Inspection on 17/07/06 for Beeches Retirement Home

This inspection was carried out on 17th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beeches Retirement Home 31/07/08

Beeches Retirement Home 31/10/07

Beeches Retirement Home 03/11/05

Beeches Retirement Home 28/04/05

Beeches Retirement Home 22/10/04

Beeches Retirement Home 26/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Beeches Retirement Home 4 De Roos Road Eastbourne East Sussex BN21 2QA Lead Inspector Gwyneth Bryant Unannounced Inspection 17th July 2006 08:00 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 Beeches Retirement Home DS0000021045.V293108.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. Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beeches Retirement Home Address 4 De Roos Road Eastbourne East Sussex BN21 2QA 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) 01323 731307 Mrs Joan Sinclair Mr Darren Sinclair Mr Darren Sinclair Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty (20) Service users must be older people aged sixty-five (65) years or over on admission. 3rd November 2005 Date of last inspection Brief Description of the Service: The Beeches is a detached two-storey Victorian property set in its own grounds in a residential area. The home is registered to provide care and accommodation for up to twenty older people, comprising of fourteen single rooms and six doubles. It is situated approximately half a mile from the town centre and is close to all travel routes and local amenities. The home aims to provide a homely and friendly service with the emphasis on comfort and care. Access to all floors is via a passenger lift. The home has one assisted bath and a portable hoist to give residents the opportunity to bathe in any of the homes baths. All rooms have en-suite facilities and two also have a bathroom. Various aids and adaptations have been provided to promote independence. Communal areas consist of a dining room, large lounge and conservatory. There are well-maintained front and rear gardens. The home has a pet bird and service users are encouraged to assist with its care. The service provides prospective service users with a copy of the homes brochure and an offer to visit in the first instance. A copy of the service users guide, the statement of purpose and a contract is supplied at the time of the visit as part of the preadmission process. The range of fees charged as from 1 April 2006 is from £322 to £400 which include personal toiletries and in-house activities. Additional charges are made for hairdressing, chiropody, newspapers and dry cleaning. Intermediate care is not provided. The homes web address is beechesretirmenthotel.com from which there is an email link. Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place over seven hours. The purpose of the inspection was to check compliance with the requirements made at the last inspection and inspect additional standards. There were seventeen people in residence on the day of which four were spoken with individually. The Registered Manager, his deputy, one relative and one carer were also spoken with. A tour of the premises was carried out and a range of documentation was viewed including care plans, personnel and medication records. Eight surveys were returned to the inspector and all were positive about the care given. All of the residents spoken with spoke highly of the care given and the dedication of staff. The registered provider provided a preinspection questionnaire. The reader is asked to be aware that where shortfalls are identified the Registered Provider is aware of them in his role as Registered Manager. Healthcare professionals were not engaged with on this occasion. What the service does well: What has improved since the last inspection? All staff have been trained in adult protection procedures to promote the protection of residents. The implementation of formal quality assurance and quality monitoring systems enables the provider to critically evaluate the service. A programme of maintenance and renewal has been created and implemented to ensure any minor repairs are carried out without delay. These Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 6 improvements have been carried out in respect of addressing the shortfalls identified at the last inspection. 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. Beeches Retirement Home DS0000021045.V293108.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 Beeches Retirement Home DS0000021045.V293108.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): 1, 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are provided with sufficient information of the services provided and the pre-admission care assessment process ensures the home can meet prospective residents’ needs. EVIDENCE: The Statement of Purpose and Service Users Guide have been recently updated and contain all the information required to enable prospective residents to make an informed choice about where to live. Pre-admission documentation was viewed for recent admissions and it is evident that these documents are used effectively to ensure the home is able to meet the needs of prospective residents. Residents spoken with confirmed that they and their family were encouraged to assess the suitability of the home prior to admission. Intermediate care is not provided. Beeches Retirement Home DS0000021045.V293108.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): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All aspects of service users health, social and care are identified and planned for and the care planning systems clearly direct staff in the delivery of appropriate care. Residents are protected by satisfactory systems for the recording, handling and storing of medication EVIDENCE: Four care plans were viewed and it was evident that pre-admission assessments are used to inform the care planning process. Care planning documents included information on meeting residents’ healthcare needs such as dental, hearing and eyesight checks and also provided clear direction to staff as to how residents daily care needs are to be met. Risk assessments had been carried out and they clearly identified the hazards and included sufficient detail for the management of risks. There was evidence to show that residents were involved in the care planning process and two residents who were spoken with confirmed they were involved in the compilation of their care plans. In addition the one relative spoken with also confirmed that he is kept informed of any changes in care needs. Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 10 There is a key worker system in place ensuring that residents receive consistent care. In addition to detailed care plans key workers are required to maintain a daily diary to ensure any changes in need are rapidly identified and addressed. Discussion with the manager, his deputy and a carer found that they were aware of residents’ individual needs and that they have strategies for meeting them. Throughout the inspection staff were noted to treat residents with care and respect and it was evident that comfortable working relationships had been developed. Residents spoken with spoke highly of the care given and comments included: ‘I couldn’t be better looked after’ ‘everyone is so kind’. Surveys returned included statements that: ‘all effort made to make clients happy’ ‘I am happy here because the staff are so kind’. Medication records and storage arrangements were viewed and systems remain effective. Medication administration charts were up to date, accurate and clear. Only staff who have been trained administer medication and this was confirmed by staff spoken with. Medication is stored in a locked cabinet to ensure unauthorised persons cannot access it. Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place for residents to experience a lifestyle that matches their expectations, choice and preferences in respect of both leisure and meals. EVIDENCE: The home has a daily programme of activities and outings to local attractions or shopping are also arranged. On the day of the inspector joined residents for a ‘Music and Motivation’ session. Those who participated clearly enjoyed the opportunity to exercise both minds and bodies. It was accepted that one resident chose to watch television in their room while this activity took place. For those residents who preferred a quieter activity, painting and embroidery was provided in the dining room. Residents spoken with said they very much enjoyed the activities and care plans showed that every effort was made to identify and meet the leisure needs of residents. Other activities provided include arts and crafts, visits by a PAT dog, bingo, quizzes, crosswords, singers, cards, films and church services. Residents are enabled to use the homes’ email facilities to contact family who live abroad and currently one resident uses this to keep in touch with their family. Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 12 The daily records showed that residents are encouraged to access the community and on the day, one went shopping in the town with a friend. The relative spoken with confirmed that the family is always made welcome and are encouraged to visit as often as possible. Meals continue to be an area that residents praise highly, both via the surveys and by those spoken with. There is a choice of main meat meal each day and a vegetarian option. Survey comments were: ‘I enjoy all meals’, ‘food very varied and enjoyable’ ‘food and accommodation excellent’. The lunchtime meal was observed and the food was attractively presented and residents clearly enjoyed it. The day of the inspection was very hot and the deputy manager explained the strategy for ensuring residents remain healthy during the heat wave in that fluids are available to residents at all times. On touring the premises it was observed that all bedrooms included a jug of squash or water and all residents in the lounge were provided with regular drinks. For those residents who are reluctant to drink fluids, a supply of iced lollies is provided. Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 13 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure with evidence that residents feel that their views are listened to and acted upon and residents are further protected by satisfactory adult protection systems. EVIDENCE: The home has detailed policies and procedures on complaints, a copy of which is in the homes hallway. No complaints had been received since the last inspection either in the home or to the CSCI. Residents said that they would be happy to speak to the manager or staff if they had any concerns. Of the eight surveys returned all stated that they knew who to speak to if they had any problems and that they felt staff listened to them. The home has policies and procedures on adult protection and staff are expected to be familiar with this document. The manager is undertaking training in adult protection as part of his National Vocational Qualification (NVQ) training and will cascade this training to staff who still need this training. The carer spoken with confirmed they had received training in adult protection procedures. Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 14 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): 19, 22 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of decor within the home is generally good, with most areas homely, safe and comfortable for residents but could be improved if minor adjustments were made to grab rails. EVIDENCE: A tour of the premises was carried out and most parts of the home are well maintained and décor is generally good. Residents’ rooms were attractively decorated and it was evident that many had taken the opportunity to personalise their rooms with pictures and ornaments. The one minor shortfall was that one resident could not reach the grab rail while using the en-suite toilet and this needs to be rectified as there is a risk of falls if a resident overreaches. This was discussed with the manager who agreed to arrange for the maintenance person to move the grab rail. Laundry facilities are clean and hygienic. Systems are in place for the control of infection and all staff have been trained in this area and were observed to Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 15 be working in ways that minimised the risk of infection, by wearing gloves and aprons when required. Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff and the skill mix is such that residents’ needs are met and consistent care is provided. The recruitment practice is not robust and does not provide sufficient safeguards for the protection of residents. EVIDENCE: Staff rotas were viewed and demonstrated that there are three carers on duty in the mornings and two for all other working shifts, in addition to the manager and his deputy. There is one waking night carer and the manager provides ‘on call’ cover at night. There is a key worker system in operation and one key worker spoken with was knowledgeable about the needs of those for who he was responsible. Residents’ spoken with were aware they had been allocated a ‘special’ person who looks after them. All residents’ spoken with mentioned the care, kindness and friendliness of staff. Of the eleven care staff, three have NVQ level 2 in care, two have level 3 in care, one is a qualified nurse and two staff are about to begin NVQ level 2. Currently homes are required to have 50 of care staff with this qualification therefore the Standard is exceeded. Recruitment records were viewed and it was found that two staff did not have an up to date Criminal Records Bureau check and one was working unsupervised without either a Criminal Records Bureau or Protection of Vulnerable Adults (POVA) first check. There was evidence to show that these checks had been applied for and the manager explained that there have been Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 17 delays in processing these checks. In allowing staff to work unsupervised, without at least a POVA first means the home is not complying with the regulations and this practice may put residents at risk. The manager explained that this was not the homes’ normal practice as the carer in question has been known to the manager, personally, for a number of years so he took the decision to employ them based on his knowledge of their good character. He confirmed that he would review the situation and either ask the carer to change to a day time shift or employ a second night carer to shadow her. There are induction and foundation programmes in place for all staff and these were viewed, demonstrating that all staff have the skills and knowledge to meet residents needs. Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff and residents benefit from clear leadership and direction and all aspects of residents’ health, safety and welfare are protected and promoted. EVIDENCE: The Manager is in the process of gaining the Registered Managers Award and an NVQ 4 in Care. In addition he has many years experience in managing a care home. The manager has begun a comprehensive quality monitoring and quality assurance process to ensure the home is run in residents’ best interests. Residents meetings are carried out as are staff meetings and minutes from these are used to inform the quality monitoring system. Minutes from residents’ meetings were viewed and showed that these meetings are used to consult with residents on a wide range of issues such as activities and staffing. Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 19 Residents are responsible for their own finances if appropriate; relatives and solicitors support others. When items are purchased on behalf of residents, receipts are obtained and satisfactory records maintained. All staff receive formal supervision and records of these sessions are maintained. These records demonstrate that the sessions are used to effectively identify staff training needs and to discuss work practices. The carer spoken with confirmed that these sessions are a useful way of discussing training needs and that any training requests are recorded. Evidence was available to demonstrate that electrical and gas systems and appliances have been serviced and are safe. Documents relating to safe working practices and Health and Safety were available and found to be satisfactory as were accident records. Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 21 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 OP29 Regulation Requirement Timescale for action 17/08/06 19(1)(a-c) That staff do not work (2-7) unsupervised unless they have an up to date Criminal Records Bureau and POVA first check as required under Schedule 2. (timescale of 03/12/05 not met) 16(1)(2c) 23(2n) That grab rails are accessible when service users are using the relevant facility. 2 OP22 17/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beeches Retirement Home DS0000021045.V293108.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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