities in their rooms and particularly those who shared a room. Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 14 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 and 15 The residents are provided with a good range of social activities that helps to stimulate them and alleviate boredom. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The records confirmed that there was a programme of social activities. These were primarily group activities but had been tailored to meet the diverse needs of the residents. The programme of social activities had been considerably improved by the employment of a part-time Activity Organiser. This person was available each afternoon during the week. She maintained records of the activities provided and it was evident that these endeavoured to take into account the needs, wishes and abilities of the residents. During the afternoon of the inspection visit the residents were encouraged to play ‘bingo’. This was done with boards with large numbers so that those residents with poor sight were not disadvantaged. This was followed by a group game of dice that Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 15 enabled the more frail residents to participate. Approximately fifteen residents attended the social activity and it was apparent that they enjoyed it. It was noted that staff were available to assist the residents during this activity. The Activity Organiser and care staff also spent time with the residents on a oneto-one basis. There was evidence that external activities had been organised. For example, a holiday had been organised in Skegness for several residents and a number of residents attended a local day centre. A number of the residents’ relatives said that they regularly took the respective resident out. The outcome of the activity programme was that the residents appeared reasonably stimulated. In order to take residents out reliance was placed on the use of taxis and public transport. A number of staff said that external activities would be improved if the home had access to its own transport that was designed to take wheelchair users. Throughout the inspection visit there was a steady stream of visitors coming into the home. The majority were relatives of residents. Those relatives spoken to all commended the service provided by the home and in particular the attitude and support provided by the staff. They all confirmed that were kept well informed as to the wellbeing of the respective resident. The home had two dedicated cooks to cover each day of the week. The cook on duty at the time of the inspection visit demonstrated a good understanding of the dietary needs of older people. She was in the process of taking a National Vocational Qualification at level 3 in Diet and Nutrition. The menus indicated that the meals provided a varied and nutritious diet for the residents. Special diets were catered for. The menus also provided a genuine choice of meal. The residents’ meal preferences were obtained by the care staff at the start of each day. Those residents spoken to confirmed this. They also commended the quality of the meals. It was apparent through observing the lunchtime meal that the catering staff and the care staff worked well together in monitoring the residents’ food intake. The dry store and freezers indicated that the home used good quality foods and that emphasis was placed on the use of fresh vegetables and meat. Fresh fruit was available to the residents in the lounges. The residents confirmed that they were able to wake up naturally and that they could have breakfast between eight and ten each morning. They also stated that they could go to bed when they wished although several retired by choice to their rooms shortly after the evening meal. Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 16 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 and 18 The residents are protected by having access to, and being supported by, sound complaints and adult protection procedures. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had an appropriate complaints procedure in place. Those residents spoken to felt confident that they could discuss any problems or concerns with their Key Worker or the manager. The residents spoken to couldn’t envisage using the formal complaints process. It was apparent that the manager had established an open relationship with the relatives of the residents. Those relatives spoken to expressed confidence that the home’s manager would quickly address any concerns they may have. They also stated that there were no restrictions on visiting the home and that they were always made to feel welcome. During the past year a concern was received by the Commission of Social Care Inspection alleging that the ‘the home smelt’ and that there was no visitors’ record book. The manager had subsequently taken action to ensure that the Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 17 home was free from offensive smells (See Environment) and confirmation was provided that a visitors signing-in book was readily available. The home had an Adult Protection policy and procedure in place. The staff were familiar with this and knew of the action they should take in the event of alleged abuse or a complaint. The staff said that had received training on the subject. This was confirmed in the staff records. The registered manager demonstrated a sound understanding of the process for Safeguarding Adults. Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 18 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, 23, 24, 25 and 26 The residents are provided with a pleasant and homely environment which meets their needs. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The premises were clean, well maintained and furnished to a good standard. The records indicated that several areas had been redecorated since the previous inspection and new carpets fitted in several bedrooms. A relative of a resident confirmed this. The home had the benefit of having several lounges which consequently provided the residents with a choice as to where and with Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 19 whom they chose to spend their time. Those residents spoken to all expressed their satisfaction with the quality of their accommodation. In response to a concern alleging that the home ‘smelt badly’ particularly at weekends, a Random Inspection Visit was carried out by the Commission for Social Care Inspection in February 2007. From discussions with the residents at that time it was established that there was some truth in the allegation. According to the registered manager the primary cause was the lack of weekend cleaning staff due to staff sickness. This has since been resolved and during this inspection visit there were no unpleasant smells anywhere in the home. The residents’ bedrooms inspected were clean, appropriately furnished and decorated to a good standard. The residents confirmed that the high standard of cleanliness was the norm. The home had a Maintenance Person who checked the rooms on a regular basis to ensure that any defects were quickly addressed. This was recorded. A programme was in place for redecorating the residents’ bedrooms. This was undertaken at the convenience, and with the agreement of, the resident concerned. The resident would generally occupy a spare room whilst the redecorating was carried out to ensure that paint fumes did not affect them. It was apparent that the residents had been encouraged to furnish their rooms with their personal belongings which helped remind them of their past lives. There were an adequate numbers of toilets and bathrooms available. The baths had hoists available to assist those residents who had mobility problems. The records confirmed that these had been regularly serviced. In the absence of any dedicated facilities the visiting hairdresser used a ground floor bathroom. The majority of the bedrooms did not have en-suite facilities which consequently meant that the occupants of these rooms had use a communal toilet adjacent to their rooms. The staff had the use of small office in which was kept the residents care records. It provided adequate facilities for the staff to complete reports and hold hand-over meetings between shifts. It was not large enough, however, to be used as a general staff room and consequently the staff generally took their breaks with the residents in the lounge. Staff meetings/training were also held in a residents’ lounge for the same reason. Appropriate infection control procedures were in place. The staff had disposable protective clothing available. The laundry facilities were appropriate and the home had the benefit of a laundry person. The residents expressed their satisfaction with the standard of the laundry service. The home had good levels of natural and artificial lighting. Procedures were in place to monitor the temperature of the hot water supply to prevent the residents from being scalded. Regular checks were also made to confirm that Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 20 the water was free from Legionella bacteria. These plus the hot water temperature checks were undertaken and recorded by the maintenance person. As far as could be ascertained from discussions with the registered manager and an examination of the records, the home satisfied the specific requirements of the Fire and Environmental Health Departments. Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 21 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 and 30 The residents are supported by a competent and well trained staff team that provides the residents with good standards of personal care. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From an examination of the staff rota it was apparent that the staffing levels exceeded the level recommended by The Staffing Forum. In general there were four care staff on duty during the day plus the registered manager and ancillary staff. The care staff stated, however, there were times when they were stretched particularly if a resident required the assistance of two staff. The amount of time that the residents’ Key Workers could spend with the residents was also dependent upon the level of staffing. The situation had been relieved to an extent by the employment of the activity organiser. It was evident from the information provided by the registered manager that less than 50 of the care staff had achieved a National Vocational Qualification. Several were in the process of taking this qualification. Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 22 Three staff records were examined. These included the most recently employed staff. The records indicated that there was a robust staff selection and recruitment process in place. This included the submission of an application form, a formal interview undertaken by the registered manager and the deputy manager and a full vetting process including a CRB check. In some exceptional cases a member of staff had been employed before the outcome of a CRB check was known. In these cases they had undergone a POVA First check and had been adequately supervised by a Mentor until their CRB check was completed. The staff had been issued with contracts of employment following the successful conclusion of a trial period. A programme of staff training was in place including a comprehensive induction training programme. The records confirmed that the staff had been provided with training in statutory subjects such as health and safety and fire safety. There had been a shortfall in the number of staff who had undergone a first aid course. This was in the process of being rectified with three members of staff having completed a course and six planning to take it within the next few weeks. A number of staff questionnaires were returned to the C.S.C.I. Comments in these, and during discussions with staff, included, “My manager is approachable and easy to talk to”; “ Each resident sees their individual care plan regularly”; “I think that the home is friendly and well managed”; “The staff treat the residents like they would their own families”; “I’ve worked in other homes but this is the friendliest. I get good support from the manager”; “We try and get the residents to as much as possible for themselves. Once they’ve lost their independence then they’ve lost everything” and “We get a lot of training but having to write reports takes up a lot of time which I would prefer to spend with the residents”. Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 23 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, 32, 33, 35, 36 and 38. The home is run in the best interests and for the safety and welfare of the residents. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the previous inspection the manager had been registered with the Commission for Social Care Inspection (CSCI) and had completed the Registered Manager’s Award. She had made a number of changes in the home over the last year including delegating more responsibility to the residents’ Key Workers particularly with regard to reviewing and updating the care plans. She had also endeavoured to get the residents and/or their relatives more involved in the care planning process but with only limited success. Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 24 Importantly she had argued the case for having an Activity Organiser and the home now had one on each afternoon during the week. The registered manager stated that she gets good support from her line manager who also undertakes a least one inspection of the home each month. This was reflected in the Regulation 26 reports provided for the CSCI As previously stated in the report the staff said that they got good support from the manager and that any problem that they take to her would be quickly but discreetly addressed. The staff also confirmed that manager provided them with regular supervision and did not hesitate to advise them if they can improve in any area. It was also evident that the manager provided the relatives of the residents with good support and encouraged them to discuss openly any problems or concerns they may have regarding the service. The home had a comprehensive quality assurance (QA) system in place that incorporated a regular audit of all aspects of the service provided and actively sought the views of the residents and their relatives regarding the quality of the care provided. A ‘remedial action plan’ had been developed from the findings of the QA audits. A number of statutory policies, procedures and records were examined. These were all maintained up to date. The maintenance person had the responsibility for overseeing general health and safety in the home and the maintenance of associated records. The health and safety records were comprehensive being kept in considerable detailed and cross-referenced. It was evident from the records and discussions with the maintenance person that all reasonable steps had been taken to ensure a safe environment for the residents and the staff. Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 25 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 X 3 2 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X 2 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 (1)(d) Requirement As a final part of the admission process the prospective resident must be informed in writing that the home is able to fully meet their needs. Care must be taken by staff to ensure that ‘encouraging’ residents to participate in social activities does not undermine their right to privacy and choice or place them under unacceptable pressure. Sufficient numbers of staff must be trained and qualified in first aid procedures to ensure that there is at least one trained person on each shift. Timescale for action 01/07/07 2 OP10 12 01/07/07 3 OP28 13 01/07/07 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 OP7 Good Practice Recommendations Care should be taken to ensure that the residents’ care DS0000019646.V335554.R01.S.doc Version 5.2 Page 27 Beech Tree House 2. 3. 4. OP8 OP10 OP13 5. 6. RCN OP27 5. OP28 plans are reviewed within the set timescale. Recording of the residents’ personal needs should be accurate, such as when a bath or shower is provided. Consideration should be given to providing basic en-suite facilities, that includes a toilet, for all of the residents. Consideration should be given to providing the home with access to specialised transport so that all residents regardless of disability are able to retain contact with the community in general on a regular basis. It would be beneficial for the staff to have a dedicated staff room/training/meeting room in order to minimise the possibility of staff compromising residents’ confidentiality. The care staffing level during the day should be kept under review to ensure that it continues to remain adequate to meet the physical, emotional and social needs of all the residents. Care staff should be encouraged to achieve a National Vocational Qualification at Level 2 or equivalent. Beech Tree House DS0000019646.V335554.R01.S.doc Version 5.2 Page 28 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. 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