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Inspection on 28/04/05 for Beeches Retirement Home

Also see our care home review for Beeches Retirement Home for more information

This inspection was carried out on 28th April 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The atmosphere of the home is relaxed and comfortable. Residents spoken with all said that food was good and that staff are kind and caring. The premises are safe and well maintained throughout. The two staff members spoken with were knowledgeable about service users care needs and daily living preferences. The Manager maintains an open door policy for both staff and residents so they are able to speak to him at most times.

What has improved since the last inspection?

Written induction and foundation training programmes have been devised and implemented and staff now receive regular supervision. Health and safety risk assessments have been carried out for the house and grounds and for all safe working practices. Medication is handled satisfactorily and residents may selfmedicate within a risk-assessed framework. Residents` healthcare needs are fully met.

What the care home could do better:

Detailed risk assessments need to be undertaken for those residents who go out into the community unescorted. A regular programme of suitable in-house activities needs to be devised and implemented. Staff meetings need to be carried out and minutes made available for inspection. Formal quality assurance and monitoring systems need to be created and implemented. Evidence needs to be provided to demonstrate that residents or their representatives are involved in compiling and reviewing care plans. All staff must provide the required documentation prior to employment.

CARE HOMES FOR OLDER PEOPLE Beeches Retirement Home 4 De Roos Road Eastbourne East Sussex BN21 2QA Lead Inspector Gwyneth Bryant 28 April 2005 08.30 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 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 v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Beeches Retirement Home Address 4 De Roos Road Eastbourne East Sussex BN21 2QA 01323 731307 Telephone number Fax number Email 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 Joan Sinclair and Mr Darren Sinclair Mr Darren Sinclair Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (OP) 20 of places Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is twenty (20) 2. Service users must be older people aged sixty-five (65) years or over on admission. Date of last inspection 22 October 2004 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 accomdation 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 enable residents 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 made 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 residents are encouraged to assist with its care. Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this unannounced inspection over 6 hours. The purpose of the inspection was to check compliance with the requirements made at the last inspection and inspect additional standards. Thirteen of the key and eight of the remaining standards were inspected. There were sixteen service users in residence on the day of which eight were spoken with individually and eleven as a group. Two staff and the Registered Manager were spoken with. A range of documentation was viewed including care plans, personnel and medication records. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 6 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 Standards Statutory Requirements Identified During the Inspection Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 7 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 standard(s) 3 and 4 Adequate assessments are carried out prior to residents moving into the home. There are satisfactory systems in place to ensure service users needs are met. EVIDENCE: The admission procedure is detailed and pre-admission documents viewed showed that no resident moves into the home unless the home is able to meet their needs. Care plans are regularly reviewed to ensure changing needs are identified and the home is able to continue to meet assessed needs. Residents spoken with confirmed that staff know their preferences and are happy to make available anything else if required. Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 8 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 standard(s) 7, 8 and 9 There is a care planning system in place to guide staff in meeting residents assessed needs. Residents or their representatives are not consulted in the care planning process. Residents’ healthcare needs are fully met with satisfactory systems for ensuring the safe handling of medication. EVIDENCE: Since the last inspection a new care planning system has been introduced. This system enables care plans to be based on the pre-admission assessment. A sample of care plans were inspected and were found to be sufficiently detailed to ensure that residents health and personal care needs were met. Risk assessments were in place but were not adequate in respect of those residents who go out into the community unescorted. There was no evidence to demonstrate residents or their representatives had been involved in the care planning process and residents spoken with were not aware of the contents of their individual care plans, however staff spoken with were knowledgeable about residents individual care needs and preferences. Care plans showed that the home works closely with the community nurse to ensure those at risk of tissue breakdown are identified and appropriate action taken. A chiropodist visits the home regularly. Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 9 The Medication Administration Record (MAR) chart was viewed and all administered medication had been properly recorded. Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 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 standard(s) 12 and 15 Regular outings to local attractions are provided but in-house activities are limited. Meals are good offering both choice and variety. EVIDENCE: Outings are arranged during the summer months and this had been discussed during the last residents meeting. The home needs to develop and implement a weekly programme of in-house activities. Residents stated that they would like more to do during the day and more opportunities to socialise with each other. Menus were viewed and found to be balanced and offer choice. All residents spoken with said that the food was always good and that they have choice over the time they eat. Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 11 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 standard(s) 18 Systems are in place to protect service users from abuse. Staff have not been trained in adult protection procedures. EVIDENCE: The home has detailed policies and procedures on adult protection that includes a whistle blowing procedure. Information on the protection adults is included in staff induction training but staff were unaware of adult protection guidelines. Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 12 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 standard(s) 19, 22, 25 and 26 The standard of the environment is good, providing residents with an attractive, safe and homely place to live. Adequate systems are in place for the control of infection. EVIDENCE: A tour of the premises was carried out and it is clear they are well maintained and décor is good throughout. Residents spoken with all agreed ‘It’s a lovely home’. On the day of the inspection work was in progress to fit additional hand rails in toilets and bathrooms as recommended by the qualified person who assessed the premises. Laundry facilities are clean and hygienic. Systems are in place for the control of infection and all certificates were available to demonstrate staff have been trained in infection control. Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 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 there are at least three carers on duty each morning and at least two during the afternoon and evening shifts. One sleeping night staff member is employed and discussion with the Manager established that he is in the process of changing this to a waking member of staff. Residents told inspectors that staff never hurry them and call bells are answered promptly. Staff spoken with were knowledgeable about residents care needs and preferences. Since the last inspection recruitment practice has remained inadequate and does not protect service users. Personnel records were viewed and it was found that not all staff provided two written references and Criminal Records Bureau checks had not been carried out for all staff. Training records were viewed and this showed that induction and foundation training programmes are implemented for all staff. This training forms the basis for staff to achieve NVQ level 2 in care. Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36 and 38 The Manager provides clear leadership and support to staff. Residents are regularly consulted. The home would benefit from reviewing its performance, including consultation with staff. Satisfactory systems are in place to ensure that the safety and welfare of residents is promoted and protected. EVIDENCE: The Manager has managed the home for a number of years and regularly undertakes relevant training. Both staff and residents spoken with praised the Manager and said that they are able to speak to him on any issues. He has begun to train for NVQ Level 4 in care and the workbooks for this were available for inspection. The minutes of the last residents meeting were viewed and showed that they are consulted on issues within the home, including outings and menu choices. Staff meetings are not undertaken and this needs to be rectified. Quality assurance and quality monitoring systems have yet to be created. Staff supervision records were inspected and it was evident these sessions are used to confirm good working practices are achieved. Documents relating to safe working practices and Health and Safety Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 15 risk assessment were viewed and demonstrated that action had been taken to ensure the safety of residents and staff. Accident records were inspected and found to be satisfactory. There were records showing the regular testing of call bells, emergency lighting and fire alarms and that fire equipment and systems are regularly serviced. Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 16 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x 3 x x 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 3 2 1 x x 3 x 3 Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 17 yes 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. 2. Standard 7 7 Regulation 13 (4bc) 15 (1&2) (b&c) Requirement Risk assessments must be underaken for those residents who go out unescorted. Evidence must be provided to demonstrate residents or their representatives are involved in compiling and reviewing care plans. A regular programme of suitable in-house activities needs to be devised and implemented. (timescale of 22.12.04 not met). That all staff be trained in adult protection. (timescale of 22.12.04 not met). That all staff provide the required documentation as listed under Schedule 2 prior to appointment. That regular staff meetings are carried out and minutes taken. (timescale of 22.12.04 not met). That formal quality assurance and quality monitoring systems are devised and implemented. (timescale of 22.12.04 not met). Timescale for action 28.07.05 28.07.05 3. 12 16 (2) (mn) 13 (6,7& 8) 19 (1a-c) (2-7) 12 (5a &b) & 21 (2) 24 (1) (a&b) (2& (3) 28.07.05 4. 5. 18 29 28.07.05 28.07.05 6. 7. 32 33 28.07.05 28.07.05 Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 18 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 7 Good Practice Recommendations That staff be trained in undertaking risk assessments. Beeches Retirement Home v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 19 Commission for Social Care Inspection 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 v215813 h59-h10 s21045 beeches v215813 280405 stage 4.doc Version 1.20 Page 20 - 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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