This inspection was carried out on 31st October 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector found no outstanding requirements from the previous inspection report,
but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Beechdene Care Home 29-31 Woodhouse Road Mansfield Nottinghamshire NG18 2AY Lead Inspector
Stephen Benson Unannounced Inspection 31st October 2005 09:30 Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 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 Beechdene Care Home DS0000008631.V263493.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 Adults 18-65. 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. Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Beechdene Care Home Address 29-31 Woodhouse Road Mansfield Nottinghamshire NG18 2AY 01623 649351 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) Mrs Doreen Parkes Mrs Doreen Parkes Care Home 15 Category(ies) of Learning disability (15), Old age, not falling registration, with number within any other category (2) of places Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Thirteen (13) residents shall fall within registration categories LD and LD/E Two (2) named residents shall fall within registration category OP. This category shall cease to exist once those residents leave the home 12/08/05 Date of last inspection Brief Description of the Service: Beechdene is a care home providing long-term personal care and accommodation for 11 younger adults who have a learning disability and 2 named older people. . The home is owned by Mrs. Parkes and is run as a family business. The home is located in a residential area on the outskirts of Mansfield town centre, close to shops, pubs, the post office and other amenities. The home was opened in 1983 and consists of a former guesthouse combined with a former domestic dwelling.Thirteen of the home’s bedrooms are single, and 5 of the bedrooms have en-suite facilities. Bedrooms are located on 3 floors in one part of the home and on two in the other. The latter has a stair lift.The home has an enclosed courtyard area that is well maintained and easily accessible. There is car parking available for up to 7 cars. Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was the second of two unannounced inspections carried out between April 2005 and March 2006. The inspection lasted for 3 ½ hours and focussed on key standards not inspected at the last inspection. The main method of inspection used was called case tracking which involved selecting 3 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with the manager, care staff on duty and care practices were observed. The premises were not inspected in detail but various areas of the home were visited as part of the inspection What the service does well: What has improved since the last inspection?
No requirements were set at the last inspection. There have been some new windows fitted and more are planned to be replaced over the next year.
Beechdene Care Home DS0000008631.V263493.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. Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The assessment process for prospective new residents is not being used properly. EVIDENCE: There was an extended community care assessment on file for a newly admitted resident as well as the home’s own pre admission form. However the Community Care Assessment was not received until after the resident had been admitted and the homes own pre admission form was completed after the resident had moved to the home. There was information contained in the Community Care Assessment that required risk assessing and care planning that had not been done, and this had not been included in the home’s own pre admission assessment. The manager explained that the resident had been admitted as an emergency as the reason why these errors had occurred. The home’ admission policy and procedures do not include details on emergency admissions. The importance of having an assessment prior to admission to assess whether the prospective residents needs can be met within the home was pointed out to the manager. Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Residents are encouraged to integrate into the local community and are supported to follow any leisure interest. EVIDENCE: Where residents attend a day centre individual programmes are developed to provide daytime activities. Two residents do voluntary work in the local community. One recently admitted resident does not have any activity arranged outside of the home despite this being identified as being in his best interest in the assessment. The manager intends to raise this at the forthcoming review. The resident said he would like to have somewhere to go during the day. Residents are actively involved in the local community using various recreational and leisure resources. The manager said that residents were going out for a meal to a local pub that evening to celebrate Halloween. One resident attends weekly Tai Kwan do classes. Where residents show an interest in an activity this is encouraged by staff. Currently there is an interest in birds. As a result there are trips out bird watching, outings to local garden centres and bird feeders have been put into the garden. There are regular holidays arranged to the manager’s caravan or to various hotels. The manager
Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 11 said that residents will be able to go away over Christmas and New Year this year. Family and friends are welcome to visit the home and residents are supported to visit them. A number of residents have their own mobile phone and more intend to get one. Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None EVIDENCE: Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents can raise anything they are worried about. EVIDENCE: The home has a complaints procedure and complaints book to record any complaint made in. A notice is displayed in the home about how to make a complaint, which would benefit from referring to the complaints procedure. There is also a complaints guide which does not have the correct information of the registering authority and this should be updated. There have not been any complaints recorded in the complaints book, although the manager was able to think of some examples where minor complaints have been made and dealt with but not recorded. Residents said that they would raise anything they were worried about with the manager. Staff have had training on the adult protection procedures. There have not been any incidents of abuse and residents said that staff are very kind and that they trust them. Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the 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 home is kept to a high standard of cleanliness. EVIDENCE: Staff support those residents who are able, to keep their rooms clean and to do their own washing. There is a separate washing machine and tumble dryer for their use. Staff were aware of the policy and procedures for infection control and protective clothing was available. Residents said that they thought the home was kept clean and one resident said he had changed his bed that morning. Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Staff have regular training opportunities. EVIDENCE: Staff said they felt they have received the training they require to carry out their duties and felt they are able to meet the needs of the residents. Some staff have successfully completed NVQ level; 3 and others are currently working towards it. There is a training record for each member of staff showing training that they have done. There is usually a training session held each month. There have not been any new staff appointed recently but the manager described the recruitment process. This includes completing an application form, attend interview, provide references and obtain a Criminal Records Bureau check. One staff file seen did not contain an application form. The manager was certain that this had been completed but did not know where it was. Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Residents are able to comment on the running of the home. The health and safety of residents is promoted with the exception of the dangers from Legionella. EVIDENCE: The provider, who is also the registered manager has been at the home for many years. A management consultant is used to help with some of the management of the home. The manager intends to undertake the Registered Managers Award in 2006. There is a quality assurance manual and this contained monthly audits of the home covering differing areas of service. Residents said that they enjoy being asked questions about the home. The Environmental Health Officer visited in September 2005 and produced a positive report as a result of that visit. All the required safety checks and tests are carried out at the required frequency with the exception of tests for the prevention of Legionella and these must be put into place. Beechdene Care Home DS0000008631.V263493.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 Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X X Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Beechdene Care Home Score X X X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 2 X DS0000008631.V263493.R01.S.doc Version 5.0 Page 18 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 Requirement Ensure all prospective residents are assessed prior to admission to establish whether the home can meet their needs Update the home admission policy and procedures to include how any emergency admission will be managed Update the complaints information and ensure all complaints made are recorded in the complaints book Ensure staff application forms are kept on file Carry out routine safety checks for the prevention of Legionella Timescale for action 01/11/05 2 YA2 14 01/12/05 3 YA22 22 01/12/05 4 5 YA34 YA42 19 13 01/11/05 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 12 Good Practice Recommendations Identify day time activities for the newly admitted resident Beechdene Care Home DS0000008631.V263493.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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