Inspection on 06/07/05 for Beechfields Nursing Home

This inspection was carried out on 6th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Beechfields Nursing Home 07/11/08

Beechfields Nursing Home 09/05/08

Beechfields Nursing Home 11/12/06

Beechfields Nursing Home 08/02/06

Beechfields Nursing Home 31/01/05

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Beechfields Nursing Home 1 Wissage Road Lichfield Staffordshire WS13 6ES Lead Inspector Lynne Gammon Announced 6 July 2005 - 09:30am 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. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Beechfields Nursing Home Address 1 Wissage Road Lichfield Staffordshire WS13 6ES 020 8423 8804 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) Tudor Care Plc Ms Linda Wheat CRH 21 Category(ies) of PD - 21 registration, with number PD(E) - 21 of places Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 Pd Minimum age 60 years on admission Date of last inspection 31 January 2005 Brief Description of the Service: Beechfields Nursing Home is situated one mile from Lichfield Town centre, on a quiet lane in a pleasant suburban area. The home was established in 1992 by the conversion of a detached house with the addition of a purpose built extension. Beechfields comprises of 17 single and 2 double bedrooms, two separate lounges, one leading to a conservatory and a dining room. Externally there are large, well-stocked gardens which are easily accessible for wheelchair users. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced visit was made on the 6th July 2005 at 10.00 a.m. The inspection was carried out by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. The total time spent for the inspection, including pre and fieldwork, amounted to 9 hours. The registered provider, Mr Anil Patel for Tudor Care Ltd, and the registered care manager, Ms Linda Wheat, an RGN, were present throughout the inspection. Also on duty were an RGN, 5 care assistants, an activities coordinator, a cook, a kitchen assistant, a domestic, a housekeeper/laundry assistant and a handyman /gardener. There were 20 residents living in the home at the time of the inspection and these staffing levels were satisfactory to meet their needs. The inspection included a tour of the building, inspection of records, observation, and discussions with service users, the registered provider and staff. Since the last inspection on 31st January 2005, no complaints nor any incidents or reports of abuse of any kind had been received and no requirements or recommendations, against the regulations or the minimum standards, were outstanding from the last inspection report. The required documentation and service user guide had been produced by the home and made available for prospective service users. All service users had been assessed prior to admission and supported to make a choice about the home. They were invited to visit the home before making a decision and an initial 4 weekly trial period when moving in helped the individual decide if the home was the right place for them. Care plans had been well written and health, personal and social care needs had been met and well documented. All aspects of service user privacy, dignity and choice were supported and endorsed. Service users confirmed that they were very happy in the home and that staff treated them with dignity and respect. The home had a homely, comfortable atmosphere and was well maintained and very clean. All of the bedrooms were decorated to a satisfactory standard and contained various personal items belonging to the individual service user. The communal areas were bright, warm and tidy, and were also decorated to a satisfactory standard with good quality furniture and fittings. Food was well presented, varied and nutritious with choices available to meet a range of needs. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 6 Staff training had been provided and over 50 of trained care staff had achieved NVQ Level 2. Staff had not received formal supervision for some months but this had recently recommenced from 1st July 2005. The home was well managed and organised, and service users were able to make their own choices and decisions about the day-to-day activities within the home. Recruitment and selection procedures within the home were thorough and detailed for the protection of service users. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 5 All service users had been assessed prior to admission and received confirmation that their needs would be met. Potential service users received information prior to moving in and were invited for a trial visit to enable them to make an informed choice about the home. EVIDENCE: The Statement of Purpose and the Service User’s Guide were inspected and found to be comprehensive and met the required standards. Records showed that pre-admission assessments were carried out by the Matron which were detailed and thorough, covering all aspects of care needs. Six week trial visits were available to all potential service users to enable them and the staff to determine the suitability of the home in meeting the needs of the individual. Service users who were spoken to confirmed that they had been able to visit the home before choosing to stay. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The care planning processes were clear and consistent and provided staff with the information they needed to meet service user’s care needs satisfactorily. The medication administration systems within the home were well managed promoting good health. Service users were treated in a respectful and dignified manner and their need for privacy was supported when required. EVIDENCE: Two service user’s care plans examined were seen to be well documented, and professionally organised. Each care plan clearly identified the social, personal and health care needs of the individual service user and was reviewed at least monthly. The standard of recording was very good and meaningful. Risk assessments were carried out for each service user and also reviewed regularly. It would be beneficial for the care plans to contain a photograph of the individual service user and it is recommended that this be carried out. Documentation and discussions with service users and staff evidenced that service users had access to a range of health care professionals such as the chiropodist, dentist, G.P, etc and that health care needs were being well met. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 10 Medication Administration Records were examined and completed in line with NMC requirements to maximise the protection of the service users. Storage was secure for all medication including additional security for controlled drugs. Throughout the inspection, it was observed that staff treated service users respectfully. One relative stated that ‘Linda (the Matron) is marvellous’ and ‘She and the staff are really good and listen to what people want’. A number of service users spoken to confirmed that they were treated politely and courteously and that their need for privacy was upheld when required. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14 and 15 Service users were supported and encouraged to maintain contact with family and friends. They were able to exercise their rights to have control over their own lives and to fulfill their individual wishes and choices. Dietary needs of service users were well catered for with a varied and nutritious selection of food available that met service users tastes and individual needs. EVIDENCE: Discussions with service users and relatives confirmed that there was an open door policy for visitors at Beechfields and contact with family and friends was encouraged and supported by staff. One relative said ‘Staff are always very friendly, they make you welcome’. A service user informed the inspector that everyone who lived in the home and staff, were invited to the home of the daughter of one of the service users for special times of the year. For instance, at Christmas time, the daughter provided mulled wine and a buffet for everyone and a number of service users mentioned that they loved going there. There was also evidence, when talking with service users, that they were offered personal autonomy and choice, and were able to state their preferences in relation to the daily routine – such as bathing, meals, retiring and rising times, and also in terms of social activities. During the day, the inspector witnessed a service user, who had been a talented pianist, asking to play the organ in the lounge. She was assisted to do this by a member of staff Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 12 who put an extra cushion in her wheelchair to enable her to be at the right height to play, and provided a great deal of enjoyment for everyone including the inspector! The dining room was of a good size, homely and well laid out. The kitchen was very clean and well stocked. Menus were examined and found to offer a varied 4-weekly cycle with choices available at each meal. Individual care plans recorded details of nutritional requirements and individual preferences, which were communicated to the cook. Special diets were catered for and presented as attractively as possible. All documentation relating to food probe temperatures and fridge and freezer temperatures were seen to be up-to-date and correct. Lunch was served during the inspection and was well presented and wholesome. Discussions with service users confirmed that the quality of food was good and nutritious and the cook was ‘excellent’ and spoke to them on a regular basis to find out their likes and dislikes. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home had a satisfactory complaints policy and service users felt that their views were taken into account and addressed. The home’s policies, procedures and staff training protected residents from aspects of abuse. EVIDENCE: Since the last inspection no complaints had been recorded or brought to the attention of the Commission. The home had a comprehensive complaints procedure and a new complaints leaflet had been designed for the benefit of the service users. It was noted that minor complaints were dealt with internally and every attempt made to resolve them as far as possible. The home had an Adult Protection procedure including whistle blowing, and new members of staff received training on how to protect service users from abuse as part of their induction. No allegations or incidents of neglect or abuse of any kind had been reported. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20, 21 and 24 Communal facilities within the home were bright, comfortable and homely. Externally, the garden was well maintained and provided easy access for all service users. Adequate and suitable toilet and bathing facilities were supplied within the home and bedrooms provided a safe, comfortable and homely environment for the benefit of the service users. EVIDENCE: Overall, the home was generally well maintained and decorated to a high standard. The lounge areas provided a choice for the service users where one did not have a TV and was generally considered to be for quiet relaxation, the other lounge did have a TV, and the conservatory was bright and sunny with good quality blinds in place for very hot days. Quality furnishings and fittings were in place throughout the communal areas including the dining room, which provided a pleasant environment to enjoy a meal. Externally, the gardens were well maintained and contained a range of shrubs and flowers with an attractive patio area which enabled easy access for all service users including wheelchair users. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 15 There were sufficient toilet and washing facilities within the home, 6 toilets and 1 bathroom and 1 assisted bathroom. No en-suite facilities were available but all bedrooms had a washing basin. The standard of cleanliness within the toilets and bathrooms was of a high quality and odour free. Individual bedrooms contained a variety of personal items belonging to the service users and were generally well appointed and very clean. Each bedroom was of a good size and contained a locked drawer to hold medication, if required, or money if service users wished to manage their own finances. Within each bedroom, it was observed that radiators were protected, adequate numbers of sockets were available and smoke detectors were fitted. Overall, a good standard of furnishings and fittings were observed. Plans were in place to extend the property and to increase the total number of beds by 11. Work was anticipated to commence over the next few months and the Commission for Social Care Inspection will be involved at each stage of the building programme. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 and 29 There were satisfactory levels of staff, with the appropriate skill mix to meet service user’s needs. The procedures for the recruitment of staff were robust and contributed to the protection of service users. EVIDENCE: At the time of the inspection, there were 20 service users accommodated at the home with a staff complement of 1 Registered Nurse and 5 care assistants. These staffing levels were satisfactory to meet the needs of the service users. Two staff files were inspected and seen to be well documented and organised. Each file contained a photograph of the staff member, an application form, two references, CRB clearances, proof of identity, a contract of employment, qualifications and training undertaken. The recruitment and selection procedures were thorough and detailed for the protection of service users and were a credit to the management and staff. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 17 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 and 36 The Matron was qualified and competent, and managed the home very well. Her management approach was inclusive and open and there were positive relationships between staff and service users. Supervision sessions with staff had not taken place for a while and therefore, they had not had the opportunity to have formal, documented, one-to-one sessions with their line manager. EVIDENCE: The Matron was a competent, and professional person with extensive experience and entirely committed to providing a high standard of quality care for the service users in the home. The service users benefited from the style of leadership that she portrayed and the positive relationships between staff and the service users and management was evidence of this. One relative stated ‘I am sure there is not a better home or more caring staff anywhere in the country’. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 18 Staff supervision had been put on hold recently due to staffing vacancies, however, the inspector was shown a ‘supervision plan’ that commenced on 1st July 2005. The plan outlined a timetable of supervision sessions to be carried out by senior members of staff within set timescales. The inspector will monitor this situation over the forthcoming months. Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 4 x 4 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 4 14 4 15 4 COMPLAINTS AND PROTECTION x 3 3 x x 3 x x STAFFING Standard No Score 27 3 28 x 29 4 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 4 4 x x x 3 x x Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 20 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 Regulation NONE Requirement Timescale for action 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. Refer to Standard OP 7 OP 36.2 Good Practice Recommendations Each individual care plan would benefit from a photograph on file of the service user. Care staff formal supervision at least 6 times a year Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 21 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Beechfields Nursing Home E51-E09 S22313 Beechfields V231307 06.07.05 Stage 2.doc Version 1.40 Page 22 - 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. 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