Inspection on 10/01/08 for Beechlands

This inspection was carried out on 10th January 2008.

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

Beechlands 06/10/06

Beechlands 21/12/05

Beechlands 28/07/05

Beechlands 05/01/05

Beechlands 24/08/04

Beechlands 11/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Beechlands 42 Alderton Hill Loughton Essex IG10 3JB Lead Inspector Sharon Thomas Unannounced Inspection 10th January 2008 09:00 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 Beechlands DS0000017764.V357596.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. Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechlands Address 42 Alderton Hill Loughton Essex IG10 3JB 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) 0208 508 5808 0208 508 1484 beechlands@southendcare.com Southend Care Limited Mrs Susan Rose Jarvis Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who only fall within the category of old age (not to exceed 28 persons) 6th October 2006 Date of last inspection Brief Description of the Service: Beechlands is a detached property, located in a residential area a short distance from local shops and facilities. Accommodation is on two floors, accessed by a through floor passenger lift. The home is divided into four units, each with its own lounge/dining area and bathroom facilities, and each accommodating seven service users. The home has 24 single bedrooms and 2 double rooms, all with ensuite toilets. The home has appropriate aids and equipment (e.g. mobile hoist, assisted bathing facilities, hand rails, etc.) to assist residents with limited mobility. Beechlands is registered to provide residential care for 28 Older People (i.e. over the age of 65), and provides 24-hour personal care and support. There were 27 residents living in the home on the day of the inspection. There are currently a few residents who have developed dementia since coming to live at Beechlands, but the home is not registered to admit people with dementia. Southend Care owns the home, and the manager is Susan Jarvis. The home’s charges on the day of inspection ranged from £422.17 - £550.00. Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 10th January 2008. Twenty-one of the thirty-eight National Minimum Standards were inspected: and all of these were met. The inspection process included: discussions with the Manager, people living in the home, staff, a visit to the home, observation of peoples interaction with staff, questionnaires completed by residents, their relatives visiting the home and information contained in the Annual Quality Assurance Assessment (AQAA) sent by the provider to the Commission for Social Care Inspection (CSCI). A partial tour of the premises included observation of six bedrooms, ground floor bathrooms, toilets, and communal areas, the kitchen and the laundry. There was an opportunity to spend a period of time observing the care being provided by the staff. The care provided was sensitive, caring and professional. The inspection included the examination of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). The home was warm clean and tidy. The residents spoke highly of the care that they receive in Beechlands and spoke highly of the efforts of the staff, their commments may be found throughout the report. The home was decorated and furnished to a good standard and was clean and comfortable. Ms Sue Jarvis, the Registered Manager assisted the inspector at the site visit. Feedback on findings was given to her during the visit with the opportunity for discussion or clarification. What the service does well: Beechlands provides people who live there with a homely environment. The premises are clean and well maintained. The gardens are attractive and fully accessible to wheelchair users. Care staff are friendly and work well as a team. Senior staff provide good support to the manager and are well informed of peoples’ needs. The standard of care is good and there is good access to health care services. The staff have built good relationships with district nurses and local general practitioners. Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 6 The standard of food is good with homely type meals and snacks are provided at times suitable to people. The chef consults with residents on an individual and daily basis to determine their preferences. People living in the home and their relatives are complimentary about the environment and the care provided. One relative said, “Service is good” and someone living in the home said, “This home is a very nice home to live in I enjoy my day” “the staff are very good to us, they are kind and caring”. 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. Beechlands DS0000017764.V357596.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 Beechlands DS0000017764.V357596.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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an good pre-admission process that ensures that the home can meet the individual’s needs and makes sure that appropriate admissions are made. Beechlands does not provide intermediate care. EVIDENCE: The manager confirmed that she would undertake the pre-admission visit to the person choosing to live in Beechlands. The assessment may be their own home or in a hospital setting. The care plans of the two newest admissions into the home were examined and contained an appropriate Social Services assessment and the homes own pre-admission assessment. All of the basic information contained in the professional assessment and the homes own preadmission assessment was transferred over into the working care plan used by Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 9 staff. All individual files examined contained a care plan and further comments regarding these may be found below. The care plans contained evidence that the individual or relative were involved in the care plan process. One relative survey contained confirmation that they had had the opportunity to come and view the home and that this had been what had helped them choose Beechlands. The service does not provide intermediate care. Beechlands DS0000017764.V357596.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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health, personal and social care needs are well met. The home has a documented plan of care that the person, or someone who knows them, has been involved in making. EVIDENCE: A sample of three peoples’ plan of care were examined. Each of these files contained an assessment form completed on admission and used to inform care plans. The assessments detailed the peoples’ needs and wishes and individual assessments had been completed in regard to specific needs (e.g. risk of falls, moving and handling, dependency, continence, nutrition, pressure sore risk, dementia etc.) that had been regularly reviewed. Care plans included nutritional assessments with regular weight monitoring and confirmed if appropriate action had been taken, i.e. referral to dietician, specialist diets, and supplements provided. The care plans were written in plain language, which made them easy to understand and follow. The records confirmed that people had good access to health care through visits by district nurses, Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 11 continence nurses, Macmillan nurses, community psychiatric nurses, GPs, dentists, chiropody and opticians, and that people attended outpatient clinic appointments as necessary. This was also confirmed from completed surveys received from people living in the home and their relatives. Positive comments were received from residents and relatives: …“We are happy that our mother is safe and well cared for” …“this is a good caring home” …“they care for them as individuals and the family is always involved with any decisions that are made and we are always asked before anything is done”. Medication management was considered again at this visit, and the quality of the storage, records and administration of medication observed confirmed that a good standard was maintained in this area of care. The home’s approach to this issue will ensure that people living in the home are well protected by the policies and procedures around the handling and storage of medication. Discussions with the manager and two members of staff demonstrated a good awareness of the need to ensure that people’s privacy and dignity are maintained, particularly with regard to personal care. Interactions between staff and people living in the home were observed on the day of the inspection. These were found to be caring and professional. Beechlands DS0000017764.V357596.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): 12, 13, 14 and 15: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person is treated as an individual and Beechlands responds to their religious, social and cultural needs on a daily basis. The home supports people to follow their personal interests and activities. Visitors are warmly welcomed into the home. The home provide people with a well-balanced and nutritious diet that offers choices. EVIDENCE: The home’s activity programme offers a variety of social activity that is suitable to the needs of the people living there. The care plans sampled detailed the social and leisure needs of individual. People were observed spending time in various parts of the home, communal areas and in their bedrooms. People spoken with said that the home provides a variety of activities in line with their preferences. One person said, …“I have never been that sociable and the staff leave me alone, but I like watching other people” …”I do join in if there is something I am interested in”. Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 13 People living in Beechlands said that their friends and relatives could visit at any time, and they could meet with them in private in their rooms. The home arranged a monthly communion service and representatives of other faiths attended the home as relevant. One person living in the home enjoyed Pie and Mash and the staff in the home regularly went to the local shop to purchase this for the individual. Another person living in the home had a television system installed in their bedroom so that they could enjoy programmes only available through this system. Peoples’ rooms were seen and were personalised, showing that people could bring their personal possessions into the home with them. All rooms had locks and residents were able to have keys to their room should they wish. Residents spoken with said they were enabled choices in their daily lives (e.g. time in getting up, going to bed, where and what they ate etc.) The home has a varied and nutritional menu with fresh fruit and vegetables provided each day. People spoken with said they enjoyed their meals. Liquidised food is provided for residents who had difficulty swallowing/chewing. Hot and cold drinks were seen being served during the day. The menu of the day was observed displayed on the notice board in a dining room. The chef said that she meets with people who make their choices and she obtains feedback on how they have enjoyed the meals. Relatives and people who completed surveys said, …“We have good food” …“I like the food” …“they will always have snacks at times suitable to residents”. The kitchen is clean and well organised with appropriate cleaning schedules in place that are adhered to. Beechlands DS0000017764.V357596.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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. If people have concerns with any aspect of their care they know who to make a complaint to. Any concern is looked into and action is taken to put things right. The home safeguards people from abuse and neglect and takes action to follow up any allegation. EVIDENCE: The home has a complaints procedure that is included in the statement of purpose/service user guide and displayed in the reception area of the home. Feedback received from relatives indicated they knew there was a complaints procedure and who to refer to if they had a complaint. One said they had no issues of concern and another …“the staff deal with any issues quickly”. No complaints had been received since the previous key inspection. From discussion with the manager it was evident that any issues would be appropriately investigated and appropriate action would be taken as relevant. The home has a policy and procedures for safeguarding vulnerable adults and a whistle blowing procedure. The records confirmed that all care staff had received training in safeguarding adults in their care. From discussion with the manager it was evident that any allegations of abuse made would be appropriately referred and relevant procedures followed. There had been no allegations of abuse made since the previous inspection. Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 15 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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Beechlands provides people with a safe well maintained place in which to live. The home is clean, warm and well lit, making it safe and comfortable to live in. The home is clean and hygienic; there are systems and facilities in place to prevent the spread of infection. EVIDENCE: Beechlands is a large detached property that has been adapted to meet the needs of older people. The building is well maintained and decorated and furnished to a good standard. A partial inspection of the premises was made that included communal areas, several bathrooms, a number of individual bedrooms, the kitchen and the laundry. The home provides a secure, friendly and homely environment and people appear happy with the environment. Records provided evidence that the building complied with the requirements of the local fire and environmental health department. The grounds of the home are large, accessible, and in keeping with the surrounding area. Peoples’ Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 16 comments regarding the environment included: “staff always keep the house clean and tidy” and “the staff clean the home and it always smells nice” …”the home is well furnished and cosy”. On tour of the premises all areas of the home were clean, tidy and free from odour. As of the last inspection visit the home is centrally heated and naturally ventilated. All bedrooms are centrally heated and radiators are guarded throughout the home to ensure the safety of people. The temperatures of the hot water from the taps in the bathrooms and bedrooms are recorded. The lighting in the home is domestic in nature, and emergency lighting is provided throughout. Once again staff spoken with confirmed that they had received infection control training. The laundry area is clean and well maintained; the washing machines have appropriate wash cycles to prevent cross infection. The home continues to provide staff with policies; procedures and training regarding levels of hygiene and safe care practice. Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 17 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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have safe and appropriate support as there are enough competent staff on duty at all times. People can be confident that the staff in the home have gone through the correct checks to make sure that they are suitable to work with them. The home provides relevant training to staff and the management provide strong support and supervision. EVIDENCE: The staff rota examined reflected that the home was providing the agreed level of staffing. The home had an appropriate number of day care and night care staff and additional numbers were on duty during busy periods. The home does not use agency staff to cover absence as it will use a member of the permanent staff team or a member of the bank staff ready to work on stand by, this results with the consistency of staff available to residents. The recruitment process used in Beechlands is rigorous. The personal files of two recently employed staff were inspected. Both had evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and copies of birth certificates, passports, and photographs obtained before the individuals commenced employment at the home. All had received a statement of terms and conditions of employment. Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 18 The manager reported that all staff recently employed had completed the Skills for Care Common Induction Standards (records were not inspected). The home had an established training programme. Records viewed confirmed that all had completed training on Protection of Vulnerable Adults. Training provided since the last key inspection comprised infection control, medication, moving and handling, first aid, fire safety and food hygiene. Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 19 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: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be confident that the home is well run by a skilled and competent manager. People if they are able to, control their own money. People opinions are used by the home to develop the service and as of a way of making sure that they are getting things right. The environment is safe for both people who live there and those who work there. Appropriate health and safety systems operate in the home. EVIDENCE: The manager continues to run the home in a calm, competent and efficient manner. The staff confirm that they are confident in her skills and find her accessible and approachable. The manager is planning to enrol for the NVQ Level 4 Registered Manager Award by the end of March 2008. The manager Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 20 stated that although she undertakes some refresher training but she has identified that she may not have done enough and is planning on completing additional training this year. The home has an established quality assurance system in place that is supported by an external consultancy company. The home has produced a well-written, glossy annual quality assurance brochure, a copy of which is sent to the CSCI. The people living in the home and their representatives are involved in the user surveys and the information gathered from those surveys has been used to enhance residents’ lifestyles within the home. The manager and people living confirmed that either they or their relatives are responsible for individual financial issues. Personal allowances held for residents were reviewed and ere accurate and well-maintained and related documentation was also well maintained. The home provided staff with appropriate Health and Safety training. Risk assessments of the premises are undertaken and regular Health and Safety checks of facilities and equipment are undertaken. The manager is aware of relevant Health and Safety legislation and is committed to the welfare of both the residents and staff group. Hot water, fire alarm and equipment checks are accurate and up to date. The staff spoken with are aware of the policies and procedures regarding Health & Safety Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 21 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 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 Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 22 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. Standard Regulation 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 Refer to Standard OP29 Good Practice Recommendations The home should make sure that the original copy of the staff CRB is held in the home and therefore available for inspection. Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Colchester Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Beechlands DS0000017764.V357596.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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