Inspection on 25/10/07 for Beechcroft Manor Nursing Home

This inspection was carried out on 25th October 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beechcroft Manor Nursing Home 10/10/06

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Beechcroft Manor Nursing Home 1 Beechcroft Road Alverstoke Gosport Hants PO12 2EP Lead Inspector Jan Everitt Unannounced Inspection 25th October 2007 09:00 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 Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 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 Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechcroft Manor Nursing Home Address 1 Beechcroft Road Alverstoke Gosport Hants PO12 2EP 02392 583908 02392 601628 sginn@contemplation-homes.co.uk www.contemplation-homes.co.uk Contemplation Homes Ltd 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) To be confirmed. Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability over 65 years of age of places (30), Terminally ill over 65 years of age (30) Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All service users must be at least 45 years of age Date of last inspection 10th October 2006 Brief Description of the Service: Beechcroft Manor Nursing Home is a very substantial detached property that was originally a family house and has been converted for its current use as a care home. It is situated in a residential area of Gosport, and there is a bus service from the locality to the town centre. The building has bedroom accommodation on three floors and access to all floors is provided by a passenger lift. The bedroom accommodation comprises 8 single rooms and 22 shared rooms. Facilities and services include assisted baths, communal rooms on the ground floor, full board and a laundry service. Contemplation Homes Ltd owns the business, and the company own several other care homes in Hampshire, including another one in the immediate locality. Potential residents are sent a detailed brochure/information pack. On admission to the home new residents are given a comprehensive service users guide. A copy of the guide is readily available in the hallway/entrance to the home as is a copy of a report of the last inspection made by the Commission of Social Care Inspection (CSCI) of the home. At the time of the fieldwork visit to the home on 25th October 2007, the home’s fees ranged from £590 to £785 per week. The fees did not include the cost of hairdressing, podiatry, newspapers, magazines and transport. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site inspection visit to Beechcroft Manor Nursing Home, which was unannounced, took place over a one-day period on the 25th October 2007 was attended by one inspector. The newly appointed manager, Mrs Dawn Swift was not on duty at the time but attended the home to assist the inspector throughout the inspection. The visit to the home formed part of the process of the inspection of the service to measure the service against the key national minimum standards. The previous registered manager had returned the Annual Quality Assurance Assessment (AQAA) to the CSCI and the focus of this visit to the home was to support the information stated in this document and other information received by the CSCI since the last fieldwork visit, which was an key inspection, made to the home in October 2006. Documents and records were examined and staff working practices were observed where this was possible without being intrusive. The inspector visited all areas of the home and spoke to most of the residents, staff and visiting relatives in order to obtain their perceptions of the overall service the home provides. Those spoken to were very happy and complimentary about the home and care that is provided. Surveys had been distributed to service users, relatives, care managers, GP and other visiting professionals. One service user survey, eight relative/carer surveys, six staff, two GPs, three care managers and one visiting health professional surveys were returned to the CSCI. The outcome of the surveys indicated that there was a high level of satisfaction with the service and that generally residents and relatives were highly pleased with the care and other services the home provides. What the service does well: The pre-admission assessment tool is thorough and covers all aspects of a persons needs. Detailed records are in place and give nursing and care staff information that enabled them to provide the help that residents’ need. A comment from care managers: ‘Assessment and care plan is always available for information’. ‘Very comprehensive nursing notes are maintained’. ‘The home provides a caring environment that always supports residents to live their life the way they choose wherever possible’. ‘Caring atmosphere that provides a caring, homelike environment with an excellent standard of dedicated nursing care’. ‘Clients friends and family are encouraged to be involved in the care planning’. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 6 ‘Care plans are developed and updated by support team; Residents expressed satisfaction and felt secure and happy that staff could look after them properly and treated them with respect. The home liaises with other professionals to ensure that residents with specific healthcare needs received appropriate care and attention. Comment from a visiting health professional said: ‘Communication with outside disciplines is excellent’. ‘The home provides expert medical care’. ‘The staff were always friendly and approachable and follow advice regarding management of residents referred to me’. The home’s routines are flexible and promotes the right of residents to make choices for themselves and exercise personal autonomy as far as was reasonably possible, of how they live their lives. Comments received: ‘The home creates a calm and reassuring ambience and staff are always on hand and very approachable’. ‘Nothing seems too much trouble in the best interests of the residents’. ‘The home provides excellent all round care’. ‘My family extend all praise to this care home’. ‘Everything is done to meet my mother’s needs’. ‘I feel this home takes exceptional care of their residents’. Residents were positive about the range of activities in which they could participate and the condition of the accommodation that they occupied. ‘Whenever able provide opportunities for residents to engage in social activities and events outside the home’. ‘Entertainment is laid on for residents and relatives’. Relatives and residents were complimentary about the quality and variety of food that the home provides. ‘Good food, well presented’. ‘Good choice of food and the meals I have seen have been nutritious, well presented and enjoyed by my mother’. Management systems and procedures in the home worked well including quality monitoring and health and safety. Staff are recruited properly ensuring that residents safety and welfare is given proper consideration. ‘My induction was in depth and anything needed to be added to it the company were receptive to any suggestions’. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 7 There was a strong commitment to staff training and development to ensure that staff were able to fulfil their roles and responsibilities and meet residents needs. Comments from relatives and staff about skills of staff: ‘The staff have the skills to look after my mother I am more than happy that they do this excellently’. ‘A high level of nursing expertise is available’. ‘We are always on training courses and constantly updated with about residents needs and what is in their care plans’. ‘We are a caring home and the needs of the clients are our main concern of every day’. ‘Staff are very friendly and work hard to achieve a high standard of care for residents’. What has improved since the last inspection? What they could do better: There were no matters of concern identified as a result of this inspection. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 9 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 Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential service users’ care needs are fully assessed prior to being admitted to the home to ensure the home can meet those needs. EVIDENCE: The AQQA states that the home has a comprehensive brochure and information pack, which is available in various formats as, required and is sent to all potential service users on enquiries. The surveys returned by the relatives and service users support this and most indicated they had sufficient information to make an informed decision about going to the home to live. Care manager surveys comment: ‘All service users I have placed in Beechcroft Manor have received a service appropriate to meet their needs’. ‘Assessment and care plans are always shared to ensure information is Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 11 available to the home’. Relatives commented that: ‘Prior to my mother’s admission the matron discussed the ethos of the home very thoroughly and took time to answer my queries very comprehensively’. ‘The home were very helpful with information’ A sample of 4 care plans was viewed which documented the pre-admission assessment. The pre-admission assessments are carried out by the manager or deputy manager and are comprehensive in content and identify physical, emotional and social care needs. Relatives are generally involved at the assessment stage to enable the home to gain accurate information if the service user is unable to communicate information. Information from the care needs assessment undertaken by a care manager is also shared with the home. The information that is gained at this assessment is the basis for the admission assessment and care plans are drawn up. The AQAA states that the pre admission assessment document has been reviewed and updated through regular feedback at group Matrons meetings. The AQAA identifies that the barriers to improving the process of admission is that there is lack of written transfer information from hospitals. This was discussed with the manager who said that she is working with the hospitals to improve communication between them and to inform them what information the home needs when a patient is transferred to them. The home does not provide intermediate care. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had procedures in place to ensure the personal and healthcare needs of residents are met. The practices and policies of the home ensure that the home manages medication safely and effectively. The home’s ethos and staff working practices ensure that residents’ privacy and dignity is promoted. EVIDENCE: The AQAA stated that the care plans are person centred and promote independence. The inspector evidenced this by viewing a sample of five service users’ care plans and records, two of which had complex needs. The care planning system is thorough and person centred. The documents Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 13 examined were detailed and the plans were based on the assessments the home carried out in order to identify what help individuals need. Risk assessments included a range of potential risks to residents e.g. pressure sores; falls; moving and handling; and malnutrition. etc. Where an assessment had indicated that an individual was at risk of malnutrition it was noted that the corresponding plan of care for the person concerned referred to how that risk was to be managed and it was observed that a food and fluid chart was maintained daily. Where care plans referred to the use of equipment or how a specific needs were to be met, these were observed to be available, or in place e.g. profile beds, pressure relieving aids; hoists, and mobility aids. Service users spoken with said they had all they needed to help them and one resident commenting: ‘Oh this bed is lovely and comfortable and I have a special mattress on it’. Turning charts were also being recorded for those service users who were bed bound unable to move themselves and needed assistance to turn in bed to relieve pressure and prevent pressure sores developing. The plans examined set out clearly the actions staff had to take and what specialist equipment was needed to provide the support and assistance each person required. There was evidence from signatures on care plans and discussion with residents and relatives that wherever possible individuals and/or their representatives had been involved in developing the plans and agreed with the contents. Comments from relatives and service users are: ‘The home inform me about everything to do with my mother’s care’. ‘My mother has full nursing care and her needs are always met’. ‘All my mother’s care needs are catered for’ ‘Provides excellent all round care’. ‘I feel this home takes exceptional care of their residents and always communicates with me about my mother’s care’. ‘I am grateful I have been able to keep mother is such are caring environment’. A relative spoken with said that when her husband was admitted to the home with complex needs, she had been involved with the assessment and was very satisfied with how well he is cared for. Records indicate that care plans are reviewed at least monthly and daily notes refer to the actions taken by staff to provide the needs set out in those plans. Staff spoken to and from observation of staff practices, confirmed that staff were familiar with the needs of the individual residents being tracked. A member of staff comment on the survey said: Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 14 ‘We are told each day about our clients and what has been happening with them that is written in the care plans and we are constantly updating what has happened throughout the day’. Care plans record the visits by health care professionals. The visiting health care professionals are encouraged to document the outcome of the visit themselves in the care plans. Physiotherapy, dietician, dialysis nurse and GP are currently visiting the home when requested. The GP visited the home at the time of this visit. The manager reported that the home has good relationships with the multi disciplinary primary health team who support the home well. Two GPs returned the surveys to CSCI and none identified any concerns with the care their patients are receiving in the home. The community psychiatric nurse (CPN) returned a survey to CSCI and commented that she had been visiting the home for ten years and had no concerns about the care. She commented: ‘I was impressed with the retention of staff who were friendly and approachable and the home would contact me for support if they needed advice’. Communication with outside disciplines was excellent’. Service users have optician and dentistry available to them and also a visiting chiropodist. The home had written policies and procedures concerned with the management and administration of medication. The home uses a monitored dose system supplied by the local chemist. Other medicines that could not be put into cassette boxes because they could spoil, such as liquids or those that were to be taken’ only when required,’ (PRN) are dispensed from their original containers. Medication is kept in a locked and secured medicine trolley, cupboards and where required in a medical refrigerator. Controlled drugs are stored securely and appropriately. The inspector observed the storage areas to be well organised and clean and there was no obvious overstocking of ‘only when required’ (PRN). Registered nurses administer all medication. The inspector observed that safe procedures were being followed when observing the registered nurse administering medications. Records were viewed of the ordering, receipt, administration and the disposal of medicines and these were accurate and up to date. These are audited monthly. The senior nurse told the inspector that she does see the prescriptions before they are taken to the chemist for dispensing and this is good practice and Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 15 avoids any dispensing of unwanted medication, as recommended as good practice in the Royal Pharmaceutical Guidelines. The home reports a good service from the chemist who has held workshops for staff to observe how the MDS is made up before delivery to the home. Some sedative medication is treated as if it was a controlled drug and this is recorded in the controlled drug register. The home strongly promotes the independence of service users and those residents assessed as being able and who wish to be supported to keep and take their own medication, can do so. At the time of this visit however, no resident was choosing to manage his or her own medication. The home’s information pack that it provided to potential residents included the following statements about the promotion of individuals’ privacy and dignity: “We will endeavour to retain as much privacy and dignity as possible by; • Helping residents to personalise and equip their rooms as they wish. • By providing keys to their rooms and a secure place for their valuables. • Giving residents the opportunity to have privacy when receiving visitors, making telephone calls or opening and reading mail”. Although the home has a considerable number of double rooms, the rooms are large and are divided with privacy curtains that allow service users privacy when they wish it. Service users spoken to were quite happy with their rooms and did not find sharing a problem, some residents saying they enjoyed the company. A care manager commented: ‘The home does respect the individuals privacy and dignity and this is evident when visiting service users even those sharing rooms’. The AQAA states that privacy, dignity and residents rights form an integral part of staff training. All residents spoken to say that staff ensure that they are afforded privacy and that they could personalise their rooms if they so wish. It was observed that some individuals had brought items of furniture into the home with them and all rooms contained some personal items i.e. ornaments and pictures, belonging to the individuals concerned. All doors had locks fitted and keys are available should the service users request these. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home organised a range of social activities that provides stimulation and promotes residents’ self-determination, enabling residents to exercise choice about all aspects of their daily life. Residents are able to maintain links with relatives and representatives. The dietary needs of residents are well catered for with a balanced and varied selection of food available that met their tastes and choices. EVIDENCE: The home employs an activities organiser who role is split between caring in the morning and activities co-ordinator in the afternoon. She has been employed at the home for some years and is very familiar with the residents and client base. The co-ordinator said that the home is anticipating increasing the hours allocated to her for activities to four hours and to extend this to weekends also, which she considers will be of benefit to the residents and widen the activities programme. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 17 The care plans demonstrate a comprehensive social history is recorded with the service user being at the centre of the plan. The AQAA states the in the next year it is anticipated that the activity co-ordinator role will be reviewed and that a programme will be developed to ensure that the diversity of the residents with regards to mental capacity, will be met. The programme displayed on the reception wall for the current month was varied and identified a variety of activities from outside entertainers, quizzes, bingo, trips to the local community centre for jazz sessions, shows at festive times of the year and trips to town for lunch. Service users spoken to about trips out were very willing to share their experiences and describe how they had enjoyed their trips out. Relatives become involved with the trips to assist the staff with wheelchairs. We observed a number of service users playing floor snakes and ladders and they were participating well and which also involved a level of physical exercise when the dice had to be thrown. They were observed to be thoroughly enjoying the competitiveness of the game. The activities organiser has an obvious rapport with the residents and appeared to be able to cajole them into participating and enjoying the fun of the game. The co-ordinator showed the inspector the photograph albums of outings and events in the last year. Observations of these would indicate that much effort and time is put into organising the events for residents and families to enjoy. The co-ordinator also maintains detailed records of what activity takes place each day and the service user’s level of participation in that event and the response from the activity. Service users and relatives spoken to commented: ‘The staff put in time and effort to making her birthday a special occasion. Nothing is too much trouble in the interests of the residents’. ‘I enjoy the bingo best especially if I win some chocolate’. ‘Entertainment laid on for residents and families is done well’. ‘I enjoy some of the activities but sometimes choose to stay in my room’. Staff comments on surveys say: ‘We provide a range of activities for the residents but would like more time for further activities’. ‘I wish we had more time to spend with residents who are bed bound’. ‘I think those who are bed bound could do with a little more stimulation’. ‘Clients friends and family are encouraged to be involved’. It was also clear that thought had been given to providing stimulating activities to residents who had enduring mental health problems such as dementia, with the use of “light therapy” e.g. pulsing light chords. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 18 The home had a written policy about visitors to the home. Residents spoken to confirmed that they were able to maintain contact with the families and friends and that there were no restrictions on visiting arrangements. The visitor’s book recorded a regular stream of visitors to the home. The inspector spoke to some of the visitors and they all said they were very pleased with the home and the standard of care their relatives was receiving. Comments on surveys received by the CSCI state: ‘there is a warm, welcoming, caring, homelike atmosphere in the home’. ‘family and friends are always welcome’. ‘the home is friendly to relatives and their wishes are always taken into account’. ‘the home provides a friendly atmosphere’. ‘the home is friendly and very open to both residents and visitors. Entertainers from the community do visit the home regularly and residents do go out into the community with cares or relatives. One resident goes to the local pub for lunch on occasions and this is accommodated by her being taken by a carer and picked up later. The local vicar attends the home monthly to give communion and the Roman Catholic father attends weekly. Both are available to attend the home in times of need. Among the range of written policies and procedures that influenced practice in the home were a number specifically listed as concerned with residents rights these were: “Provision of personal telephone facilities; expressing sexuality; selfmedication; advocacy; handling monies and valuables; access to personal files and case notes; voting and electoral register; making wills; worship in their chosen faith; opening personal mail; making their own snacks; and laundering personal garments”. The front reception houses information about a free advocacy service that is available should a resident request one. There is also information leaflets relating to service users maintaining their rights. Service users can have access to their records; choose how they spend their days and where they wish to take their meals. Service user spoken with confirmed this. Residents spoken to indicated that the home’s routines are relaxed and informal and that they could exercise self-determination as far as was reasonably possible. One resident spoken with said she never rushed to get up in the morning and was able to spend the day as she wished. Some residents chose to stay in their rooms and others enjoyed the sociability of the lounge area. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 19 The home provides varied nutritious meals three times a day with drinks and snacks between meals. Residents and relatives spoken to were all complimentary about the food provided. The menus and records of food provided indicated that the food was nutritious and there was a wide range of meals provided with a selection of choices every day. In addition special diets and individual preferences and needs are catered for e.g. diabetic, soft and pureed meals. Fresh ingredients are used in the preparation of meals and the ready availability of fluids was noted in all rooms visited. The ingredients for pureed meals were prepared separately and the cook demonstrated this when the kitchen was visited. Residents could choose the meal that they wanted from a weekly menu that was made available to them. The list of menu choices for the week was on display in the entrance hall to the home. Individuals’ food preferences, dislikes and any food related allergies were recorded in their care plan documents and the details were also readily available in the kitchen. Comments from residents and relatives about the food provided included the following: ‘There is a good choice of food and the meals which I have given my mother have been nutritious, well presented and enjoyed by her’. ‘Good food well present’. ‘They come round in the afternoon to ask what we would like for tea and the next day’s lunch” The cook has worked at the home for many years and is knowledgeable about special diets. At the current time she was providing diabetic diets, low fat diets and a low protein diet. These were documented as part of the nutritional care plans. She said that at the current time she was not providing any special diets to meet a resident’s cultural needs. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a clear and satisfactory complaints procedure to address the concerns of residents and relatives/representatives. Robust procedures were in place to protect service users from the risk of abuse EVIDENCE: The home had a written policy and procedures about how complaints should be made about the service that it provided. A copy was clearly displayed in the home’s entrance hall. All residents and relatives spoken to were confident about raising any concerns with the home’s manager. The home does keep records of complaints that details any issues, and set out any agreed action to remedy the matter and its outcome. The manager said that no complaints had been made to the home since the last inspection and the CSCI has not received any complaints about the home since that time. The responsible person reviews the log monthly. Comments on relative’s surveys and speaking to service users at the time of the visit indicated that they are aware of whom and speak to if they have any concerns. Comments: ‘No concerns have had to be raised. Minor concerns have been fully answered, addressed and explained extremely satisfactorily’. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 21 ‘The complaints procedure is fully laid down in contract’. ‘Problems are dealt with promptly and professionally’. ‘No complaints my mother is cared for well’. ‘I have never had any concerns about my mother since she has been at Beechcroft Manor’. ‘We have never had any concerns but I know if I did all would be attended to pronto!’. The home has written procedures available with adult protection. These were intended to provide guidance and ensure as far as reasonably possible that the risk of residents suffering harm was prevented. Staff spoken to said that they received training about abuse and protecting vulnerable adults and an examination of the staff-training matrix confirmed this. Abuse awareness training is also part of the induction programme and is included in the NVQ level 2 training. Staff spoken to were able to demonstrate the action they would take if they suspected or knew that abuse had occurred. The comment on the staff surveys indicates that they would report it to the manager or senior nurse. The manager demonstrated her knowledge of the procedure should any incidences get reported to her. If, following a risk assessment it was considered necessary for a resident’s safety to use bed rails, written permission/consent is obtained from either the individual concerned or relatives/representatives and health care professionals. These were evidenced in the files tracked. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s environment is clean, safe and well maintained. There was an infection control policy and procedures in place and staff practice ensured that as far was reasonably possible residents were protected from the risk of infection. EVIDENCE: At the time of this visit the exterior and interior of the premises, its décor, furnishings, fittings and equipment were in good repair. The AQAA states that the organisation has employed a facilities manager who oversees the maintenance of the homes. There is an on-going programme of refurbishment and redecoration. In the past twelve months several rooms have been redecorated and re-carpeted. New profile beds have been purchased and pressure relieving mattresses. The garden has also been Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 23 restocked with plants and further landscaping undertaken. This was confirmed by the maintenance man employed at the home who described his role in the home and said: “As rooms become vacant we decorate them but of course if we have to do a room at any other time we may have no option but to work around the residents. Carpets and furniture are replaced as necessary. I test the portable electrical items every year. …. I am here 5 days a week for 4 hours a day”. The manager said that there are plans to install patio doors from the lounge leading to the garden and both lounges will be redecorated. The AQAA states that a new area of garden with raised beds is to be constructed this coming year to enable residents to enjoy the garden fully. Bedrooms were observed to be pleasantly decorated and had been made homely with the resident’s personal belongings. At the time of this visit a bedroom had been recently decorated and a new carpet was being laid. The home has purchased a number of profile nursing beds throughout the last year and two residents told the inspector that they were comfortable. The home was observed to be very clean and well organised and the benefit of this being that the home was not cluttered and provided a safe environment for residents and staff. . The environment presented a very homely atmosphere. Service users spoken with at the time of this visit were very positive about the level of cleanliness of the home. We visited the laundry, which is an outhouse to the home. The environment contained machines fit for purpose as all the laundry is undertaken on the premises. The lady who does the laundry said that she had worked at the home for many years and was aware of the procedures for dealing with soiled linen. The service users looked well presented and when asked about their laundry said that they were satisfied with how their clothes were laundered. Comments from relatives indicate a high level of satisfaction with the cleanliness of the home and the care to personal hygiene of those who are unable to care for themselves. ‘The home care for my mother in a sensitive way and they clean her and change her regularly’. ‘Mother always looks cleaned and well groomed’ ‘The home always looks clean’. ‘They care for my mother’s needs very well’. ‘The home is clean and staff make residents look tidy’. ‘The home is very clean and that is something that impressed me.’ The kitchen was visited and this was clean and well organised and systems were in place to monitor the standards of cleanliness and kitchen equipment. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 24 The AQAA records that the infection control policy and procedures have been reviewed this year and are in line with the Department of Health guidelines. It was noted that in accordance with best practice all communal WCs that were seen were provided with liquid soap dispensers and paper towels. Protective clothing was readily available and staff were observed using gloves and aprons appropriately. Staff spoken with were aware of the infection control procedures and most have received mandatory training on this. Recently installed sluice disinfectors are available in the home on each floor. It was observed that the cleaning chemicals were kept in a locked environment and were not left unattended when in use. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home employs an appropriate and satisfactory level and mix of staff that ensure the needs of residents are met. The home has clear staff recruitment, training and development procedures that ensure that service users are protected and supported and staff are trained to meet the needs of the service users. EVIDENCE: Staffing rotas were observed. The manager said that there are always two registered nurses on duty and she is in the home five days a week during the day. At the time of this visit there were 29 service users in residence and the care staff rota setting out the minimum number and skill mix deployed in the home was as follows: 08:00 to 14:00 3/2 4/5 7 14:00 to 20:00 3/2 2/3 5 20:00 to 08:00 1 2 3 Registered Nurses Health Care Assistants Total Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 26 The home employs a multicultural group of registered nurses and health care assistants. The manager said that she is recruiting new staff at the current time and were awaiting the POVA and CRB checks. Agency staff can be used to compliment the staffing numbers but this is not necessary very often as the sister home down the road will supplement the numbers if possible to allow for continuity of care for the residents. The staff were observed to be working well together and communicating well. Staff spoken to said they did have sufficient staff on duty at any one time to meet resident’s needs but there were odd times when they were short staffed and ‘just got on with it’ to support one another. Comments on staff surveys say: ‘Sometimes due to holidays and people leaving we may have gaps but generally they are covered well’. ‘There are always times when we feel more staff is required but we work as a team’. ‘We always phone around if staff go sick at short notice’. Comments from service users and relatives were: ‘Staff are wonderful’. ‘A high level of nursing expertise provided’ ‘The staff are busy all the time but are very good’ Generally staff consider they are well informed and supported to do their job. Staff were observed not to be rushing about and bell alarms were being responded to quickly. Staff were observed to be taking time to chat to service users and there appeared to be good relationships between staff and residents. The home employs a separate staff group for housekeeping, laundry, cooking and kitchen. assistant and an activities co-ordinator. An administrator is also employed in the home. The AQAA records that 70 of staff have achieved NVQ level 2 or 3 qualifications. The organisation encourages and support staff to undertake this training. Staff training files and the training matrix demonstrated that staff do receive a high level of varied training. Health care assistants who are employed without NVQ level 2 complete an induction programme that satisfies the requirements of the training body for the social care workforce ‘Skills for Care.’ Following completion of this programme they then continue on to undertake the NVQ level 2 qualification. The home has a separate induction programme for registered nurses and carers who are employed having achieved their NVQ level 2 qualification. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 27 Staff training needs are identified through appraisals and individual supervision sessions. The home had a staff training programme that includes the following topics: Fire safety; moving and handling; Liverpool care pathway i.e. palliative care; dementia awareness; infection control; health and safety; first aid; NVQ level 2; wound care; male catheterisation; care planning; common induction standards; bereavement; mentorship; abuse/adult protection; NVQ level 3; syringe drivers; venapuncture; basic nursing care; and food hygiene. The training is based on the needs of the service users. The AQAA states that all staff are to undertake the mental capacity act training in the next year and policies, procedures and care plans will be reviewed to reflect any changes that are influenced by the act. The AQAA states that the home supports overseas nurses to undertake appropriate training. Staff comment surveys returned indicate that the staff feel supported in their roles and receive training to enable them to meet the needs of the service users. Some comments say: ‘There are regular updates of mandatory training and other training outside the home that I can attend’. ‘Regular update and in-house training provided’. ‘Training is excellent covering a multitude of areas’. ‘Training of staff is excellent’. The home had a written policy and procedures in place concerned with “selection and recruitment of staff”. A sample of three personnel files were examined, two of which were the most recent recruits. The files demonstrated robust recruitment practices and all information and checks required were evidenced. The files also evidenced training records and records of supervision and appraisal. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 28 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s manager provides effective leadership There are systems and procedures in place for monitoring and maintaining the quality of the service provided and promoting the safety and welfare of everyone living and working in the home. EVIDENCE: The AQAA was completed by the previous manager who is now the operational manager, the current manager having been in post for the last month. She has been the registered manager in another home owned by the organisation and is in the process of applying for her registration with the CSCI for Beechcroft Manor. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 29 The manager has many years experience of nursing and has been a registered manager for the organisation for the past nine years. She is in the process of undertaking her Registered Manager’s Award (RMA) and has achieved NVQ level 4 in care. As a result of discussion with the manager and staff and also from observing her at work, she presented as providing clear direction; having high personal and professional standards and was well organised and knowledgeable about the residents, and although still being new to the home she interacted effectively with her staff. The manager said that she had settled into the home well and was enjoying the new challenges of managing a different home, but continued to be well supported by the outgoing manager who was now her operational manager. Comments from staff about the manager were positive and said: ‘We are well supported by the manager’. ‘Excellent management support at all levels’. ‘If you have any worries or problems matron always finds time to speak and give advice if needed’. The home and the organisation have policies and procedures about monitoring the quality of the service that the home provides. A system had been implemented that includes the distribution of questionnaire to obtain the views of residents and relatives. The manager said that the results of these surveys are feedback to her verbally. The manager showed the inspector a file of the audits that are undertaken monthly to inform the quality assurance system. These include care plans, MAR sheets, the cleanliness of the home and the group catering manager audits the catering service. The company had established a group comprising the managers of 4 care homes to review a number of policies and procedures and aspects of service provision every month. The company is also comparing the performance of it’s homes against guidance that the CSCI had published about evidence that would indicate how the National Minimum Standards for Care Homes could be met called, “Key Lines of Regulatory Assessment” (KLORA). As the home is owned by an organisation, the responsible individual representing the organisation visits the home unannounced each month in order to ascertain how the home is being conducted. A report of such visits is produced. There are copies available of reports of visits under Regulation 26. The inspector evidenced September 07 report. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 30 Staff meetings and resident/relatives meetings are held and minutes of these meetings are maintained. The manager said that she was undertaking her first staff meeting imminently and this was advertised on the wall for staff to add to the agenda. At the time of the site visit the home was looking after small amounts of money for some service users. These monies are administered by the administrator and are maintained in a locked environment and records maintained for each transaction. All monies are stored in separate containers. ‘We are well supported by the manager’. ‘Excellent management support at all levels’. ‘If you have any worries or problems matron always finds time to speak and give advice if needed’. The home and the organisation have policies and procedures about monitoring the quality of the service that the home provides. A system had been implemented that includes the distribution of questionnaire to obtain the views of residents and relatives. The manager said that the results of these surveys are feedback to her verbally. The manager showed the inspector a file of the audits that are undertaken monthly to inform the quality assurance system. These include care plans, MAR sheets, the cleanliness of the home and the group catering manager audits the catering service. The company had established a group comprising the managers of 4 care homes to review a number of policies and procedures and aspects of service provision every month. The company is also comparing the performance of it’s homes against guidance that the CSCI had published about evidence that would indicate how the National Minimum Standards for Care Homes could be met called, “Key Lines of Regulatory Assessment” (KLORA). As the home is owned by an organisation, the responsible individual representing the organisation visits the home unannounced each month in order to ascertain how the home is being conducted. A report of such visits is produced. There are copies available of reports of visits under Regulation 26. The inspector evidenced September 07 report. Staff meetings and resident/relatives meetings are held and minutes of these meetings are maintained. The manager said that she was undertaking her first staff meeting imminently and this was advertised on the wall for staff to add to the agenda. At the time of the site visit the home was looking after small amounts of money for some service users. These monies are administered by the Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 31 administrator and are maintained in a locked environment and records maintained for each transaction. All monies are stored in separate containers. Records examined indicated that the home’s equipment, plant and systems are checked and serviced at appropriate intervals i.e. passenger lift and hoists; fire safety equipment portable electrical equipment; hot water system; etc. There were contracts in place for the disposal of clinical and household waste. Records were kept of accidents and are completed in detail. Conversations with staff, comments from surveys and the staff training matrix demonstrate that staff attend regular and compulsory fire and other health and safety training. The manager said that she working to ensure all staff have undertaken the infection control training. The moving and handling trainer has moved homes and the current manager is hoping to train as a trainer to enable staff to continue to have in-house mandatory training. The inspector viewed the fire risk assessment for the premises and regular risk assessments of the premises and working practices are undertaken. Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 32 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 3 X X 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Beechcroft Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 33 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. Standard Regulation Requirement Timescale for action 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 Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Manor Nursing Home DS0000065694.V347385.R01.S.doc Version 5.2 Page 35 - 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. 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