Inspection on 06/07/06 for Beechmore Court

This inspection was carried out on 6th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Beechmore Court 15/07/08

Beechmore Court 16/11/05

Beechmore Court 07/06/05

Beechmore Court 01/12/04

Beechmore Court 15/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Beechmore Court 267 Southlands Road Bickley Bromley Kent BR1 2EG Lead Inspector Cheryl Carter Unannounced Inspection 6th July 2006 09:30 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 Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 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. Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beechmore Court Address 267 Southlands Road Bickley Bromley Kent BR1 2EG 020 8468 7778 020 8295 0596 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) Cedarmore Housing Association Limited Julia Isaacson Care Home 36 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (20) of places Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th November 2005 Brief Description of the Service: Beechmore Court is a purpose-built two-storey home providing care for older people. The upper floor is accessed via a lift. The home is generally well maintained and each resident has his or her own room, which is centrally heated. The resident can control the central heating in their rooms. Residents are able to personalise their rooms. There is access to a telephone and residents are able have their own telephone in their room at their own expense. For safety purposes all the radiators and hot pipes are guarded. There are grab and hand rails on stairs and passageways. Toilets, showers and bathrooms have specialised bathing, toilet equipment and lifting aids. All toilets, showers, bathrooms and bedrooms are accessible from the outside in case of emergency. Service users can also have a radio, television and video in their room at their own expense. Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Overall this was a satisfactory unannounced inspection carried out in the presence of the Deputy manager in the morning and the Manager in the afternoon. The inspector received comment cards from 10 service users a, GP, and district nurses and relatives all comments received were favourable. Prior to the inspection the manager provided a completed ore-inspection questionnaire and additional information. 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. Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives have the information they need to make an informed choice as to whether to move into the home. Service users and their relatives have a copy of the terms and conditions attached to living in the home. Service Users needs are assessed prior to them moving into the home. EVIDENCE: The home has a comprehensive Statement of Purpose and Service User’s Guide. Files examined had contracts and a statement of terms and conditions Assessment of need and general risk assessments that had been done prior to moving into the home, however the information was inconsistent and not always fully completed. The registered manager must ensure that all residents are appropriately assessed prior to admission and the home must confirm in writing its ability to meet the service user needs. (Req.1) Relatives and or serviceusers can visit the home prior to moving in. No service users are admitted primarily for intermediate care. Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is good. The judgement was made using available evidence including a visit to this service. Care plans and risk assessments need to be more detailed to fully reflect the needs of residents. EVIDENCE: Service users have a plan of care that takes on board general risk assessments, moving and handling that involves mobilising, bathing, toileting outdoor mobility, pressure sore prevention tables and behaviour rating scales. Some files that were tracked had no pen pictures of the service user however some did have information gathered from friend and families. Some files had no current assessments and some care plans needed to be reviewed. There were initial needs assessments on file but there was no record about how often or when these assessments were reviewed. The information was inconsistent as not all files contained all of the information. Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 9 There is one service use who self medicate. There is a locked cabinet inside his wardrobe for the storage of his medication. Plans in case of a service user’s death are written into the care plans. The inspector found that care plans were out of date and the helpful information about service users incomplete. Care plans generally reflected the physical health needs with limited information about psychological needs and mental health issues. Generally the inspector felt that the staff were aware of the physical needs of the Service users. The registered provider and manager must review care plans to ensure that they fully reflect the needs of the service users. (Req. 2) Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. The judgement was made using available evidence including a visit to this service. Service Users appear to have choices in their day but these are limited. EVIDENCE: The home has a designated activity worker. Service users showed me the name cards they have made and these are used at the dining table to indicate where each service user will sit for their meals. There is a good variety of activities and as far as possible all service users are encouraged to participate in the activities. Family contact is encouraged. Service users have a choice of when they go to bed and when they get up. They can also choose to stay in their rooms or come down stairs to lunch. Meals times are unrushed and menus provide evidence of a wholesome balanced diet. Each service user have a name card at the table where they sit and these cards were made as part of their activity. Service users are shown the menu the previous evening and they can pick what they want for breakfast and lunch. The use of more visual aids in terms of choosing their meals should be introduced. (Recommendation 1) There are some information around the home about the date and weather, and there are pictures of service users when they were young. Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18 Quality in this outcome area is good. The judgement was made using available evidence including a visit to this service. The home has a complaints procedure. The inspector found evidence c complaints are being recorded and actioned. EVIDENCE: The inspector saw the records of complaints made and these records contained information about how the complaints were responded to and the outcomes. Records also showed who has financial responsibility for the financial affairs of each service user. There is a copy of Bromley’s Adult protection procedure in the home and the staff spoken to was able to identify areas of practice that would be seen as adult abuse. Staff has received training in the protection of vulnerable adults and Staff was also conversant in how to respond in such cases. Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good. The judgement was made using available evidence including a visit to this service. The home is well maintained. Service users have the specialist equipment they need and there are sufficient suitable toilets and washing facilities for the service users. Bedrooms were personalised to meet the service users needs. EVIDENCE: The home is well maintained clean and free from unpleasant odours. Communal areas were well maintained Bedrooms were personalised: they had photographs, ornaments and personal items. Window restrictors were in place ensuring the safety of service users. Residents who had chosen to stay in their rooms had jugs of water and some were watching television while others had chosen to listen to the radio. Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. The quality rating in this section is good. This is based on all information including the site visit. The staff in this home is subject to robust recruitment procedures and are they fully inducted and trained to undertake the work. EVIDENCE: The rotas seen indicated that there are always sufficient numbers of staff on duty to meet the residents’ needs. Most of the staff team have now completed the Level 2 NVQ. Training for all staff is a priority. This will be reflected in how often the records of the home are audited and updated. Staff interviewed identified training on specific topics such as Dementia, depression and protection of vulnerable adults food handling first aid and manual handling. Staffing levels appear to be satisfactory. Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32, 33, 34, 35, 36, 37, 38 The quality rating in this section is good. This is based on all information including the site visit. Service users benefit from a qualified and experienced manager. Records relating to service users are securely stored. Equipment is serviced in line with this regulation. EVIDENCE: The registered manager is a qualified nurse and holds the registered managers award. Service users and staff spoken to confirmed that the Manager and the staff are approachable. Staff feels that they are well supported by the manager and senior staff team. The manager of the home has two days designated for the administrative tasks of the home and the remainder of time works as part of the nursing team. The home could benefit from a full time manager who is surplus to the staff team at all times. (Recommendation 2) Records relating to service users are stored securely. The home has appropriate Employers Liability Insurance. Fire safety equipment has been serviced and tested as required. Staff evidenced being provided with regular fire safety training. Staff said that they receive regular supervision, however Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 15 the inspector found that not all staff responsible for supervision have a good understanding of supervision and therefore training in this area is recommended. (Recommendation 3) Servicing records relating to lifts and hoists, portable appliance testing and the Parker Bath have been appropriately maintained. Hazardous substances had been stored securely and accidents had been recorded and reported as required. Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 3 2 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 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 2 3 3 3 3 2 3 3 Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 17 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 OP3 Regulation 14 Requirement The Registered Manager must ensure that all residents are appropriately assessed prior to admission and must confirm in writing that the home’s ability to meet the service user’s needs. The registered manager must ensure that care plans, risk assessment and all supporting documentation is completed on all residents with comprehensive interventions on how to address the problems identified. Timescale for action 29/09/06 2 OP7 15 29/09/06 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 Refer to Standard OP15 OP31 OP36 Good Practice Recommendations The use of more visual aids in terms of choosing their meals should be introduced. The home could benefit from a full time manager who is surplus to the staff team at all times The registered manager should ensure that all staff receive DS0000006912.V294979.R01.S.doc Version 5.1 Page 18 Beechmore Court good quality supervision six times a year. Beechmore Court DS0000006912.V294979.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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. 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