Inspection on 31/10/05 for Beechwood

This inspection was carried out on 31st October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beechwood 25/06/07

Beechwood 27/04/06

Beechwood 23/06/05

Beechwood 10/05/05

Beechwood 29/11/04

Beechwood 08/09/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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Seabourne House

33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Beechwood The Lodge High Pitfold Hindhead Surrey GU26 6BN Lead Inspector Susan McBriarty Unannounced Inspection 31st October 2005 10:00 Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 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 DS0000013702.V262774.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 Adults 18-65. 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 DS0000013702.V262774.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beechwood Address The Lodge High Pitfold Hindhead Surrey GU26 6BN 01428 604278 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) Robinia Care - South Region To Be Confirmed Care Home 6 Category(ies) of Learning disability (6), Sensory impairment (1) registration, with number of places Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be 18-50 YEARS To accommodate one person with a sensory impairment. Date of last inspection 10th May 2005 Brief Description of the Service: Beechwood and The Lodge are both part of the Robinia Care Group. The Southern Region Organisation specialises in services for people with learning disabilities and challenging behaviours. The homes located on the Robinia South Old Grove site, just off the A3 South of Hindhead and situated on a small complex of largely purpose built single storey buildings, one providing day care (The Grove) and the remainder are residential. Beechwood is a five-bedroom bungalow and The Lodge is a two-bedroom bungalow with one service user, supported by two members of staff over a twenty-four hour period. The Lodge is registered for one service user only. Beechwood and The Lodge are staffed independently of each other with the Registered Manager overseeing the two homes. Each of the homes has its own communal facilities and enclosed secluded gardens with adjacent parking. The service users all present with challenging behaviours. The service is some distance from the local facilities transport may be available on occasion at Beechwood to access the community and the amenities at Hindhead, Grayshott and Haslemere. The Lodge has access to transport on a regular basis. The service users, on weekdays access the on-site day centre, with its cafeteria facilities. Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection the second for 2005 – 2006. Since the last inspection an enforcement notice had been served and two Regulation Inspectors had undertaken a compliance inspection. During the inspection a number of documents were sampled including risk assessments, the statement of purpose, financial records and care plans. A tour of the both homes took place with the manager and the General Manager of the organisation was spoken with. Staff members were observed working with the residents throughout the inspection. An enforcement notice was served on the 27th July 2005 and the home had received a compliance inspection on the 28th September 2005. The Commission for Social Care Inspection is continuing to review the Robinia Care Group plc homes in Surrey as part of an investigation into a protection of vulnerable adults allegation. In another forum from this report a number of recommendations were made and these are in the process of being planned or completed by the Robinia organsiation. Further recommendations or requirements may be made as a result of the review. What the service does well: What has improved since the last inspection? What they could do better: It was concerning to find that Beechwood had a number of environmental issues that had not been addressed since the last inspection. Some work had been completed however further damage was found in some areas. There was a pervading odour within the home as a carpet that been recommended for removal had remained in place. The majority of risk assessments had been reviewed this year, they were due for review by the time of the inspection on the 31st October. A number of risk assessments were sampled that had not been updated since November 2004. On sampling the menu information and financial records the Inspector noted that a number of meals appeared to be fried foods or fast foodstuffs. It was Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 6 strongly recommended that the homes review the residents’ diets to ensure that it is varied and nutritional. Although not assessed during the inspection of the 31st October it was noted by the Inspector that Beechwood had not yet been provided with the means of transport and remain reliant on being able to access transport from another resident or home. The requirements and recommendation made are noted at the end of this report. 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 DS0000013702.V262774.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Further work is required to ensure that the home’s statement of purpose provides prospective service users with the information they need to make a decision about moving to the home. The residents’ needs are assessed and the home is aware of the needs of each of the residents. Limitations on choice and freedom are assessed. EVIDENCE: The statement of purpose had been reviewed and updated since the last inspection. However the document indicates that the home is able to meet the specialist medical needs of particular residents. This aspect of the document requires review. A requirement was made to review the document and ensure the information is accurate. The residents have complex needs and are not able to full verbalise their needs and wishes they are therefore reliant on the staff team and others to meet their needs. Initial care plans are based on information and assessments provided by care managers and other professionals. Restrictions on choice, freedom and services are risk assessed. See also Standard 9. Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8,9 The residents have complex needs and meaningful participation in the running of the home would be problematic. Detailed risk assessments are undertaken on all aspects of the residents’ daily lives. EVIDENCE: The residents have complex needs including communication problems. Meaningful participation of the residents regarding understanding and taking part in drawing up the homes policies and procedures would pose considerable communication problems. Having limited verbal skills also limits the option of joining the home’s staff meetings or representing their home in management meetings. Detailed risk assessments were seen during the inspection, most of the assessments seen by the Inspector were due for reassessment and review. A number of the risk assessments had not been reviewed since November 2004 and a requirement was made to ensure that risk assessments are reviewed and updated. Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 Further work was recommended to ensure that the residents’ meals are nutritious and varied. EVIDENCE: The home uses a pictorial system to support residents in making a choice for their main meal. The pictures provide the opportunity to ensure a varied and nutritious diet to the residents’. A record is kept of each meal eaten by the resident. In addition any meals taken out are recorded either on the personal finance record or by checking the receipts of such purchases. On sampling the meals eaten record and finance records the Inspector was concerned that the residents meals were not as varied as they might be. A strong recommendation was made that a check was made on meals eaten to ensure that the diet was as varied and nutritious as required. Although not assessed during the inspection on the 31st October it was reported by the manager that the home does not yet have its own transport and remains reliant on the availability of another’s transport. The manager stated that the home expects to have a vehicle available for use soon although a specified date was not available. Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 11 The Lodge a small one person home managed by the same manager has access to a vehicle on a permanent basis. Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed during the inspection of 17th May 2005. EVIDENCE: Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed during the inspection of the 17th May 2005. EVIDENCE: Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26,27,28,29,30 Further work is required to ensure the home can meet the Standards. EVIDENCE: The residents’ bedrooms had been personalised and in some due to some of the challenges presented a number of items of furniture had been bolted to the floor to reduce the risk of injury. The Inspector toured the home with the manager and discussed the issues raised with the General Manager of the organisation. It was of concern that a number of environmental issues were present. This was the third inspection during 2005 when repairs and or refurbishment requirements were noted. Requirements and recommendations from the inspection on the 10th May had not been met. These issues will be replaced by one requirement for the home to rectify the repairs and refurbishments necessary for the health and safety needs of the residents. One bedroom required the urgent removal of a carpet. The carpet had been cleaned however a strong smell remained. The removal of the carpet until the floor could be replaced with a washable non-slip option would reduce the odour. In another bedroom the furniture had been repainted however it Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 15 appeared that the wood underneath was seeping colour and made the items look unsightly. Both bathrooms required some work to make a pleasant space in which to wash and or bathe. In one bathroom tiles were cracked and others that had been replaced recently were coming away from the wall. The handrails and shower rails were rusty and the walls had not been made good where items had been removed. The vent in one bathroom was still not working. Some work had been completed in the kitchen for example; the veneer covering the cabinets had in some places been tacked down to prevent further peeling. The Inspector also observed that a metal rail on the floor had a gap between it the base cupboard creating a space where it would be difficult to clean. Some plinths were either missing or were not attached correctly enabling dirt to get under the cabinets. One part of the worktop was showing signs of heat burns. The freezer in the kitchen had remained without drawer fronts. The work completed by the organisation was not adequate to enable to kitchen to be cleaned thoroughly. A new cooker has been ordered although a date for arrival is not yet known. A requirement was made that the home rectify the repairs and refurbishments necessary in order to ensure the home is maintained appropriately enabling the home to be kept safe and hygienic for the benefit of the residents. The home was being redecorated at the time of the inspection and the residents were being assisted to make their own choice of colour for their bedrooms. It was agreed with the General Manager during the inspection that the organisation would ensure that the repairs or refurbishment noted by the Inspector and any other work found would be carried out effectively and efficiently within a reasonable timescale. The manager reported the work was planned to the external areas of the home. Trellis fencing was to be providing hiding the large skip in a neighbouring area. Garden furniture had been purchased and was in place for use in the future. The rear gate enables the staff and residents to evacuate in case of fire, it was found the bolt was very stiff and required some work to ensure smooth running. The Lodge is a one person home overseen by the same manager and is within a short walk of Beechwood. This home was also toured as part of the inspection. A requirement was made that the guttering be reviewed and repaired or replaced as necessary. One part of the guttering allowed free flow Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 16 of water onto a small flat roof. Internally there was mould growth and some damage to the wood in a cupboard. The shrubs and bushes external to the home had been cut back and the area improved. Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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 The staff members are aware of their roles and responsibilities. EVIDENCE: The job descriptions are held by the Human Resources Department including that of the manager. A requirement was made that a copy of the job descriptions are placed on the staff files in the home. The manager reported that the staff had been provided with a copy of the General Social Care Council code of conduct. The home has ten (10) care staff of whom four (4) are doing their National Vocational Qualification (NVQ) Level 2. A requirement was made that the home provide the Commission for Social Care Inspection with an action plan of how they intend to meet the target of 50 of staff qualified by 2005. The home has a multi-cultural mixed gender staff team the residents are white British. The staff members were able to meet the cultural needs of the residents; the staff team were also able to introduce some different food experiences through their diverse cultures. Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 A new manager was in place and was unable to advise if a quality assurance process was in place. EVIDENCE: The home uses sharp boxes, normally used for clinical waste, to store used razors. The home must ensure that the date of opening is placed on the box to ensure that regular disposal takes place. The manager has been at the home since January 2005 and an application for registration had been made. The manager reported that he was undertaking the NVQ Level 4 and the organisation’s present plan was to enable access to the registered managers award in mid 2006. A requirement was made to review the date for admission to the registered managers award (RMA) as the RMA is a required qualification for registered managers. In discussion with the manager the Inspector was unable to evidence whether a quality assurance procedure was in place for the home. A requirement was Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 19 made that the home investigates whether a quality assurance audit had taken place at the home and inform the CSCI of the outcome. Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 1 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 2 2 X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beechwood Score X X X X Standard No 37 38 39 40 41 42 43 Score 2 2 X X X X X DS0000013702.V262774.R01.S.doc Version 5.0 Page 21 YES 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 YA1 Regulation 4(1)(c) Requirement Timescale for action 30/11/05 2 YA9 3 YA30 4 YA30, 42 5 YA30, 42 The registered person must ensure the statement of purpose is reviewed and updated. 13(4)(a)(b)(c) The registered person must ensure that all the required risk assessments are updated and thereafter at least every six months and when necessary. 16(1)(c)23(1(2(a(b(d The registered person must ensure that all repairs and refurbishments required within the home and noted within this report are completed within a reasonable timescale. 13 (3)(4)(c) The registered person must ensure that sharp boxes are dated on opening. Timescale of 10/05/05 not met. 13(4)23(1)(2)(a(b(d Tiles in bathroom sharp broken and cracked. Timescale of 30/06/05 not met. DS0000013702.V262774.R01.S.doc 30/11/05 30/11/05 23/11/05 30/11/05 Beechwood Version 5.0 Page 22 6 YA30, 42 7 YA31 8 YA32 9 YA37 10 YA39 13(4)23(1)(2)(a)(b(d End of shower head and taps missing in one bathroom making hot and cold impossible to see. Timescale of 10/05/05 not met. 17(2)Sch’ 4(6)(f) The registered person must ensure that staff job descriptions are held on personnel files. 18(1)(a)(c)(ii) The registered person must provide the CSCI with an action plan of how it intends to meet the requirement for 50 of staff to be NVQ qualified by 2005. 18(1)(a)(c)(ii) The registered person must review the start date for the registered managers award of the applicant manager and inform the CSCI of the outcome and revised start date. 24(1)(2)(3) The registered must forward a copy of the outcome of any quality assurance audit regarding Beechwood/The Lodge. 30/11/05 30/11/05 12/12/05 12/12/05 12/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 17 Good Practice Recommendations It is strongly recommended that the home review the actual food eaten by service users each day to ensure that it is varied and nutritional. Beechwood DS0000013702.V262774.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 DS0000013702.V262774.R01.S.doc Version 5.0 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. 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