CARE HOMES FOR OLDER PEOPLE
Beechcroft House St Johns Road Rowley Park Stafford Staffordshire ST17 9BA Lead Inspector
Sue Jordan Announced Inspection 14th November 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 Beechcroft House DS0000004916.V258455.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. Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Beechcroft House Address St Johns Road Rowley Park Stafford Staffordshire ST17 9BA 01785 251973 01785 212652 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) Beachcroft Homes Limited Mrs Rita Elaine Sandra Middleton Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability over 65 years of age (6) of places Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. PD(E) - REGISTERED FOR 6, 2 OF WHOM MAY BE 50 ON ADMISSION Date of last inspection 23/05/05 Brief Description of the Service: Beechcroft House is an extended Victorian town house standing in its own grounds adjacent to the main Wolverhampton road into Stafford town. Local services and shops are within half a mile, and all other services, railway station, hospitals, entertainment venues and large and national retail outlets are situated one mile away, in the town centre. Beechcroft offers 24 hours residential care, for up to 25 adults of either sex in 21 single, and two shared rooms. Thirteen of the single rooms also have their own en-suite facilities. Those bedrooms on the upper floor can be reached by means of stairs that also have a chair lift on them, or by a vertical shaft lift. All places are available to persons falling within the category of Old Age [OP], and six places are available for persons over 65 with physical disabilities [PD(E)]. The home has two large communal lounges, a conservatory, and an additional small quiet lounge for residents to share with their visitors. The separate dining room has a serving hatch through to the kitchen. The Home is well maintained and there is a continuous programme of redecoration. Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This Announced Inspection took place over six hours and the methodologies used were pre-inspection scrutiny and collation of the manager’s, residents and relatives’ questionnaires; a tour of The Home, lunch with the residents, observations of an activities session and informal discussions with a number of the service users. Formal interviews took place with a member of staff, the manager and one of the proprietors. A number of records were checked including some staff files, care records and Health and Safety documents. What the service does well: What has improved since the last inspection?
Care planning continues to improve and the staff are becoming more familiar with their maintenance. The manager is now ensuring that she obtains copies of Local Authority care plans and assessments prior to accepting a new resident referral. Recruitment procedures have vastly improved. One of the staff files seen contained all of the required information and relevant checks and this was highlighted as an example to be used for all staff. However the proprietor must ensure that Protection of Vulnerable Adults and Criminal Records Bureau checks are undertaken appropriately in all cases. The staff are currently completing the ‘Safe Handling of Medicines’ distance learning training.
Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 6 The manager has completed NVQ 3 in care and has almost completed the Registered Manager’s Award. The provision of activities has been a major achievement this year and one, which is remarked upon in the questionnaires, sent to the Commission for Social Care Inspection prior to this visit. The manager held a residents’ meeting in July 2005, although she was advised to takes notes of these meetings. It is recommended that these meetings become a regular feature. The manager has introduced a staff supervision system. 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. Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 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 Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 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): 1, 3, 4, 6 The needs of potential residents are assessed by the Care Management team and the management of The Home. This ensures that The Home and the staff are able to meet their needs. EVIDENCE: The Statement of Purpose and Service Users’ Guide are available in the lobby area of The Home, although these were not checked during this visit. Some of the completed questionnaires indicated that some relatives were not aware of the availability of these documents or the Commission for Social Care Inspection report. The manager and proprietor was advised to periodically remind them. The care records for three recent admissions into the Home were checked. All three were assessed by a member of the management team prior to admission and Local Authority assessments were obtained. Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 9 The Home is to be commended for its enthusiasm in assessment. However some of the information, particularly with regard to manual handling and mobility is repetitive and could be streamlined. The manager was advised to put together one format covering all of the required areas of assessment, which as a consequence will allow for more specific, clearer guidance. Staff training, supervision and care plan completion continues to improve ensuring that the needs of the residents are continually monitored and the staff equipped accordingly. There is evidence of medical health intervention as appropriate. On the day of this visit, a number of the residents were receiving health care due to prompt responses from the Home and the subsequent action taken. The Home does not provide intermediate care. Beechcroft House DS0000004916.V258455.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, 9, 10 Care planning and the maintenance of residents’ records continues to improve; however in order that they are truly worthwhile documents, accuracy must be ensured. EVIDENCE: Care planning continues to improve. Staff report being involved in record completion and there is evidence of resident involvement in some cases. The manager reported recently involving a family member. Three care plans were checked. The manager was advised that she must check the accuracy and reality of the information. For example the records for one diabetic resident do not actually describe how this is to managed, even though a nutritional assessment had been undertaken. The assessment does state that the resident must be weighed monthly, although weight had not been recorded since 20/09/05. Another example is that arrangements for nail cutting and dental care should be explained. Medical, health professional support is recorded appropriately. During this inspection one resident was taken to the Accident and Emergency Department
Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 11 with health concerns, another was accompanied to a hospital appointment and a General Practitioner attended the Home. The staff are now diligent in their recording of medical intervention and appointments. A family member praised the care delivered in The Home in one of the questionnaires sent to the Commission for Social Care Inspection, “I am totally pleased with the care offered. All the staff are very sensitive, caring, supportive and friendly. My relative’s privacy and dignity are very well respected and his health and general well being has benefited hugely from this package”. The staff are undertaking a medication distance learning course, which they have nearly completed. Beechcroft House DS0000004916.V258455.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, 13, 14, 15 The residents are given the opportunity to join in regular activities. EVIDENCE: The provision of activities has been a major achievement this year and one, which is remarked upon in the questionnaires, sent to the Commission for Social Care Inspection prior to this visit. Preferred daily routines are recorded in the care records. Many of the residents like to watch television in the privacy of their bedrooms in the evening and this is respected and the environments conducive. The residents report having regular visitors and this is evident in the Home’s visitors’ book. There is a separate visitors’ area and family members report being made welcome in The Home. The manager is hoping to arrange a trip to the local pantomime. A residents’ meeting was held in July 2005, although minutes were not taken. This was recommended.
Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 13 The Home is still having difficulties recruiting a cook, however the staff involved in food preparation, including the manager and the proprietor have all undertaken food and hygiene training. Choices are offered at breakfast and teatime. The main meal at lunchtime is set, although alternatives can be offered to accommodate personal taste. The residents spoken to said that they had enjoyed their lunch and one praised the quantities saying “no-body needs to go hungry”. Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The Home has made positive improvements in the last twelve months to address the concerns raised in December 2004. The residents will be further protected by the provision to staff of appropriate Adult Abuse training and the correct procedures to be followed. EVIDENCE: There have been no complaints made to the Home or the Commission for Social Care Inspection since December 2004. The issues raised at that time and the action taken to address them have resulted in a number of noted improvements in the last twelve months. The management team have obtained Protection of Vulnerable Adults training booklets, although these have not, as yet, been completed by the staff. The staff undertake basic training in Adult Abuse during their NVQ training, however it is recommended that this be expanded by, if possible, training from the Local Authority with regard to the local procedures to follow in the event of an abusive situation or allegation. The staff member spoken to during this visit understood the action required. Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 15 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, 24, 26 The Home is kept clean and there is a continuous programme of maintenance and redecoration ensuring the residents a pleasant, safe environment. EVIDENCE: A tour of The Home was undertaken. It is obvious that there is a continuous programme of improvement and re-decoration. Many of the bedrooms have been re-decorated and there have been new carpets in some of the upstairs hallways. The grounds are accessible to the residents and well used during the summer months. The Home has two large lounge areas, a conservatory, large dining room and a separate visitors’ space. There are assisted bath chairs in many of the bathrooms. The records indicate that they are regularly serviced, however a couple of them needed to be cleaned more thoroughly underneath.
Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 16 The residents are encouraged to personalise their own bedroom space and they are well equipped. A vacant bedroom has been re-decorated and provided with new furniture. The Home employs two cleaners and was seen to be clean and hygienic. There were no malodours. A new washing machine and tumble dryer have been purchased. Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 17 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 Residents are safeguarded by adequate staffing levels and major improvements in recruitment procedures. The staff are to be commended for their commitment to NVQ and training provision has increased. However this needs improvement to cover all mandatory training and all staff and ensure that the residents are cared for by a fully trained workforce. EVIDENCE: Adequate staffing is provided and sickness is covered to ensure safe levels. On the day of this visit two senior care workers; two care workers and the manager were on duty. In addition, one of the proprietors was working in the kitchen, another was present for the Commission for Social Care Inspection, two staff were cleaning The Home and the activities co-ordinator organised a two hourly music and movement session for the residents. The residents spoken to praised the staff team and one resident said that they had helped him to settle in The Home. Staff were praised within the questionnaires received by the Commission for Social Care Inspection prior to the inspection. A staff member interviewed was enthusiastic about her job. The staff were observed positively interacting with the residents. Eleven of the care staff have achieved NVQ 2 or above, which is 48 of the workforce.
Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 18 Four staff files were scrutinised and major improvements were noted. Protection of Vulnerable Adults and Criminal Records Bureau checks are now being undertaken appropriately, although the proprietors were reminded that Protection of Vulnerable Adults checks must be in place prior to commencement of employment, pending a Criminal Records Bureau disclosure and ‘to whom it may concern references’ are not acceptable. One of the staff files seen contained all of the required information and relevant checks and this was highlighted as an example to be used for all staff. There was no evidence that a Criminal Records Bureau disclosure had been obtained for one existing member of staff, even though this was confirmed. Evidence must be available in the staff file that a disclosure has been obtained. Training provision has improved and courses have been undertaken and planned. However the matrix used for monitoring training still contains gaps meaning that some staff are not receiving mandatory training at the required frequencies. Additional efforts now need to be made to ensure that all staff receive the appropriate training. The proprietor and manager were reminded that staff should undertake manual handling training during induction. Training provision will continue to be monitored. Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 19 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, 33, 36, 37, 38 Management systems continue to improve benefiting both the staff and residents. EVIDENCE: The manager, Rita Middleton has now completed the NVQ 3 award and hopes to finish the Registered Manager’s Award by December 2005. Many of the managerial responsibilities have improved in the last twelve months. The manager is also supported by a consistent senior care team, who were praised by the residents. Staff and residents spoken to praised the approachability of the manager. Systems are being introduced which will improve the management of the Home, including staff supervision and residents’ meetings.
Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 20 Quality questionnaires have been sent to residents and their families. On receipt the results should be collated and included in The Service Users’ Guide. The Commission for Social Care Inspection received 10 completed relatives/visitors comment cards and 10 from residents of The Home. They were generally very positive. The manager has started a staff supervision system, which was confirmed by the staff member interviewed. She also reported attending regular staff meetings. This will continue to be monitored. Generally record keeping continues to improve in The Home. A random selection of the Health and Safety records were checked and confirmed appropriate testing and maintenance. Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 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 2 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X X 3 3 3 Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 22 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. 2 3 Standard OP7 OP7 OP18 Regulation 15 15, 18 (2) 13 (6) 18 (ci) 19, 18 19, 18 18 © 24 (2) Requirement Care planning information must be accurate and cover all the assessed needs. The manager must ensure that the staff follow the instructions in the care plans. Staff must receive training in Protection of Vulnerable Adults and the procedures to be followed. Protection of Vulnerable Adults checks must be received prior to commencement of employment. Evidence must be available that Criminal Records Bureau disclosures have been obtained. Mandatory training must be delivered to all staff at the appropriate frequencies. The results of quality assurance questionnaires must be included in The Service Users’ Guide. Timescale for action 01/12/05 01/12/05 01/01/06 4. 5 6 7 OP29 OP29 OP30 OP33 01/12/05 01/12/05 01/01/06 01/01/06 Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 23 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 OP1 Good Practice Recommendations The manager is advised to periodically remind the residents and their relatives of the availability and whereabouts of The Statement of Purpose, Service Users’ Guide and Commission for Social Care Inspection reports. The manager is recommended to streamline assessment information, to avoid confusion and repetition. The manager is advised to minute the residents’ meetings. The manager is recommended to contact the Local Authority Adult Protection department and request training and guidance as to how to correctly follow the local procedures. 2 3 4 OP3 OP14 OP18 Beechcroft House DS0000004916.V258455.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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