Inspection on 30/01/07 for Beechfield Lodge

This inspection was carried out on 30th January 2007.

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 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

Beechfield Lodge 29/06/07

Similar services:

Chirnside House

Keer Sands Residential Home

SignHealth

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Beechfield Lodge 232 Eccles Old Road Salford Manchester M6 8AG Lead Inspector Sue Jennings Unannounced Inspection 30th January 2007 10:00 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 Beechfield Lodge DS0000067821.V307848.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. Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechfield Lodge Address 232 Eccles Old Road Salford Manchester M6 8AG 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) 0161 707 6747 sharon.blackwell@anchor.org Anchor Trust Ms Margaret Thomas Care Home 59 Category(ies) of Old age, not falling within any other category registration, with number (59), Physical disability (1), Physical disability of places over 65 years of age (59), Sensory Impairment over 65 years of age (59) Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of fifty nine (59) service users may be accommodated who are aged 60 years and over and require care by reason of old age (OP) and who may also have a sensory impairment (SI(E)) and/or a physical disability (PD(E)). One (person maybe accommodated who is under the age of 60 years in the category of Physical Disability (PD). 10th August 2006 2. Date of last inspection Brief Description of the Service: Beechfield lodge consists of 44 self-contained flats, which consist of a small kitchen, en-suite shower and toilet facilities. There are 12 en-suite residential bedrooms and the facility for 1 respite care place in a room which is not ensuite. The home has a range of communal facilities, including a cinema room, courtyard and barbeque area with a patio and shrubs. The premises are specifically designed for people with visual and physical impairment and include a talking lift, textured floor coverings, tactile signs, entrance lighting and colour contrasting decoration to aid residents. Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was undertaken as part of a key inspection, which includes an analysis of any information received by the Commission for Social Care Inspection in relation to this home prior to the site visit. The visit was unannounced and took place over the course of 4 hours on Tuesday 30 January 2007. During the course of the site visit time was spent talking to the manager, 4 residents, a visitor and 5 members of staff to find out their views of the home. The inspector spent time examining records and the residents and staff files. A tour of the building was also made. What the service does well: The home’s décor, furniture and the facilities are of a high standard. Each resident is registered with a local General Practitioner (GP) and where possible residents are able to retain their own GP. The home had a comfortable and homely atmosphere. The home carries out an assessment of need on all prospective residents before an offer of a place is confirmed. Residents are able to attend religious services either in the local community or a minister of their chosen faith can visit them in the home if preferred. All staff spoken to said that the home has a good training programme in place and there were a number of positive comments made regarding the manager of the home. The home continues to support the residents to pursue social and leisure activities. Family and friends are encouraged to visit regularly. Where this is not possible staff at the home will assist residents to maintain contact via telephone or letter. The home has a complaint procedure and information about how to make a complaint is included in the home’s statement of purpose and function. Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 6 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 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. Beechfield Lodge DS0000067821.V307848.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 Beechfield Lodge DS0000067821.V307848.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): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents’ needs are assessed before an offer of a place is confirmed. However, more detail needs to be recorded to ensure residents’ needs can be met. EVIDENCE: During the course of the visit time was spent examining records, talking to the manager, and five members of staff. The home produced a Statement of Purpose and Function and a Service User Guide. The organisation is in the process of producing this information on audiocassette and in Braille. Prospective residents are encouraged to visit the home before making a decision to move in. Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 9 The manager or deputy manager would visit the person prior to admission to carry out a pre-admission assessment. This is to make sure that the home can meet the person’s needs. The home has started to use a new pre-admission assessment form. This is then used to develop a care plan. A sample of care plans was examined. The pre-admission assessment form was not in place on all files and there was little information recorded about the service users’ needs. It is recommended that the pre-admission forms are fully completed for each service user. This home does not provide intermediate care. Beechfield Lodge DS0000067821.V307848.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the residents were generally being met by the home. However, residents were being placed at unnecessary risk by the failure of staff to administer/record prescribed medications in accordance with the General Practitioner’s (GP) directions. EVIDENCE: There was still no evidence that the home used the good practice of involving the resident or their representatives in the care planning process. One relative spoken to was asked if they had been involved in developing the care plan, but could not recall being asked. The home had begun using a new care plan format. This included a preadmission assessment form. Of the files examined only one had a preadmission assessment form. The information recorded on this form was Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 11 minimal. This did not give enough information about the person to write a care plan. The new care plans gave details about significant life events such as children’s birthdays, wedding anniversary’s, death of spouse etc. This made staff aware of times when residents may need additional support and was good practice. Care plans contained a photograph along with a signed consent form giving permission for the home to take the photo. It was clear that the home had worked hard to improve the care plans. A separate care plan was completed for each area of need with an activity sheet/daily record to record what staff had done each day to meet that area of need. However, where the need was ongoing for example the resident needing help with washing and dressing every day, there were no daily records attached to this care plan to show that this had been done. It was discussed with the manager that this was not good practice and that the home was not providing evidence that they were meeting the resident’s assessed needs in this area. Not all sections of the care plans were fully completed, the mobility assessment gave details of what equipment and numbers of staff were needed to help a resident but not what help was needed from staff. Some of the care plans had not been signed or dated by the staff completing them making it difficult to know when they had been written. A number of recommendations were made in relation to the care plans. The medication was stored in a locked storeroom, there were three metal trolleys secured to the wall one for each area of the home. Excess medication was stored in a locked metal trolley and there was also a night medication trolley. These were also secured to the wall. Controlled medication was stored in a double locked metal wall cabinet. A sample of the Medication Administration records was examined and a number of errors in recording were noted. This included medication still in the blister pack having been signed for as given to the resident. There were a number of residents prescribed pain relief medication to be taken 4 times a day. A large amount of tablets remained in the blister pack with no reason for them not being taken recorded on the Medication Administration Sheets. The controlled drug book had been signed to show that medication had been given to one resident but the medication was still in the blister pack. A large amount of medication was stored in bags and a box under a table, this medication had not been entered into the returns book and there were no Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 12 immediate plans for the pharmacist to collect it. The manager must make arrangements for returns to be collected as soon as possible. Priority must be given to monitoring the administration of medication to ensure good practice is adhered to at all times. A lockable refrigerator was provided for the storage of those prescribed medicines requiring cold storage. Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided a good environment with some activities available. Meals served at the home were nutritious, well balanced and offered a healthy and varied diet for residents. EVIDENCE: The menus were planned on a four-week rota. The meal on the day of the site visit was cheese and onion pie, vegetables and chips. There was a choice of menu each day. The catering staff checked with residents each day to ask what they would like from the days choice of meals. Residents spoken to said that the food was “always nice”. The manager said that a review of the menus was underway. Previously soup was served at lunchtime with the cooked meal. This had been altered and soup is now served before the light meal at teatime. This is to give a more substantial evening meal to residents. Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 14 The home had a vacant activity organisers post. One of the care staff had been carrying out these duties. The home had a programme of activities that include cinema evenings, where old films were shown. Trips and in-house entertainment was arranged. The manager said that they were planning a cheese and wine evening for residents on Valentines Day and staff were talking to residents about how they would like to celebrate the day. Ministers from various faiths visit the home and where possible residents go to the local church to attend mass. The home has an open visiting policy and relatives and friends of the residents are able to visit at any time during the day. The residents are able to receive visitors in the privacy of their own rooms or in one of the communal lounges. Many of the residents have a telephone in their room to help them stay in contact with family and friends. A relative spoken to said that a telephone was fitted very quickly and was a “lifeline for the residents to maintain contact”. There are no restrictions on visiting unless the resident has agreed this. Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had policies and procedures that served to protect the residents from abuse. A complaint procedure was available and was known to residents. EVIDENCE: The home had a copy of the Salford City Council’s Adult Protection Policy and Procedure and the manager and staff were aware of the procedure to be followed in the event of an allegation of abuse being made. Two members of staff were asked what they would do in the event of an alleagation of abuse being made. Both said they would “make sure the resident was safe” and then “tell the manager or senior in charge”. A visitor spoken to said “ I have had a couple of concerns, we have met with the manager and I was very happy with the outcome and that it had been dealth with properly”. Policies and procedures were in place to help the staff protect the residents from harm or abuse and the staff spoken to were aware of these policies and procedures. Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 16 Examination of training records indicated that the staff received induction training and Protection of Vulnerable Adults training. A training record was seen on staff files. There was a complaint logbook in place that detailed all the complaints received by the home. Complaints were dealt with appropriately by the home. The Commission for Social Care inspection have not received any complaints or comcerns regarding this home since the last inspection. Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable and safe environment for residents with specialist equipment available as required by individual residents. The standard of decoration was generally well maintained both internally and externally. EVIDENCE: The home felt comfortable and homely and was clean and tidy with no offensive odours. The decoration both externally and internally was of a good standard and the furniture was domestic in nature. Residents were seen sitting in various lounges listening to music or reading and there was a good staff presence. Staff in one lounge were observed in discussions with residents. Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 18 Bedrooms were personalised with items brought from residents homes. Some had a television and radio and were able to spend time in the privacy of their rooms if they wished. Resident’s bedrooms had been fitted with a privacy lock suited to their capabilities and accessible to staff in emergencies. The residents wear a pendant alarm so they can summon help if needed. One resident said “I press this and the staff come quickly”. One resident said, “I have a lovely room, and I have brought in my own bits and pieces and some photographs”. A visitor spoken to said “the flat is ideal, it gives my parents some degree of independence but also the security of having staff around to help them”. A talking passenger lift was in place. Grab rails and other aids were provided in the bathroom and some of the communal areas. Beechfield Lodge DS0000067821.V307848.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff appeared sufficient to meet the needs of the residents accommodated. EVIDENCE: The manager reported that a number of new staff had been appointed and that the home was using fewer agency staff. The numbers and skill mix of the staff, at the time of inspection appeared to be sufficient to meet the needs of the number of residents accommodated. The gender mix of staff was good with male carers being on the team. This enabled the male service users to have some choice about whether they wished to have a male carer to help with their personal care needs. Five staff files were examined evidence was seen that they contained copies of the application form, references and CRB disclosures. All records held in respect of staff working at the home are in place before a member of staff is employed. Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 20 Training needs were identified during supervision and the home provided ongoing refresher training in Health and Safety, Basic Food Hygiene, Fire Safety, First Aid and Moving and Handling. Staff files examined indicated that the staff received regular supervision to allow them to support the residents appropriately. This was confirmed in discussion with three members of the staff team one said “I have supervision with the deputy manager, we discuss the residents and any training”. Another said “yes we get supervision about every 8-weeks we talk about the residents needs and any problems”. Beechfield Lodge DS0000067821.V307848.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates in the best interests of the residents with quality monitoring systems in place to protect residents. EVIDENCE: The home’s certificates of registration and public liability insurance were displayed in the entrance hall. These were accurate and up to date. Families assist residents who are unable to manage their own finances. All residents were in receipt of their personal allowances. Small amounts of money were held for residents to purchase small items. Receipts were kept of all purchases made on resident’s behalf. The home’s administrator kept a record of resident’s finances. Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 22 This included a communal receipt for the payment of hairdressing and chiropody. It was recommended that the home ask for separate receipts that can be filed on the individual’s financial record so that shared information is not accessible should relatives wish to see the record. Relevant certificates were on file to show that appropriate servicing of equipment used by residents in the home had been carried out. Fixed Gas and Electricty appliances had been regularly maintained and a periodic test of portable appliences and lifting equipment had been carried out. Fire equipment had been regularly maintained and staff had received fire awareness training. The handyman tests fire alarm systems on a weekly basis. A quality assurance and quality monitoring system was in place, which includes obtaining views of residents and their relatives. Anonymous questionnaires had been sent out to resident’s relatives/representatives in an attempt to gain their views. Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 24 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Timescale for action The registered person shall make 25/04/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. Requirement 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. 2. 3. 4. Refer to Standard OP7 OP7 OP7 OP7 Good Practice Recommendations It is strongly recommended that the home adopt the good practice of involving the resident and or their representative in the development of care plans. It is recommended that care plans are signed and dated to show when they were developed and when they are due for review. It is recommended that daily records are maintained for all aspects of need identified in care plans to evidence that the needs are being addressed and met. It is strongly recommended that the care plans be signed and dated to identify when the plan was developed and when it is due for review. DS0000067821.V307848.R01.S.doc Version 5.2 Page 25 Beechfield Lodge Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection CSCI, Local office 11th Floor Westpoint 501 Chester Road Manchester M16 9HU 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. Extracts may not be used or reproduced without the express permission of CSCI Beechfield Lodge DS0000067821.V307848.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!