This inspection was carried out on 11th October 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOMES FOR OLDER PEOPLE
Beechcroft House 75 North Road Midsomer Norton Bath & N E Somerset BA3 2QE Lead Inspector
Jon Clarke Unannounced Inspection 11th October 2005 09:45 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 DS0000008148.V256901.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 DS0000008148.V256901.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Beechcroft House Address 75 North Road Midsomer Norton Bath & N E Somerset BA3 2QE 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) 01761 419531 01761 419531 Mrs Sarah Louise Thomas Mrs Sarah Louise Thomas Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. May accommodate up to 14 persons aged 65 years and over requiring personal care only. 07/06/2005 Date of last inspection Brief Description of the Service: Beechcroft is a small family run “ care home for 14 older people established by the current owner 15 years ago and situated in the town of Midsomer Norton. The home is an extended and converted detached house. Accommodation is provided in single rooms over two floors with stair lift access to the first floor. All rooms other then 3 have en-suite facilities the remaining three have washbasins; there are bathrooms as well as shower facilities. There are two lounges one of which includes a dining area in addition there is a conservatory with level access to the garden. Beechcroft aims to provide its residents with a secure, relaxed and homely environment in which their care, well being and comfort are of prime importance. we pride ourselves on offering a highly professional care service, with a personal touch. (From the homes Statement of Purpose) Beechcroft also offers day care by arrangement. The homes Mission Statement states Beechcroft Residential home strives to provide consistent high standard of care at all times. To do this we try hard to: Understand our clients needs, Promote the best care values and Train and motivate our staff. Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day. This inspection looked at the core standards not examined on the previous inspection. Documents seen included training records, care plans and assessments for residents admitted since the last inspection. The inspector spoke with a number of residents about their experience of living in the home. Staff were also spoken with and observed during the inspection. What the service does well: What has improved since the last inspection?
There continues to be good practice in care planning making sure that care needs are identified and records of care are good. Reviewing of care plans to update and record any changes in the resident’s health and physical health are regularly held. Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beechcroft House DS0000008148.V256901.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 DS0000008148.V256901.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): Standard 3 was looked at on the previous inspection and this standard was met. EVIDENCE: Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 The working practices in the home ensure that residents are treated with respect and there are positive and appropriate relationships between residents and staff. Standards 7,8,9 were looked at on the previous inspection and other then a shortfall in Standard 7 about reviewing of care plans which has now been addressed all standards were met. EVIDENCE: Residents confirmed that staff treat them with respect “ I am treated as I would want to be” another resident stated that “they always” respect my privacy. Staff were observed assisting residents this was always done in a sensitive and caring way particularly where a resident was confused. Staff spoke in a positive and respectful way when asked about the care of residents and recognised the individual rights of residents “ its their choice” “its up to them”. Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 10 Care plans were not looked at in full detail however it was noted that whilst general reviews were being completed the specific reviewing of moving and handling assessments were not. Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 The home recognises the importance and supports residents in maintaining social and family contact. Standards 12,14,15 were looked at on the previous inspection and were all met. EVIDENCE: Residents spoke of the home welcoming their relatives when they visited and relatives who were visiting at the time of this inspection confirmed this. “they always make us feel welcome”. It is part of the home’s practice to encourage and support residents who are able to go out to the local church or clubs. Staff will also accompany residents if this is possible. The homes organises events to which relatives and friends are invited a choir coming to the home being one such recent event. Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The home through its policies and training of staff has a safe environment where residents are protected from abuse and as far as possible their health and welfare is safeguarded. Standard 16 was looked at on the previous inspection and was met. EVIDENCE: Some staff have attended POVA training and this needs to be extended to all staff at the home including domestics and cook. The home has a whistle blowing policy as well as vulnerable adults policy. Residents stated that they felt safe in the home and would “definitely” say something if “ I wasn’t happy about something” or not treated in an appropriate way. Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 The home has good practice in protecting resident’s health providing a clean, pleasant and hygienic environment. Standard 19 was looked at on the previous inspection and the standard was met. EVIDENCE: Notices are displayed providing instruction about the correct practice in use of chemicals and protecting residents from MRSA through washing laundry at correct temperature and the availability to staff of anti-bacteria handwash. Safety Date sheets set out good practice in use of hazardous cleaning materials. The home has a copy of the Avon & Wiltshire Infection Control Guidelines for Care Homes. Some staff have received Infection Control training and as a minimum all senior care staff should receive this training. Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 14 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): 27,30 The staffing of the home is at a level that makes sure that the needs of residents are met by trained and competent staff. EVIDENCE: Staffing rotas showed 2 staff am 8-1.30, 2 pm 4.30-8.30 or 130.8.30 and 1 waking night. There is domestic staff on duty daily except Saturday & Sunday. Staff have completed the necessary mandatory training: moving & handling, fire drills and fire safety (General Principles of Fire Safety & Awareness), first aid. Staff who administer medication have completed City of Bath College Medication Administration training. Some staff have completed BANES Vulnerable Adults training. Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 15 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): 35,38 The home’s practice ensures that the health, safety and welfare of residents is protected and their financial interests are safeguarded. Standard 33 was looked at on the previous inspection and this standard was met. EVIDENCE: Where able residents are encouraged to manage their own financial affairs if this is not possible relative or others act on their behalf. It is the homes policy not to manage resident’s finances. Residents are invoiced for any items or services provided by the home no money is held on the resident’s behalf. Records showed the necessary checks of fire systems and alarms are carried as required. Equipment is maintained regularly: stair lift 23/08/05, gas supply and equipment 16/03/05, Appollo bath 30/06/05. There are risk assessments undertaken in relation to the home environment.
Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 16 Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X 3 Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (20 Requirement Ensure all elements of an individual’s care plan specifically Moving & Handling assessments are reviewed at regular interval. Ensure all staff undertake Adult Protection training to Alerters level. The manager and deputy to Investigators level. Timescale for action 11/10/05 30/04/06 2 OP18 13 (6) 18 (1a,c) 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 Beechcroft House DS0000008148.V256901.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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