Inspection on 31/07/08 for Beeches Retirement Home

This inspection was carried out on 31st July 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Beeches Retirement Home 31/10/07

Beeches Retirement Home 17/07/06

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Beeches Retirement Home 4 De Roos Road Eastbourne East Sussex BN21 2QA Lead Inspector Judy Gossedge Unannounced Inspection 31st July 2008 09:20 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.V366958.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 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 beechesretirementhome@aol.com 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.V366958.R01.S.doc Version 5.2 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. 31st October 2007 Date of last inspection Brief Description of the Service: Beeches retirement home is a detached two-storey Victorian property set in its own grounds in a residential area near to Eastbourne town centre. The home is registered to provide care and accommodation for up to twenty older people. Accommodation is presented across three floors with a shaft lift providing level access to most parts of the first floor and additional chair lifts fitted to small flights of stairs. Access to the second floor is by way of a stairway and residents accessing the two bedrooms on this floor will need to be fully mobile. Resident’s private accommodation consists of twenty single bedrooms; all have toilet and wash-hand-basin en-suite facilities with some having their own bathroom. Communal facilities include a dining room, lounge and conservatory. There is a rear secure garden, which has seating areas and a barbeque area. The home aims to provide a homely and friendly service with the emphasis on comfort and care. The range of fees charged at the time of the Inspection is from £350 to £450, which includes personal toiletries and in-house activities. Additional charges are made for hairdressing, chiropody, newspapers and dry cleaning. There is a detailed Statement of Purpose and Service Users Guide to reference. Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place over five hours and forty minutes on 31 July 2008. Prior to the Inspection an Annual Quality Assurance Assessment (AQAA) was sent to the home, which has been completed and returned and information detailed within is quoted in this report. A tour of the premises took place to look at communal areas and a selection of resident’s bedrooms and care records were inspected. Seventeen residents were resident, two were spoken with individually in their bedroom, two in the garden and a number were spoken with as part of the Inspection process during the tour of the building. The care that three of the residents received was reviewed. The opportunity was also taken to observe the interaction between staff and residents in the communal areas. One care worker, the deputy manager and the Owner/Manager were all spoken with. Ten residents and six staff surveys were sent out on this occasion and six residents and six staff surveys were completed and returned. What the service does well: What has improved since the last inspection? The home continues to undergo a gradual refurbishment this has included the redecoration of several bedrooms, a new shower room and the fitting of a digital internal phone system. Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 6 The Manager and deputy manager stated that staff do not work unsupervised unless they have an up-to-date Criminal Records Bureau (CRB) and POVA First check as required under Schedule 2. The Manager stated that residents or their representatives are provided with a copy of the terms and conditions of residency, in order that they are aware of charges and their rights and responsibilities whilst residing at the home. Suitably qualified persons prior to admission have assessed the needs of prospective residents in order that their needs are identified and can be met safely at the home. Each resident has a plan of care which records their health, personal and social care needs and the actions needed to meet these needs, which is reviewed regularly to reflect any changes in needs and preferences. The monitoring of the quality of the care provided includes a system for obtaining feedback from residents their representatives and other stakeholders on the services provided and the performance of the home. The policy on safeguarding adults has reviewed and updated in accordance with the East and West Sussex County Council, Brighton and Hove safeguarding adults’ procedures, to include the reporting procedures and the responsibilities of the home. 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. The summary of this inspection report can be made available in other formats on request. Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 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.V366958.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is detailed information available for residents and/or their representatives to view. Potential new residents are individually assessed prior to an admission to ensure that their care needs can be met in the home. Intermediate care is not provided in the home. EVIDENCE: A copy of the Statement of Purpose and Service User’s Guide are available to read in the entrance of the home. The documents were read, are detailed and have been reviewed. Some residents were receiving respite care at the time of the Inspection and the care to be provided should be clearly detailed in these documents. The Manager was aware of the need to further update these documents to reflect recent changes to the home and stated this would be addressed. So a Requirement has not been made on this occasion. Four residents surveys stated they had received enough information about the Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 9 home and two could not remember. One new resident spoken with had come straight from hospital and had not been able to visit the home. The AQAA detailed that the homes contract/terms and conditions has been reviewed and all residents have had a copy. Two residents surveys stated they had received a copy of the contract/terms and conditions, three could not remember and one stated they had not. A sample of the contract/terms and conditions was viewed and were in place, and for one, which was not for a new resident the Manager, stated this was in the process of being completed. The AQAA detailed that the pre-admission assessments completed has been an area, which has been improved in the home in the last twelve months. The deputy manager stated that herself or the Manager visits all potential new residents prior to any admission, and that a detailed pre-admission and assessment format, which is in place, is completed. This is to ensure individual residents care needs can be met in the home and to provide staff with information on the care to be provided. A copy of the assessment undertaken by the local authority is also sometimes received and available to reference. The documentation for two new residents admitted to the home since the last Inspection was viewed and there was detailed pre-admission information in place. Intermediate care is not provided in the home. Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are protected by a detailed individual plan of care being in place, where all their personal, social and health care needs are identified at the start of their stay and which informs staff of the care, which needs to be provided and with supporting risk assessments completed. Risks assessments should be further developed and provide guidance to staff as to how these risks are to be managed. Medication policies and procedures are in place. EVIDENCE: The AQAA detailed that changes and improvements have been made to the quality of the care plans. Four of the residents individual care plans were viewed. All were detailed and gave clear guidance to staff of the care to be provided, resident’s health care requirements, dietary needs, and social and leisure interests. Not all the residents had a risk assessment in relation to falls or where residents go out from the home independently and should be Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 11 developed to give staff guidance as to how to manage any identified risks. These documents had been regularly reviewed. Three residents surveys stated they always received the care and support that they needed, and three usually. Four staff surveys stated they were always given up-to-date information about residents care needs and two usually. Comments received were, ‘staff always make sure a proper handover is done at the end of each shift, if not in care plan information may be put in the daily diary.’ Records viewed detailed that residents are registered with a local General Practitioner (GP) and have access to other health care professionals, including district nurses, via the surgeries. It was noted, in care plans that were examined, that appointments with or visits by health care professionals are recorded. Three of the residents surveys stated they always received the medical support needed and three stated usually. The atmosphere of the home was comfortable, open and relaxed and residents are encouraged to remain independent and to exercise choice over their daily lives. Staff was observed to deliver care with dignity and respect. The residents spoken with felt the care provided respected their privacy and dignity. Feedback from residents was that they were pleased with the overall care provided in the home. The AQAA detailed that medication policies and procedures are in place. Medication is now stored in a new locked trolley and sample of the recording of medication administered was viewed. Changes in the requirements for the storage of control drugs was discussed with the Manager and a Requirement made for the necessary changes to be implemented. Records were viewed of the pharmacist visits, although the record of the last visit was not available to read. Where issues were identified the deputy manager stated these had all been addressed. The AQAA detailed that a number of staff had received medication training, but the training records were not up-to-date so it was not possible to evidence the staff that had completed the training. Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Where possible residents are enabled to exercise choice in their lives whist resident in the home, there are opportunities to participate in social and recreational activities provided, residents are encouraged to maintain contact with family and friends as they wish and a varied diet is provided. EVIDENCE: Residents social interests are recorded on their individual care plans and the AQAA detailed that a varied activity programme is in place, which is constantly reviewed and updated with new features. That over the last twelve months a regular fortnightly physiotherapy session has been arranged, a new rhythm music activity, and a new easy listening music session. Further plans for improvement over the next twelve months include a new activity area in the conservatory and the introduction of PAT therapy. A copy of the activities programme is available to view in the home and the deputy manager stated that there could be changes to the planned activities as residents are asked on the day what activity they would like to participate in. On the day of the Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 13 Inspection a video was due to be played during the afternoon. This did not take place as the deputy manager stated the residents had wanted to watch a programme on the television instead. Some residents go out and access local activities in the community and two residents spoken with confirmed this. Three of the resident’s surveys stated there were always activities provided and two usually. One comment received was, ‘I find it difficult to join in as I have poor eyesight.’ The AQAA details that residents are able to have visitors in private at any reasonable time, either in their own room or in any of the communal areas. Guests are made welcome, offered light refreshment and on occasion can eat with their friend or family member at no extra cost. The residents spoken with who had visitors confirmed there was flexible visiting, that staff are very welcoming and they could see their relative/friend in private if they wished. The care and support provided was observed to enable residents where possible to exercise choice whilst at Beeches. The four residents files viewed, staff and the four residents spoken with confirmed this. Residents are able to bring pets into the home on a trial basis with a view to being permanent providing other residents are in agreement if it will be in communal areas. A rotating menu is place, which the deputy manager stated has been seasonally varied and was seen to identify the choices available at all meals. Lunch on the day was chicken curry, chicken in mushroom sauce or fish fingers with mashed potatoes and mixed vegetables, followed by hot pears with cream or ice cream. Special diets are catered for. Residents were observed eating their lunch in the dining room and it was a relaxed environment taking into account the different length of time that individual resident would need to finish their meal. Records are kept of food consumed individually by each resident to ensure they are receiving an adequate diet. Four residents surveys stated they always like the meals provided, one usually and one did not complete the question. Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place to enable residents or their representatives to raise any concerns about the care being provided and to ensure that residents are protected from abuse. But not all of the home’s processes and procedures are being followed to provide adequate safeguards for residents. EVIDENCE: The AQAA details that there is a complaints policy and procedure in place and that no complaints had been received during the last year. The CSCI have not been made aware of any concerns in relation to the care provided at Beeches. A copy of the policy and procedure is detailed in the Service Users Guide. Two of the resident’s surveys stated they always, three usually and one did not complete the question when what asked it you know who to talk to if not happy. Four of the residents surveys stated they knew how to make a complaint and two did not complete the question. Six staff surveys stated that they knew what to do if a resident had any concerns, and stated they would ‘talk to manager,’ ‘the manager has to be informed immediately, follow the whistle blowing policy.’ Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 15 The AQAA detailed that there are policies and procedures in place in relation to the protection of vulnerable adults. The deputy manager evidenced that a copy of the new East and West Sussex County Council, Brighton and Hove safeguarding adults’ procedures is available to reference in the home and that the homes policy and procedure had been updated using this as a reference. The AQAA details that staff has regular training in adult abuse basic awareness, but the training records were not up-to-date and it was not possible to evidence all staff had received this training. As discussed under Standard twenty-nine of this report resident’s are not always safeguarded, as staff is not being fully vetted before working at the home. Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment, decorated and furnished to a good standard. The home ensures that residents private accommodation is equipped to provide comfort and privacy and to meet the assessed needs of those people residing in the room. EVIDENCE: A tour of the building was made. The home is decorated and furnished in a homely style, with a good standard of the décor, carpeting and furnishings. The AQAA detailed that during the last twelve months the residents en-suites have been refurbished, a new shower room, two new bathrooms one with a hoist facility and two new bedrooms have been provided. Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 17 There was a range of individual aids and adaptations to assist resident’s mobility and independence, including a passenger and chair lifts, raised toilet seats, walking aids, assisted baths and grab rails. Fitted throughout the home are call points, which enable assistance to be summoned when pressed. A digital telephone system has been installed which allows residents to make and receive calls anywhere in the home. There are twenty single bedrooms on all floors in the home. Two new bedrooms have been built on the second floor of the home since the last Inspection. The homes registration of twenty residents has not changed as the Manager stated it is intended all the bedrooms will now be single bedrooms. The Manager stated that all the required building regulations had been met, but was unable to evidence this during the Inspection. The evidence was subsequently provided. A number of bedrooms were viewed and displayed resident’s individual styles and interests. The Manager stated that on moving in to the home residents can have their room decorated to their own choice and can furnish it with their own effects. Two vacant bedrooms were in the process of being redecorated and carpeted. New towels and mattress covers have been purchased and were being distributed in the home. All of the bedrooms have en-suite facilities of a toilet and wash-hand-basin and some have their own bathroom. Bathroom facilities are provided throughout the home. Residents are able to control the temperature in their own bedrooms. The Manager stated there is regular testing of the hot water temperatures in the home, but the records was not available to view during the Inspection. This was discussed with the Manager to ensure these records are available to view and records were subsequently provided. The four residents spoken with confirmed there is adequate heating and hot water in the home. A passenger lift is available from the ground floor providing level access to most parts of the first floor and additional chair lifts are fitted to small flights of stairs. Access to the second floor is by way of a stairway and residents accessing the two bedrooms on this floor will need to be fully mobile. There is one lounge with a large conservatory and a separate dining room on the ground floor. There is a small rear well maintained garden, which has a patio, barbeque and seating areas, making this an attractive area to use and overlook. The AQAA details that further seating is planned for the garden. The AQAA details that there is a policy in place for managing infection control, but that the Department of Health Guidance to assess current infection control management has not been referenced. The deputy manager stated a copy to would be made available in the home. The home was clean and free from offensive odours at the time of the Inspection. Five of the resident’s surveys stated home was always fresh and clean and one usually. The AQAA detailed Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 18 that all staff had received training in the prevention of infection and the management of infection control and control of substances hazardous to health (COSHH) training has been provided, but the staff training records were not up-to-date and it was not possible to evidence. Staff is able to access protective clothing where required. The deputy manager agreed to seek guidance as to ensure that the COSHH information held in the home in the home met requirements to safeguard residents and staff. Recording was viewed of routine fire checks that had been carried out in the home. Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use this service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A robust recruitment procedure needs to be in place to ensure residents are in safe hands at all times. Staff should be provided with the required training or updates to ensure they have the skills to meet all the residents care needs. EVIDENCE: The AQAA details that staff levels are calculated according to the needs of the residents and the general function of the home. Staff spoken with during the Inspection confirmed the staffing levels in place. Three staff surveys stated there was always enough staff to meets residents care needs and three usually. All staff was found to have a good rapport with residents, which promoted a relaxed atmosphere in the home. The deputy manager, and two care workers were on duty during the morning. A further care worker was called in to help provide care at lunchtime and the Manager was present in the home during the afternoon. Two care workers were on duty during the afternoon and at night the home deploys one ‘waking night,’ member of staff. This should be kept under review to ensure the care needs of individual residents continues to be met. A designated care worker or the Manager undertakes the cooking in the home and currently care workers are Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 20 undertaking domestic tasks in the home, as there is no domestic staff following this post recently becoming vacant. The deputy manager stated that it was intended to recruit again to this post. Comments received from the staff surveys when asked what the service does well, ‘provides the right care for individuals needs, ‘provides a good and safe environment and friendly atmosphere,’ ‘gives all the residents good care and services they need as an individual,’ ‘provides a homely environment for the residents, caters for individual needs and requirements,’ ‘activities, connection with residents, general care, celebration of birthdays, and public holidays,’ and ‘it provides an excellent service to all its residents. Proper assessment is carried out before admitting a resident.’ The AQAA detailed that ten of the twelve care workers working in the home holds an NVQ Level 2 in care and one further care worker is working towards this qualification. The AQAA detailed that new staff working in the home had satisfactory preemployment checks. The documentation was viewed for the three new members of staff, who had been recruited since the last Inspection. All demonstrated the completion of an application form, all had two written references in place, but for one member of staff a verbal reference had been sought, but the written reference had not been received until after the member of staff had commenced working in the home. All had completed a Criminal Records Bureau (CRB)/and a Pova First check. For another member of staff a POVA First check had not been received prior to commencing work in the home. The Manager was not also able to demonstrate that all staff working in the home have had a CRB check undertaken. A sample of staff documentation was viewed and all had had a check completed. The Manager stated that the new computer programme to be installed in the home will enable this information to be viewed for future Inspections. Five of the staff surveys stated that recruitment checks were carried out before they started work. The Acting Manager evidenced that induction training for new members of staff is in place and stated that this meets the requirements of the General Skills for Care induction standards. Records viewed evidenced that some staff had completed this. One new care worker spoken with confirmed completion of a local induction. The deputy manager stated that some staff were waiting the induction and it was discussed the need to ensure that the induction is started and completed within the required timescale. The four staff surveys stated the induction covered everything very well and two mostly. Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management team provides a sense of leadership and direction and run the home in the best interest of residents however shortfalls in some key management responsibilities means some practices do not promote and safeguard the health, safety and welfare of residents. Quality assurance systems enable ongoing feedback about the care provided in the home. Feedback from the outcome of the quality assurance process undertaken in the home should be collated and available to read. EVIDENCE: Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 22 The Owner/Registered Manager for the home has completed the Registered Managers Award and NVQ Level 4 in Care. There have also been further training opportunities which the Registered Manager has attended. There is a deputy manager to support the Manager, who is also undertaking the Registered Managers Award and stated that when she has completed this will then be undertaking NVQ Level 4. Both staff confirmed changes to the deputy’s role since the last Inspection to enable the deputy manager to be more office based and undertake management tasks such as care planning. The deputy manager was knowledgeable on the daily running of a service for older people and showed much commitment to ensuring good standards of care were maintained. A quality assurance system has been developed. It was evidenced that feedback about the service provided has been sought from residents, relatives/representatives through surveys and residents meetings and the AQAA details other health care professionals who attend the home will be surveyed later in the year. Feedback from the outcome of the quality assurance process undertaken in the home has not been collated and should be available to read. The AQAA detailed that policies and procedures are in place, but not all are in place as required. This was discussed with the deputy manager during the Inspection to ensure all the required policies and procedures are in place. Residents are encouraged to retain control of their own finances for as long as they are able to do so and if unable then this responsibility is taken on by a relative or another responsible persons external to the home. The Manager reported that they do sometimes hold small amounts of money for a few residents, and that a receipting system is in place. Staff spoken with and records viewed confirmed that staff supervision does not occur to meet the requirements of Standard 36. The deputy manager stated this is in the process of being fully implemented, so a Requirement has not been made on this occasion. A sample of staff training records was viewed. These were not fully up-to-date and with staff feedback evidenced that not all staff had received training in moving and handling, basic food hygiene, fire training/fire drills, first aid and infection control within the required timescales. The AQAA details this is an area, which needs to be improved over the next twelve months. The AQAA detailed that some the maintenance of equipment and services has been carried out. There was no record of the electrical circuits having been maintained, the emergency call system or the homes hoist. This was discussed with the Manager who stated the emergency call system is run by batteries which are regularly checked each month and has subsequently Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 23 confirmed that the evidence of the maintenance of the electrical curcuits could not be found and a new check of the system has been arranged. The hoist is rarely used, but the Manager acknowledged it is due to be serviced and stated that the maintenance of the hoist would be arranged. So a Requirement was not made on this occasion. The Manager commissioned an external agency in 2008 to complete a fire risk assessment for the home. The Manager stated an external agency was commissioned last year by the to undertake an environmental risk assessment of the building, but this was not available to view during the Inspection. Recording was viewed of incidents and accidents, which had occurred in the home. Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 24 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 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 13(4)(c) Requirement That residents photographs are taken as part of the admissions process. Timescale for action 30/09/08 2 OP9 13 (2) 3 OP29 19 (1) (a) (b) That the recorded risk assessments in place include a falls risk assessment for all residents and where residents go out from the home independently. All risk assessments give clear guidance to staff as to how the risks are to be managed and detail individual residents care needs. To protect residents and staff. That suitable storage and 30/10/08 recording is in place for control drugs to meet the new requirements. To protect residents and staff. That a thorough recruitment and 30/09/08 selection process is in place and this staff do not commence work in the home before a satisfactory POVA First /CRB check has been received and two written references. To protect residents. That there is photographic evidence of staff members held Beeches Retirement Home DS0000021045.V366958.R01.S.doc Version 5.2 Page 26 4 OP38 23 (4) (d) 5 OP33 24 (1) (2) (3) at the home. That all staff have received the required training/updates in moving and handling, basic food hygiene, infection control, fire training, protection of vulnerable adults and first aid and this can be evidenced. To protect residents and staff. That the results of the quality assurance for the home are collated and made available to residents and their representatives. To ensure residents and their representatives have adequate information about the home and enable the quality of the care provided to be monitored and demonstrate improvements made. 30/09/08 30/09/08 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.V366958.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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