CARE HOMES FOR OLDER PEOPLE
Beechwood The Beeches Holly Green Upton-upon-Severn Worcestershire WR8 0RR Lead Inspector
Mrs Yvonne South Unannounced Inspection 22nd December 2005 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 Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 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. Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Beechwood Address The Beeches Holly Green Upton-upon-Severn Worcestershire WR8 0RR 01684 593474 01684 593095 beechwood@heart.of.england.co.uk www.heart-of-england.co.uk/care/beechwood Heart of England Housing and Care Limited 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) Mrs Susan Janette Milward Care Home 38 Category(ies) of Dementia - over 65 years of age (38), Old age, registration, with number not falling within any other category (38), of places Physical disability over 65 years of age (38) Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12th July 2005 Brief Description of the Service: Beechwood is registered to provide long-term and respite care for up to 38 older people who may have a physical disability and/or dementia care needs. The home also offers a day care service to older people living in the local community. The home is located in the residential area of Ryall on the outskirts of Uptonupon-Severn. It was purpose built, twenty-five years ago, and is a single storey building divided into four separate units. Each unit has nine single bedrooms with separate toilets and adapted bathrooms. All the corridors have rails for ease of access. The registered providers are Heart of England Housing and Care Ltd and the registered manager is Mrs Susan Milward. Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place over approximately three hours from 9.30am until 12:15pm. The focus was on the requirements and recommendation that had arisen out of the previous inspection, and key standards that had not previously been assessed this year. Mark Morgan, the Hotel Services Manager, assisted the inspector and Janet Chill, the Care Services Manager, arrived shortly before the inspection ended. A short tour of the home was undertaken and the inspector spoke to five residents and a member of staff. A service questionnaire was sent to the manager prior to this inspection, which was completed and returned to the Commission for Social Care Inspection. The manager was also asked to distribute other questionnaires regarding the service to residents, relatives and health care professionals. The completion of these is voluntary but proves useful in assessing the various views that are held. Thirteen responses had been received prior to this inspection. What the service does well:
The home provides a warm, comfortable environment that is suited to the needs of the residents who live there. It is well decorated, maintained and furnished. The staff relate well to the residents and laughter can frequently be heard between them. The staff are well recruited and have access to the training they need in order to do their work. Comments made in the questionnaire that were returned to the Commission for Social Care Inspection included; “I am satisfied with the way my relative is treated.” “I have always found the staff, from the home manager to the most junior member, to be courteous, cooperative, conscientious and most importantly approachable at all times during the 16 months my relative has resided at Beechwood”. “ My relative frequently says how lucky she is to be at Beechwood. The management could not have been more helpful. I have never seen a member of staff impatient with a resident”. Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 6 “At times when visiting my relative I am kept waiting quite a long time at the door due to the shortage of staff at the time of my visit i.e. evenings and weekends. The staff do their best to answer the door as soon as possible”. “I have every confidence in the staff at Beechwood. They immediately contact me if there is a problem and we sort it out together. I have observed a professional attitude on the part of the staff when dealing with the residents and there is always a welcoming attitude in the establishment”. “My relative has received good care from the home. The staff are always helpful and courteous”. 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. Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 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 Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: These standards were not assessed during this inspection. Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 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 the following standard(s): 7,8,9 The care record system in use makes it difficult for staff to fully maintain and retrieve information. Therefore there is a risk that their knowledge may be out of date. Medication storage is secure and safe for the people in the home. EVIDENCE: These standards were not assessed in full during this inspection but compliance was checked with the five requirements that that had previously been made. Care records for two residents were assessed. Reviews had last been carried out in October this year and were therefore overdue. Risk assessments had been carried out but would be improved, more informative and therefore more useful if they contained more detail. Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 10 The home now had four medication trolleys and management and staff appreciated the improvement to safety and convenience. Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 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 the following standard(s): 14 The residents remain in control of their lives and are able to make choices and decisions when they wish. EVIDENCE: The care records and the residents confirmed that they were able to lead the style of life they chose in the home. They chose their meals and moved freely around the home within their ability. They could use their bedrooms whenever they chose and be private when they wished. The questionnaire responses were positive and the residents confirmed that they were well looked after. The management of personal monies held for residents in safekeeping was secure and well documented. The services of advocates and solicitors had been obtained for residents when appropriate. Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 12 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): 18 Policies and procedures are in place to enable to staff to protect the residents from abuse. EVIDENCE: These standards were not assessed during this inspection. However the two recommendations regarding the availability of policies and procedures and information regarding gifts and wills had been met. Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 13 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): 26 Policies, procedures and systems are in place to control the risks of cross infection. However better management of the laundry area would reduce the risks further. EVIDENCE: The home was generally clean, well maintained and decorated. Staff had received training in infection control and had access to policies and procedures and the personal protective equipment they needed in order to carry out their work safely. It was observed that one bathroom was being used for storage and a quantity of items had been lodged in the laundry because of the shortage of storage. The situation was worse than usual because a large stock of continence products had been obtain to ensure sufficient over the Christmas holiday.
Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 14 In addition to the extraneous items held in the laundry there was linen on the floor. The floor appeared to be damaged near to the washing machines and needed to be cleaned behind the machines. Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 15 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, 29, 30 The staff team is well managed through recruitment and training to provide residents with a safe, acceptable care service. EVIDENCE: The duty roster indicated an acceptable staff skill mix and the number of staff on duty each day was constant. During the evenings and at weekends, when the receptionist was not on duty, there could be a delay in answering the doorbell. The staff records seen were complete with the exception of the photograph. This task was in hand. It was noted that there was no written explanation in the file for an employment gap recorded in the application form. The home was committed to staff training and there were documents demonstrating what had been planned and achieved. Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 16 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): 33, 38 Views are sought from residents and their supporters so that the standard of care can continue to develop and improve. Policies, procedures and systems are in place to ensure the home is managed in a healthy and safe manner. EVIDENCE: Residents are asked to give their opinions on the standards of different areas of the service, such as care, catering and housekeeping. Their supporters are also invited to give their views when they attend their relative’s review. In addition the home maintains a commitment to good communication and an open door policy. This was evidenced in the questionnaire comments that were completed and returned to the Commission for Social Care Inspection.
Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 17 The records indicated that health and safety was addressed in relation to COSHH, water safety and fire. An audit was conducted monthly and the fire log indicated that checks were being undertaken at the frequency recommended by the Hereford and Worcester Fire Authority. The fire risk assessment for the home was drawn up in October 2004. It is usually recommended that it be reviewed annually. However the estates manager for the providers had said that, as there had been no major changes to the premises this was not considered necessary. The Hotel Services Manager incorporated an awareness of fire safety in the daily work in the home. The records of fire safety training were somewhat dispersed and it was difficult to assess if everyone had received updates every quarter as required. A monitoring tool was recommended. Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X 2 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 3 Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? YES 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. 2. 3 Standard OP7 OP8 OP26 Regulation 15 13 13 Requirement Care plans must be updated as residents needs change. Risk assessments must be reviewed and updated as residents’ needs change. The laundry must be maintained in a manner those promotes infection control. Timescale for action 22/12/05 22/12/05 22/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Beechwood DS0000018628.V268645.R01.S.doc Version 5.0 Page 21 - 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!
