Inspection on 23/05/05 for Beechcroft House

This inspection was carried out on 23rd May 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.

Other inspections for this house

Beechcroft House 02/09/09

Beechcroft House 19/02/09

Beechcroft House 28/08/07

Beechcroft House 22/08/07

Beechcroft House 26/03/07

Beechcroft House 09/05/06

Beechcroft House 14/11/05

Beechcroft House 15/03/05

Beechcroft House 14/12/04

Beechcroft House 21/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Beechcroft ST Johns Road Rowley Park Stafford ST17 9BA Lead Inspector Sue Jordan Unannounced 23 May 2005 09:50 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. Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Beechcroft Address ST Johns Road Rowley Park Stafford ST17 9BA 01785 251973 01785 212652 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) Beechcroft Homes Limited Mrs Rita Middleton Older Persons Care Home 25 over 65 25 - 6 Category(ies) of OP registration, with number PD(E) of places Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 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 15 March 2005 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, so that the meals (which are served ready plated) can be taken to the tables without chance of cooling. There were 24 residents in the Home at the time of this inspection. Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over three and three-quarter hours and the methods used were pre-inspection preparation, discussions with the manager, proprietor, a relative and residents; observations of staff and service user interaction, lunch with the residents, a short tour of the environmental improvements and scrutiny of care records. What the service does well: What has improved since the last inspection? Increasing improvements have been noted at this and the last inspection. Major efforts have been made to meet the previous requirements, including better care planning. The management and staff are being more diligent in their recording of important information, including all medical appointments and interventions. In particular the records of existing residents have improved and these are also being reviewed regularly. Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 Page 6 There has been some more re-decoration in the Home and all of the radiators are now covered. More staff training is being organised and planned, ensuring that they have the skills and knowledge needed to care for the residents. 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 E09 E51 S4916 Beechcroft V228784 230505 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 Beechcroft E09 E51 S4916 Beechcroft V228784 230505 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, 3, 5, 6 Assessments of potential residents are carried out before they move into the Home ensuring that their needs can be met. However this information should be collated as soon as possible in order that staff know what care is required. EVIDENCE: The Home’s Statement of Purpose and Service Users’ Guide are kept in the Home’s lobby area, accessible to the residents and the staff. There have been two new permanent residents since the last inspection and two people are staying in the Home for a respite period. The records for all four were checked. Assessments have been carried out for all four prior to admission into the Home and Social Services care plans received for three. The manager was reminded to date all of the documents and to complete all of the information sections, where possible. The Home’s assessment does not contain all of the information contained in the Local Authority care plans, which is understandable, however the Home is strongly recommended to develop care plans from the assessment information as soon as is practically possible Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 Page 9 after admission. However the Home is to be commended for ensuring that pre-admission assessments are undertaken. The manager would prefer that potential residents come into the Home for trial periods and visits so that assessments could be carried out in the Home’s environment. This should be further explored. The Home does not provide intermediate care. Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, There have been major improvements in care planning and recording for the existing residents, however a system must also be set up for the residents receiving respite. This will ensure that the staff also have all of the information required as to how they are to meet these residents’ needs safely. EVIDENCE: There have been major improvements in care planning since the last inspection. The records are being regularly reviewed and important details such as medical interventions are being documented. Two residents have now been in the Home for over a month and although their assessment information is available, the care plans have not yet been developed. It is strongly recommended that this be completed as soon as possible following admission and reviewed and amended as necessary. Assessments are carried out for potential respite service users, however the development of a simplified form of care planning was discussed, which includes risk assessments. Some of the care plans seen were signed by the residents and the manager discussed getting families more involved. Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 Page 11 Medical interventions are being recorded individually in the care plans and provide ample evidence that the residents have access to general practitioners, chiropodists, opticians and dentists. A record checked showed that regular weight monitoring takes place for the individual following a nutritional assessment and the necessity identified in the care plan. A previous requirement was made that staff administering medication be appropriately trained. A distance learning, ‘safe handling of medicines’ course is being planned. Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15 Activities are organised three times a week for those wishing to join in and visitors are made welcome. In order that the opinions of all the residents are heard and known, it is advised that ways of offering more choices be explored. EVIDENCE: The Home employs an activities co-ordinator for three afternoons a week. Some of the residents said that they really enjoyed this and others said that they preferred not to get involved and for instance, “go to my room and watch television”. The activities include music and movement and table games such as dominoes or bingo. The Home also organises outside entertainers. A number of visitors were seen coming and going on the day of the inspection. One said that she always felt really welcome in the Home and another said that the Home provides excellent care. He visits his relative daily. One of the residents was waiting for a taxi to spend the day and evening with a family member. Another said that he goes out for a pub lunch most weekends with family. Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 Page 13 One of the residents said that the time she goes to bed depends on what she is watching on the television and another spoke of being offered a cooked breakfast, which he personally declines. However based on various discussions with the residents about complaints and meals it is still felt that the Home should explore further how they can offer more ‘daily life’ choices to the residents. This could take the form of residents’ meetings or one to one discussions for those less assertive service users. The Home could use this process to enhance their quality assurance procedures. The comments regarding the food in the Home from residents varied. The residents did not know what they were having for lunch. Some said that they had absolutely no complaints, that there “is almost too much food”, two said that they did not like the sausages served on the day of the inspection, “that they were too peppery”. It was observed that the residents are offered ‘extras’ and alternatives were given to two of the service users. It would be good to see an alternative being offered on the actual menu as further evidence of choice. The Home has had an on-going problem employing a cook and at present the owner, manager and a senior care worker are taking it in turns to do the cooking. Food and hygiene training has now been delivered to staff. Diabetic needs have been identified in an individual’s care plans and some residents require pureed foods. Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 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 standard(s) 16 There is a complaints procedure and forms for making written complaints available for those residents and/or their families able to access or complete them. EVIDENCE: Discussions with the residents about their right to complain received various answers; some said that they had no complaints anyway; others that they would talk to the manager and others said that there was no point in complaining. This could be further explored by offering the residents more opportunities to state their opinions and wishes. It was noted that the Home provides complaints and compliments forms in the lobby area, together with the complaints procedure. Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 25, 26 The Home is well maintained and provides a clean, safe environment for the residents. EVIDENCE: The Home is nicely decorated and cleanliness maintained to a high standard. The re-decoration in the hallways is now complete and new carpets have been fitted in some of the first floor areas. New lighting compliments this bright and airy space. The radiators have all been covered. The flooring in two of the first floor bathrooms has been replaced. Ramps are available for those residents wishing to use the garden and one of the residents said that she enjoyed sitting in the garden in the warm weather. One of the residents said that she had recently been offered the chance to move to a bigger bedroom, which she had accepted and now enjoyed. The bedrooms seen at this inspection were attractively decorated and full of personal possessions and photographs. Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 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 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, 29, 30 The Home has a consistent, friendly staff team and regular training is now being arranged, however evidence must be available at the next inspection that the recruitment practices provide full protection for the residents. EVIDENCE: On the morning of this inspection there were three care staff on duty plus the manager, two domestics and a senior care worker was doing the cooking. One of the proprietors comes to the Home daily. The Home is still trying to recruit a new cook, so that the senior care worker and the manager can fully concentrate on their own duties. There is a consistent staff team at the Home, many of whom have worked there for many years. At the last inspection in March 2005, a new care worker had started at the Home. She was observed at this visit interacting kindly and sensitively with the residents and said that she had settled well at the Home. Staff recruitment concerns were raised at previous inspections and subsequent requirements made that the staff files be updated to contain all of the elements listed in Schedule 2 of The Care Homes Regulations. The proprietor said at this visit that work is progressing but that he knows more work is needed. It was agreed that these requirements would be carried over into this report and the staff files thoroughly checked at the next inspection. A requirement was also made that the Home follow the correct Criminal Records Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 Page 17 Bureau procedures and the proprietor also explained that he is in the process of obtaining new disclosures for the staff. It was also agreed that this would be checked at the next visit. Two new care staff have recently been interviewed and the Home is waiting for references etc so that they can start work. A number of training courses have been planned since the last inspection and these include manual handling, infection control, medication, fire safety and supervisory management. The manager reported that she has completed five units of the Registered Manager’s Award. The manager is unable to evidence the staff training received as one of the proprietors keeps the records. It is still recommended that an updated matrix be kept in the Home. Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 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 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, 33, 36, 37 Major improvements have been made in the management and administration systems in the Home, which allow for better protection of the residents. In order that this be further improved more evidence of staff supervision is required. EVIDENCE: There have been major improvements in the record keeping in the Home and the manager demonstrates a commitment to maintaining this standard. She explained that she has changed some of the routines in the Home to allow her the time to complete her responsibilities. The manager is also undertaking the Registered Manager’s Award. The results of a service user questionnaire are contained in the files kept in the hallway. It was noted that very few residents participated in this and further Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 Page 19 methods could be explored. Some suggestions have been made earlier in this report. Supervision of the staff tends to be on an informal basis and more evidence of this is required. Supervision of staff can take various forms, including one to one written sessions, observation of tasks, team meetings and appraisals. There should be evidence available that staff are formally supervised at least six times a year therefore records should be made. The senior care team could be involved in some staff supervision, for instance observations or running team meetings, which would assist the manager. The Health and Safety records and procedures were not checked on this occasion and will need to be available for the next inspection. However staff have received fire safety training and the provision of mandatory training has improved. The radiators are now all covered. Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x x x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 x 3 x x 2 3 x Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 Page 21 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. Standard 7 Regulation 15 Requirement Care planning information must also be available for those residents receiving a respite service. Information and documents in respect of staff working in the care home must be maintained as specified in Schedule 2. Previous Requirement All staff should have a CRB check prior to the commencement of employment, unless a POVA 1st check has been successfully undertaken and evidence available that a CRB application has been submitted and the staff member supervised prior to the receipt of a suitable disclosure. Previous Requirement Evidence is required that staff receive a minimum of six supervision sessions per year. Timescale for action 01/07/05 & on-going 01/07/05 & on-going 2. 29 Sch 2 7,9,19 3. 29 19, 18 Immediate & on-going 4. 36 18 (2) 01/07/05 & on-going RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Beechcroft Refer to Good Practice Recommendations E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 Page 22 1. 2. 3. 4. 5. 6. Standard 3 7 14 15 16 33 It is recommended that assessment information be collated and some form of care plan developed as soon as possible following admission. It is recommended that care plans be developed as soon as possible following admission. It is recommended that the Home explore more ways of offering daily life choices to the residents. It is recommended that a written menu include alternatives and that these be discussed with the residents. It is recommended that the Home allow the residents more formal opportunities and methods to discuss their concerns or wishes for any changes to daily life. It is recommended that the Home explore more ways of gathering residents and/or their significant others views, which can also be used for quality assurance purposes. Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Stafford - 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 © 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 Beechcroft E09 E51 S4916 Beechcroft V228784 230505 Stage 4.doc Version 1.30 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!