Inspection on 08/03/06 for Beechcroft Residential Home

This inspection was carried out on 8th March 2006.

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 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 Residential Home 19/01/07

Beechcroft Residential Home 22/02/05

Beechcroft Residential Home 18/11/04

Beechcroft Residential Home 16/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Beechcroft Residential Home Salop Drive Oldbury West Midlands B68 9AG Lead Inspector Linda Brown Unannounced Inspection 8th March 2006 11:00 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 Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 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 Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beechcroft Residential Home Address Salop Drive Oldbury West Midlands B68 9AG 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) 0121 429 2993 0121 429 6995 Mr Anthony Billingham Ms Carole Jenkins Jennifer Maisie Kelway Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation letter dated 5.1.2005 may be accommodated at the home in the category of SI(E). This will remain until such time that the service users placement is terminated or whilst the home is able to meet the service users needs. 17th September 2005 Date of last inspection Brief Description of the Service: Beechcroft is a purpose built residential care home, providing residential accommodation for fifty older people. The home is privately owned. Beechcroft is situated in a quiet cul-de-sac in a residential area of Oldbury, within close proximity of local shops and public transport. There is a car park adjacent to the home for visitors to the home. The home comprises of two lounge/dining rooms, 48 single bedrooms (11 of which have en-suite facilities), 1 shared bedroom, bathrooms and WCs. The home is of two-storey construction and built in a rectangle providing an inner sheltered courtyard, which has shrubs, garden furniture and has the benefit of a security light. The home is approached either by a sloping pathway or a flight of steps with handrails. The stated aim of Beechcroft is to provide an environment in which elderly people may lead as normal a life as they are able, maintaining individuality, dignity and retaining their status as independent adults. Beechcroft aims to promote good care, respect, and independence for every resident whilst responding to the needs and wishes of all. Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over a four-hour period. Time was spent observing a residents meeting, talking to service users, interviewing two members of staff and talking with other staff. The inspector examined records for the standards to be inspected along with assessing the progress from the requirements made at the last inspection. The inspector would like to thank the service users, staff, manager and team manager for their cooperation and assistance during the inspection. What the service does well: What has improved since the last inspection? The manager is committed to improving standards and has worked hard to implement the requirements made at the last inspection. 18 requirements were made at the last inspection and 16 have now been met. The manager has made plans to meet the two remaining standards. Six recommendations were made at the last inspection .The manager has obtained the necessary advise and reviewed systems where appropriate. Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 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 Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 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 Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 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): Not assessed at this inspection. All the key standards were assessed at the last inspection and standards were met. EVIDENCE: Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 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): Standards 7,8 and 9 were assessed at the last inspection and requirements were made. All but one requirement has now been met and arrangements made to meet the last requirement in the near future. EVIDENCE: Key worker reports are now being completed every six to eight week’s evidence was seen on the three service users files examined. The inspector discussed with the manager the need to regularly assess the needs of service users to ensure they can be met. Service users are weighed on a monthly basis and outcomes recorded. Evidence was seen of risk assessments for service users on PRN medication. PRN medication is recorded on MAR sheets. All prescribed creams and lotions are now dated when opened and recorded on medication sheets. All four of the above requirements have now been met. Accredited medication Training has been booked for 4 staff to attend on 16th March 06. This will remain outstanding until evidence is seen of completion. Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Service users are helped to exercise choice and control over their lives. A requirement was made at the last inspection with regard to activities this has now been met. EVIDENCE: The manager showed copies of residents meetings from November and December where activities were planned and discussed. Cheese and wine evenings, fish and chips suppers, punch and mince pies night, trip to Walsall lights. Service users told the inspector they had been to Worcester and had stopped for fish and chips on the way back. The inspector was shown the Easter hats and baskets that had been made by service users. The inspector spent time sitting in the lounge talking to service users, they explained family and friends can visit at any time. Sometimes they go out with their visitors or they can see them in private in their rooms. Service users explained they have use of a pay phone but can also have phones in their rooms. Some residents prefer this as they can arrange for their families to contact them at times convenient to them. Whilst touring the building one service user invited the inspector into their room, bedrooms were clean and personalised with ornaments, plants, flowers and pictures. The manager explained a redecoration programme was in place and had identified the rooms to be completed first. Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 Page 11 The Service Users Guide gives information regarding other agencies and advocates. Service users are able to manage their own finances where appropriate. Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 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): 16 Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon appropriately. EVIDENCE: The management actively promotes the complaints procedure. There is a notice on the reception desk inviting service users and their families and friends to talk to staff and raise any concerns. The complaints procedure is included in the Service User Guide. This covers aims, policy statement, action to be taken when receiving a complaint, the complaints panel and follow up action, along with details of the Commission. There have been four complaints since the last inspection, all complaints are taken seriously. The manager investigates complaints and records the outcomes. The manager must send a letter to the complainant to confirm the outcomes of the investigation. Regulation 37 notifications are also sent to the commission. Service users confirmed to the inspector they knew how to make a complaint. They also told the inspector “we tell the staff and they sort it out, but we can always tell the manager”. In discussion with staff they confirmed how complaints are received and reported to the manager. The manager is in the process of planning adult protection training for all staff. Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 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): Not assessed at this inspection. However the manager must address the malodour in one of the rooms to ensure service users are provided with an environment that is free from offensive odours. EVIDENCE: During the tour of the building one of the bedrooms had an unpleasant odour. This was discussed with the manger who assured the inspector it would be dealt with appropriately. Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 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): 30 The requirement made at the last inspection in respect of Standard 29 has been met. Staff are trained and competent to do their jobs. EVIDENCE: A signed declaration from staff stating there position in relation to cautions reprimands or warnings is now included in the application form. Training is ongoing and the manager keeps a training matrix to identify gaps. Every member of staff has completed fire training. There is an ongoing programme of core training for staff. The core areas cover, infection control, food hygiene, manual handling, first aid, abuse, health and safety and fire. NVQ is promoted and 17 staff have now achieved level 2, three staff have level 3 and two staff have level 4. Evidence was shown to the inspector of induction booklets completed. Staff work through the books with their supervisor. The books are based on the topss induction pack. Staff keep the workbooks whilst they are completing their induction however evidence was seen of completed books. Staff informed the inspector that the induction booklet had been very helpful, at first it had seemed a lot to digest but working through it with their supervisors had been beneficial. Staff confirmed they have access to training and “regardless of length of service there is always the opportunity to learn”. One member of staff stated, “We are able to ask if we feel we need any particular training but there are often small courses available and we are encouraged to attend”. Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 Page 15 Staff stated they had regular supervision and they felt able to talk to their supervisors. All staff spoken to informed the inspector how supportive the team was. They also felt Beechcroft was “a nice environment to work in” Three staff files were examined and evidence of training and certificates seen, along with yearly appraisals and supervision records. Supervision takes place every two months unless the manager feels additional support is required. Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 Page 16 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): 33 The home is run in the best interests of service users. The manager must remove the furniture stored under the stairwell in order to promote and protect the health and safety of service users The manager has met the requirement made at the last inspection with regard to the safe keeping of service users money. EVIDENCE: The manager has reviewed the system for the safe storage of service users money. A recording system is in place with signatures and receipts for expenditure. Three service users’ monies were checked and found to be correct. The manager has an excellent, detailed in-house monthly monitoring system, which includes health and safety inspection checks. Health and safety issues identified from monthly audit are then discussed at manager’s supervision and regulation 26 visits. Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 Page 17 The manager also monitors care issues such as pressure sores care where applicable, violent incidents, accident reports, dependency levels and staff training and supervision. The team manager undertakes occasional checks on the above, evaluates the findings and completes a yearly report. Questionnaires are sent out yearly to service users, family / friends and visiting professionals. These are also evaluated and a report is completed. Views are also gained from residents meetings. The inspector was invited to observe the meeting. Posters had been displayed around the home to remind service users of the date and time. The manager explained the plans made to celebrate Beechcroft’s 10th anniversary. One resident and one member of staff had also been at Beechcroft 10yrs and recognition would be made of this. The local MP would be attending, a photographer and an entertainer have been booked . The cook discussed plans for a special menu with service users. A cooked lunch will be provided and party food planned for the afternoon. The celebration will take place over about 2 hours. The plans for the event dominated the meeting however brief discussions did take place about other activities. One service user commented, “I have really appreciated the tapes from the library” and about new ideas for activities e.g. large playing cards, bingo and trips out were discussed. The manager reminded all service users that if they had any concerns or worries about the plans or any thing else, to ask staff and they would clarify the details. The cook usually attends the service users meeting to discuss new ideas for menus. During the tour of the building the inspector observed furniture being stored under the stairwell. The manager explained that it had been removed from a room and the handy person was on leave, but it would be removed on his return. The manager must ensure the furniture is removed as this poses a risk to the health and safety of service users. Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 Page 18 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 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 4 X X X X X Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 14(2) Requirement The manager must ensure that service users needs are regularly assessed to ensure the home can continue to meet their individual needs. Provide all staff who administer medication with accredited training (Requirement originally made November 2004) The manager must inform the complainant in writing the outcomes of any investigation made. All staff must receive Adult Protection training. Requirement originally made November 2004) The manager must ensure action is taken to address the malodour in one of the rooms. The manager must ensure all furniture is removed from under the stair well Timescale for action 01/05/06 2 OP9 13(2) 01/06/06 3 OP16 22(4) 14/04/06 4 OP18 10(1) 01/06/06 5 OP26 16(k) 21/04/06 6 OP38 13 14/04/06 Beechcroft Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 Page 20 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 Residential Home DS0000004776.V285293.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. 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