CARE HOMES FOR OLDER PEOPLE
Beechcliffe Residential Home 16 Park Drive Heaton Bradford BD9 4DR Lead Inspector
Michael Smithson Unannounced 10.30 am 3 May 2005 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 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 J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Beechcliffe Residential Home Address 16 Park Drive, Heaton, Bradford, West Yorkshire BD9 4DR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 487207 01274 497352 Mr Jamail Singh Bassan Care home only 25 Category(ies) of Dementia - over 65 (12), Mental Disorder (1), registration, with number Old age (25) of places Beechcliffe Residential Home J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None. Date of last inspection 11 January 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 J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the morning and early afternoon of the 3rd May 2005. This was the first visit for inspection year 2005/6. The inspection focused on any outstanding issues from the last inspection, records and discussions with service users. A number of service users were able to discuss issues relating to the care provided and were happy living at the home. A significant number of service users do find it difficult to communicate their feelings. During observations of the interaction between staff and service users, the staff approach service users in a friendly manner. What the service does well: What has improved since the last inspection?
The general organisation of the records is being improved. In particular the service user records. The care plans chosen for the case studies were generally well recorded and included the identified aims and objectives for service users. One care plan had not been reviewed within the homes usual timescales. This was brought to the managers attention and will be addressed. This did appear to be an isolated incident. The new deputy manager is in the process of reorganising the records, policies and procedures. She making sure that service users and their family have access to information about the home. Beechcliffe Residential Home J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 Page 6 The premises are still being upgraded and improved as part of planned improvements for the home. The numbers of double bedrooms are being reduced and en-suite facilities added to some of the new bedrooms. This is good practice. The home is making steady progress in achieving the required level of 50 NVQ 2 qualified staff. 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. Beechcliffe Residential Home J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Beechcliffe Residential Home J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4 and 5. Service users are provided with information to enable them to make an informed choice about the home. The admission process is good and includes introductory visits. EVIDENCE: The home offers a choice for service users and levels of care are highlighted in the statement of purpose and service user guide. The statement of purpose and user guide are kept up to date and reflect the care provided at the home. A copy of the information is being provided for all service users and relatives. Case studies were undertaken for 2 service users and included information regarding a pre-admission assessment. The information gave staff a good picture of the needs of service users. The 2 service users are private fee paying and had not been issued with terms and conditions of residency. This must be addressed. The service users family were involved in the admission and the bedrooms have been personalised with items from home.
Beechcliffe Residential Home J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 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 standard(s) 7,8 and 10. The home is able to meet the health and personal care needs of service users. The health care needs are identified and monitored. EVIDENCE: The 2 case studies chosen included the identified needs of service users. Both the case studies were new admissions to the home. The health care needs are identified and standard assessment information is recorded. The information includes, pressure care, nutrition, manual handling and cultural needs. Individual risk assessments have been completed to monitor issues such as wandering and falls management. The information was generally kept up to date, however one of the case studies did require a review following admission. This was brought to the attention of the staff on duty. The service user information appeared better organised than has been noted at previous inspections. This allows easier access to information and provides staff with a clear understanding of individual aims and objectives. Beechcliffe Residential Home J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12,13 and 14. The home provides a good range of activities for service users. The staff are aware of the cultural needs of service users. EVIDENCE: On the day of the inspection an activity organiser was present. She worked 3 days a week and provided a range of activities for service users including, games, music and arts and crafts. In the early morning service users were playing bingo and later enjoyed a sing along and music and movement sessions. The care plans include the cultural and religious needs of service users. These are included in a separate diversity and equality care plan. The service users said they enjoyed the range of activities offered and had the choice to join in or not. Some service users enjoy a walk in the grounds which have now been made secure. Beechcliffe Residential Home J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 Page 11 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 standard(s) 16,17 and 18. The home has a detailed complaints and adult protection procedure which is robust and protects service users. EVIDENCE: No complaints had been made since the last inspection. The complaints procedure is assessable to service users and visitors and is included in the statement of purpose and user guide. Contact information for CSCI is on display within the home. Beechcliffe Residential Home J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 Page 12 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 standard(s) A full building visit was not undertaken during this visit. EVIDENCE: Beechcliffe Residential Home J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 The staffing is maintained to adequate levels, however when the recently advertised posts are filled it will improve the flexibility to cover the home. The recruitment procedure is adequate, however details must be recorded of when and if references have been received. EVIDENCE: A number of vacancies exist at the home. These include cover for 3 fulltime care staff currently on sick leave. The staff rotas were checked and some additional cover was required at weekends. The existing staff work extra shifts to cover the short fall. The recruitment records were checked for the last member of staff employed at the home. The records showed only 1 reference had been received despite 3 different references requested. No staff induction training records were available. The numbers of staff with NVQ 2 now stands at 4. A further 6 are in the process of completion. When all staff have completed the home will achieve the required level of 50 NVQ 2 qualified. Brief discussions took place with the staff, who showed a good understanding of the needs of the service users and the daily routines. The senior care staff are responsible for the day to day running of the home and completion of the service user records.
Beechcliffe Residential Home J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,36 and 37. The management of the home is reasonably well organised and staff are able to contribute to the decision making process. EVIDENCE: The manager is still completing NVQ level 4. However she does hope to finish the course this year. A new deputy manager has been employed to co-ordinate and organise the records and management systems at the home and for the other homes in the group. This also includes setting up and implementing a staff supervision programme. Beechcliffe Residential Home J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 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 3 13 3 14 3 15 x
COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 3 x x x 3 3 x Beechcliffe Residential Home J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 Page 16 YES 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. 2. 3. 4. 5. 6. 7. Standard OP2 OP21 OP27 OP28 OP29 OP30 OP31 Regulation Reg 17(2) Reg 23(2)(n) Reg 37(1)(e) Reg 18(1)(a) Reg 19 Reg 18(1)(a) Reg 9(2) Requirement All service users must be issued with terms and conditions of residency. An emergency call system must be fitted in the bathroom next to bedroom 10(b). The staffing vacancies must be filled as soon as possible. The home must meet the required levels of NVQ 2 staff. Two written references must be available for each new member of staff. All new staff must complete induction training. The manager must complete NVQ level 4 within the required timescale. Timescale for action 01/07/200 5 01/08/200 5 Immediate Action 31/12/200 5 Immediate Action. Immediate Action 31/12/200 5 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 Good Practice Recommendations Beechcliffe Residential Home J52 S1227 Beechcliffe V224079 030505 Stage 4.doc Version 1.30 Page 17 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
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