CARE HOMES FOR OLDER PEOPLE
Beechbrook Residential Home The Holt Hare Hatch Wargrave Berkshire RG10 9TA Lead Inspector
Susan Burton Unannounced Inspection 31st January 2006 09:50 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000011400.V273701.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. DS0000011400.V273701.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Beechbrook Residential Home Address The Holt Hare Hatch Wargrave Berkshire RG10 9TA 0118 940 3987 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) Mrs Catherine Seagrim Mr Michael Paul Seagrim Mrs Catherine Seagrim Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places DS0000011400.V273701.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 26th July 2005 Brief Description of the Service: Beechbrook is a privately owned and managed home that is registered to provide care for up to fifteen older people. The service offers a hotel style of holistic care that is planned to enhance quality of life in a dignified and relaxing environment. Accommodation is offered in a two-storey building that was once part of Hare Hatch Grange, a nearby Georgian Mansion. Single rooms and suites of rooms are available. The house is situated in its own attractive private gardens that include a tennis court and swimming pool. The property is located in rural countryside near to Twyford and Henley. There is easy access to the motorway and the property offers ample space for car parking. DS0000011400.V273701.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection on Monday 30th January 2006 which commenced at 09.50 am. The Manager/Proprietor was away on a training day and the deputy manager and administrative assistant assisted the inspection process. The inspection focused on care plans, health & safety, training and recruitment and feedback from residents. The inspector also discussed the potential registration of the Grange Suite a separate suite of rooms located at the rear of the main house, which was occupied by a tenant. What the service does well: What has improved since the last inspection?
The homes refurbishment of its kitchen has been completed and now provides a modern easy to clean working area. The Fire Service has confirmed that the home has met/complied with the Fire Deficiency notice issued earlier in the year.
DS0000011400.V273701.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000011400.V273701.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 DS0000011400.V273701.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): 4 The home should consider registering the suite of rooms known as the Grange Suite to ensure there is no breach of registration arrangements. EVIDENCE: The staff informed the inspector that the suite of rooms/flat at the rear of the house was occupied by a tenant. This flat is not registered with CSCI and therefore should not be providing personal care to any person residing there. Staff were very open and honest and advised the inspector that the tenant came into the home and had meals and shared the facilities and was assisted when taking a bath. The inspector took the opportunity to meet the tenant to clarify the service arrangements. The tenant was happy to discuss how well the service provided to her was working. The home should review its arrangements and consider applying for a variation to add the Grange to its registration. This would ensure that there are no breaches to the Care Standards Act. DS0000011400.V273701.R01.S.doc Version 5.1 Page 9 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): 7,8,9 Care plans set out in a matrix style format the assessment by staff of an individuals needs. This format does not allow for full detailed information about an individual. Care plans provide information on each residents health care needs. The homes of medication policies and procedures protect the residents; those that self medicate are risk assessed. EVIDENCE: The home has a tick box style format to its care plans which staff use to assess an individuals needs. This format does not allow a full and detailed record of each residents individual and specific care needs; the deputy manager of the home was in agreement and had already been considering improving the format prior to this inspection. The home is recommended to review the format to ensure that staff are able to record pertinent and relevant information about each individual. On those care plans examined evidence was seen of a signature by the resident to confirm that consultation had taken place, which is good practice.
DS0000011400.V273701.R01.S.doc Version 5.1 Page 10 Care plans evidenced information about the individuals health care needs but with limited detail and as stated above could be improved by a slightly better format. The homes medication policy and good practice guidelines were examined and found to be appropriate. Medication training had taken place for staff. The home encourages those residents where able, to continue to self medicate, and appropriate risk assessments and details were seen on individual care plans. The homes drug cupboard was examined and found to be well organised and tidy. Medication charts evidenced appropriate signatures with no gaps. DS0000011400.V273701.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): None of these standards were inspected on this occasion. EVIDENCE: DS0000011400.V273701.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 homes complaints log had not recorded any concerns since the last inspection. Residents pass on any concerns to the manager and staff and evidence was seen of homes responses. The homes adult protection policies and procedures were seen as appropriate. EVIDENCE: The homes complaints log as previously stated had recorded no concerns or complaints. The inspector discussed with the deputy manager the ways in which residents are able to comment on pass on their concerns. Feedback is positively encouraged (see standard 33). Evidence was seen of the minutes of the last residents meeting where comments had been recorded from a number of residents with the responses from the home, these were seen as appropriate and satisfactory. The home had a copy of the local into agency guidelines for the protection of vulnerable adults, a copy of the Department of Health CRB and POVA guidance and also an appropriate adult protection policy, which had recently been reviewed. The home has a whistle blowing policy for staff. DS0000011400.V273701.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 A recommendation from the previous inspection that the home confirmed in writing to CSCI that it had met the fire authorities deficiency notice had been acted upon and a letter from the fire authority confirmed that no further action would be taken. The refurbishment of the homes kitchen had been completed. The flat at the rear of the home known as the Grange suite is not registered with CSCI to provide personal care. The inspector was able to visit the suite and see the environment and how it is used. EVIDENCE: CSCI had received a letter from the fire service stating that they were satisfied that the home now met the deficiency notice and that no further visits would be made.
DS0000011400.V273701.R01.S.doc Version 5.1 Page 14 The inspector visited the homes kitchen and was pleased to see that the refurbishment programme had been completed. The kitchen now provided staff with an easy to clean and hygienic working area. The kitchen was seen to be very clean and tidy. A visit from an Environmental Health Officer had taken place in November of 2005 and no follow-up visits had been required, minor issues for the home to attend to had been recommended. The inspector asked the tenant of the Grange suite if it would be possible to meet with her and see her accommodation in regard to potentially registering suite with CSCI. The suite is on the first floor and a stair lift had been fitted to enable the tenant to reach her rooms. A nurse call system had been fitted and the tenant assured the inspector that it always worked whenever shed used it. The suite has a small self-contained lounge area with a small step down. The ceiling has sloping roofs with two dormer windows. The lounge was seen to be comfortable, light and airy. A small landing provides access to a bedroom and small bathroom again which have sloping roofs, the bedroom was seen to be of a reasonable size (exact measurements are not taken) but the bathroom was quite small and very limited in height and width. A full-sized bath, sink and toilet are provided for the tenant and staff advised the inspector that the room would not take a hoist. The proprietor and staff were currently assessing what equipment would be most suitable for this room. The home if it wishes to register this room needs to consider how equipment and resources can be provided to meet the needs of any person using the suite. DS0000011400.V273701.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): 27,28,29,30 Despite staff sickness on the day of inspection, sufficient staff were on duty to meet the needs of the residents. The home had been making significant progress to ensure that 50 of its staff had achieved NVQ 2 or above, the standard remains unmet. The homes recruitment practices were not seen as satisfactory. The home enables staff to access a range of training courses provided in the local community. The home should review provision to ensure that basic mandatory training is accessed. EVIDENCE: The inspector examined the shift rotas and found that four staff were on duty. The deputy manager advised the inspector that some changes had been made due to staff sickness but this had not resulted in a reduction in service. The inspector observed three staff on duty attending to the needs of the residents; this did not appear to cause any great disruption or any reduction in the service. The manager of the home was on a training day and the deputy manager had been able to make effective arrangements for staff cover. The homes administrator provided the inspector with the training log and explained the difficulty the home had had with an organisation that had
DS0000011400.V273701.R01.S.doc Version 5.1 Page 16 facilitated its NVQ training. The home has six members of staff who have completed NVQ training but had not been provided with verification or certification of achieving the qualification. The inspector was able to see evidence of letters sent to the organisation from the home requesting certificates to be sent, unfortunately the organisation had not complied and therefore evidence to support the standard being met was not available and remains outstanding. The inspector examined the recruitment files of the last employee taken on by the home. The file evidenced next of kin details and induction training, CRB and POVA check, but no written references or career history/CV. Evidence was seen on file from the homes administrator requesting references. Full and satisfactory information is required by regulation and schedule and is to be obtained prior to the commencement of employment. The home is required to obtain this information for each employee and for it to be available for inspection. The home has accessed training within the local community over the last two years for its staff, which included first aid, death and dying, and medication training. The home should ensure that the basic mandatory training such as manual handling and fire training is provided and updated on a regular basis. DS0000011400.V273701.R01.S.doc Version 5.1 Page 17 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): 33,35,38 The home appears to be run in the best interests of the residents. Financial arrangements are managed by the residents or their families. The health, safety and welfare of residents and staff are generally promoted and protected by the homes health and safety arrangements. EVIDENCE: The inspector was able to see evidence that residents can and do provide feedback to the home from the minutes of last residents meeting in November 2005. The manager or deputy sends out a flyer to each individual resident with a suggested agenda for the residents meeting and also requests items from the residents to be included on the agenda or any issues for discussion. The inspector was able to see a number of the fliers that had been returned by
DS0000011400.V273701.R01.S.doc Version 5.1 Page 18 the residents, there were some minor issues recorded such as the postal arrangements, noisy chairs and a request for an improved selection of cheese biscuits. A quality assurance survey had been undertaken in May 2005, comments from residents included that staff treat residents well, we are treated with respect, I am made to feel welcome, staff are lovely and other comments such as how much residents appreciate the grounds, gardens and general homeliness of the care home. The homes administrator advised the inspector that the home does not handle any of the residents finances. Each individual resident or family member/representative is invoiced directly from the hairdresser, chiropodist or physiotherapist and will pay by cheque for the service received. The home has a separate fire safety file which included a detailed fire risk assessment, evidence of weekly tests and drills, evacuation procedures and when the fire system had been tested by an outside contractor. The health and safety policy included risk assessments, COSHH procedures, and a health and safety policy on stress, kitchen hazard analysis procedures and food safety. The home has service contracts in place for pest management, the maintenance of hoists, waste, gas servicing and maintenance and lift maintenance. An outside contractor comes in to do PAT testing on the homes electrical equipment. There was no evidence that Legionella testing had been undertaken which is recommended. DS0000011400.V273701.R01.S.doc Version 5.1 Page 19 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 X X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 DS0000011400.V273701.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP4 Regulation 16 & 23 Requirement The Registered Person reviews the arrangements of the Grange Suite and considers its registration to ensure no breaches to regulations. The Registered Person ensures that full and satisfactory information is available on file as required by regulation for each employee, which is to be available for inspection. Timescale for action 30/04/06 2 OP29 17 (2) 19 30/03/06 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 2 3 Refer to Standard OP7 OP30 OP38 Good Practice Recommendations The home should review the format that it uses for care planning to ensure that all individual care needs are fully documented. Training provision is to be reviewed to ensure that manual handling and fire training is provided and updated on a regular basis. The home is to take advice on testing its water systems
DS0000011400.V273701.R01.S.doc Version 5.1 Page 21 for Legionella. DS0000011400.V273701.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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