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Inspection on 25/10/05 for Beechcliffe Residential Home

Also see our care home review for Beechcliffe Residential Home for more information

This inspection was carried out on 25th October 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The care records are much improved. The new format is very easy to use and was kept up to date. The care plans and assessments reflect the needs of individual service users and highlight any progress or deterioration. The organisation provides excellent training for all the staff. Excellent training facilities are provided on the premises. The training organiser has produced a wide range of information geared at all levels of care staff. The medication system is well organised and the home receives very good support and training from the local pharmacist.The core of the senior staff team has remained stable. This has allowed the home to provide good continuity of care despite some difficulty recruiting care staff.

What has improved since the last inspection?

Terms and conditions of residency have now been provided for all the private fee paying service users. An emergency pull cord has now been provided in the bathroom on the first floor. The staff shortfalls have been improved. The care staff vacancies are being filled. The increased staffing levels have improved the morale of the management and the care staff. The staff induction training records were checked and were up to date. The new staff all had induction and foundation training records.

What the care home could do better:

Recruitment references must be available for all staff. If they cannot be obtained from the referees highlighted on the job application forms, this must be recorded. The manager must continue to complete the Registered Managers Award and NVQ level 4.

CARE HOMES FOR OLDER PEOPLE Beechcliffe Residential Home 16 Park Drive Heaton Bradford West Yorkshire BD9 4DR Lead Inspector Michael Smithson Announced Inspection 25th October 2005 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 Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 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. Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beechcliffe Residential Home Address 16 Park Drive Heaton Bradford West Yorkshire BD9 4DR 01274 487207 01274 497352 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) Mr Jarnail Singh Bassan Mrs Barbara Ann Ingram Care Home 25 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (25) Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for MD is for the named service user only. Date of last inspection 3rd May 2005 Brief Description of the Service: Beechcliffe is a large detached Victorian building standing in its own grounds in the Heaton area of Bradford. The home can now accommodate 24 service users in a mixture of single and double rooms. The home does not provide nursing care. There is good disabled access into the premises and a large garden available for residents. Car parking is available to the front of the building. The home is fairly close to a number of amenities within the local area including shops, public houses and a large park. The home is also well served by local transport. Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of 2 inspections undertaken for this inspection year. The first inspection was unannounced. Copies of the inspection report for this and previous inspections are available either from the home or the CSCI website. The inspection took place over the morning and early afternoon. A poster was displayed informing the service users and visitors about the inspection. Feedback comment cards for service users and visitors were provided and a small number were returned prior to the inspection. The comments cards contained positive information about the home. The inspection focused on the requirements and recommendations outstanding from the last inspection, records, discussions with staff and service users. There were no visitors present during the inspection. The feedback from staff and service users was positive, however a significant number of service users have dementia and found it difficult to express an informed opinion. The service users were well presented and appeared content. The staff morale has improved with the increase in staff recently employed. Many of the staff have benefited from the excellent training provided. It has allowed staff the opportunity to pursue training and give them confidence and greater job satisfaction. What the service does well: The care records are much improved. The new format is very easy to use and was kept up to date. The care plans and assessments reflect the needs of individual service users and highlight any progress or deterioration. The organisation provides excellent training for all the staff. Excellent training facilities are provided on the premises. The training organiser has produced a wide range of information geared at all levels of care staff. The medication system is well organised and the home receives very good support and training from the local pharmacist. Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 6 The core of the senior staff team has remained stable. This has allowed the home to provide good continuity of care despite some difficulty recruiting care staff. What has improved since the last inspection? What they could do better: Recruitment references must be available for all staff. If they cannot be obtained from the referees highlighted on the job application forms, this must be recorded. The manager must continue to complete the Registered Managers Award and NVQ level 4. Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 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. Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 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 Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3. Service users are provided with information to enable them to make an informed choice about the home. The admission procedure is very good and includes introductory visits and an admissions checklist. EVIDENCE: Terms and conditions of residency are provided for service users. The majority are funded by the local authority, however 4 are privately funded. The homes terms and conditions are provided for private fee paying service users. The care records for the last 2 admissions were checked. They included a detailed pre-admission assessment and an admission checklist. The preadmission assessment helps to determine that the placements are appropriate and within the registration categories. Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. The health and personal care needs of service users are well met by the staff at the home. The care records are informative and kept up to date. EVIDENCE: Case tracking was undertaken for 3 service users. The new service user record system provides very good information about service users. The records were well organised and easy to use. The care plans include life histories, assessment of daily living skills and health care assessments. The care plans are regularly updated to accurately reflect any progress or deterioration. The daily reports were very detailed and informative. They often relate to issues identified in the care plans, which is good practice. The health care assessments include, pressure care, manual handling and a falls assessment. A record is kept of service user weight and includes any comments regarding changes in diet and appetite. This is good practice. A medication check was undertaken during the inspection. The medications were maintained in good order and the drug administration records were kept Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 11 up to date. The home was recently inspected by the pharmacist who praised the drug administration system. The pharmacist has provided an information pack for staff and has agreed to provide training sessions. Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12. Beechcliffe provides a good range of activities geared to both individuals and small groups. EVIDENCE: A good range of activities are provided and a record is kept of what activities service users participate in. An activity organiser visits the home each week to undertake craft activities and music and exercise sessions. The care staff spend time chatting to service users and undertaking games, bingo and outings. The home has a mini bus, which can be used for outings, and shopping trips. Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 13 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 and 18. A robust adult protection and complaints policy and procedure ensures that service users are listened to and are protected from abuse. EVIDENCE: The complaints procedure for the home is available for service users and visitors. There have been no complaints recorded since the last inspection. Adult protection training is included in the staff induction package. A detailed adult protection policy and procedure are available and an information file is provided for staff. Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 14 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, 20, 21, 22, 23, 24, 25 and 26. The home provides a safe environment for staff and service users. The refurbishment is still being completed. The refurbished bedrooms have been completed to a good standard. EVIDENCE: The home is in the middle of a refurbishment programme. A number of bedrooms have been refurbished with many of the double rooms now being changed to single en-suites. The standard of the refurbished rooms is very good. New furnishings, bedding and curtains were provided which has greatly improved the facilities offered. The communal areas are maintained to a good standard. The stair protection rails are to be replaced with something more suitable and the stair carpet is due to replaced. The bathrooms were maintained to an adequate standard of hygiene and a variety of lifting equipment is available. The newly refurbished bathroom on Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 15 the first floor requires a threshold between the carpet and the tiled floor. The panel behind the toilet must be replaced. The ground floor bathroom is due for refurbishment. However the provider and the manager are looking at plans for how the immediate area can be improved. The grounds are maintained to a good standard and security systems are available to maintain a safe environment for service users who may wander. Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 16 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, 29 and 30. The staffing levels were adequate to meet the needs of the service users. An excellent level of training has been provided to ensure staff had appropriate skills to meet their needs. EVIDENCE: The staffing levels have improved since the last inspection. This has allowed the manager to undertake a number of improvements to the recording system and general organisation of the home. The recruitment records for 3 staff were checked. One was in order with all the information required available. One had different refences than had been provided on the application form. The manager had difficulties obtaining the original references so alternatives were obtainined. This needs to be reflected in the records. The third file had a lot of the required information missing from the file. The manager felt that the information had been obtained. The manger agreed to investigate where the missing information had gone and bring the file up to date. An excellent training facility is offered by the home. A training co-ordinator is employed to organise the training for all the homes in the group. Detailed induction and foundation training is offered, together with a wide range of both mandatory and specialist training. The training co-ordinator has undertaken a number of courses which allow her to provide much of the training provided and has built up an excellent training information library. Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 17 A number of staff were spoken to during the inspection and 1 member of staff was interviewed in private. The feedback from staff was very positive they showed a very good understanding of the daily routines and the needs of individual service users. The staff felt they had benefited from the training available and felt it gave them the self-confidence to develop their career. Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 36, 37 and 38. The home is very well run and staff are involved in the decision making process. EVIDENCE: The home is well managed by the registered manager; a deputy manager and a team of senior care staff. The registered manager is nearing completion of the Registered Managers Award and NVQ level 4. A staff supervision and appraisal system has been put in place and regular staff meetings are held. The staff appraisal system links with the training provided. Health and safety policies and procedures are provided and the safety checks for the premises are undertaken. The manager is currently in negotiations with a local contractor to complete the water safety checks. Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 19 Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X X 3 3 3 Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 21 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 OP29 Regulation Reg 19 Requirement Timescale for action 01/12/05 2. OP19 Reg 12 (1)(a) Reg 9 (2) 3. OP31 Two written references must be available for each member of staff. The references must be the same as found on the application form. It these cannot be obtained then this must be recorded. A new threshold must be 01/12/05 provided between the carpet and tiled floor in the bathroom on the first floor. The manager must complete 31/12/05 NVQ level 4 within the required timescale. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beechcliffe Residential Home DS0000001227.V262315.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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