Inspection on 04/07/06 for Beechwood Care Home

This inspection was carried out on 4th July 2006.

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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beechwood Care Home 25/11/05

Beechwood Care Home 07/06/05

Beechwood Care Home 07/03/05

Beechwood Care Home 11/08/04

Beechwood Care Home 31/03/04

Beechwood Care Home 17/12/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Beechwood Care Home 60 Burlington Road Sherwood Nottingham NG5 2GS Lead Inspector Jayne Hilton Key Unannounced Inspection 4th July 2006 3:15 Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 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 Care Home DS0000002245.V302258.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 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 Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechwood Care Home Address 60 Burlington Road Sherwood Nottingham NG5 2GS 0115 924 5893 0115 960 9077 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) Nottingham Regional Society for Autistic Children and Adults Mr Wesley Williams Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th November 2005 Brief Description of the Service: Beechwood is situated in the Sherwood area of Nottingham and is a large older adapted property, with much of its original character maintained. Arranged on 2 floors, the accommodation consists of 8 single bedrooms with shared bathing facilities, and communal lounge and dining rooms. It is close to local amenities and bus routes into Nottingham. Focusing on assisting service users to attain maximum personal development. The fees charged is £1,092 a week this information was provided to CSCI on the 21st July 2005. [No information was specified as to any additional costs service users would be expected to fund such as for hairdressing.] Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 4th July 2006 at 3.15pm and concluded at 7pm. The methodology used at this inspection was by speaking with the service users and two staff, direct and indirect observations of practice, a part tour of the building and by examination of some records in the home, which included a selection of support plans and associated information, staffing rotas, risk assessments and fire safety records. Some records could not be examined, as the manager was not present at the visit as he was at a business meeting and staff did not have access to these. The manager did telephone to speak to the inspector during the inspection. The service users appeared happy and relaxed on the day of the inspection and the inspector wishes to thank the service users and staff for their hospitality and help to the inspection process. The inspection was carried out in a period of heat wave and the home is well equipped with large ceiling fans. Jugs of juice were provided and topped up as needed and staff were observed advising service users in relation to appropriate clothing and ensuring the home was well ventilated. The outcomes for service users remain positive and Beechwood provides a relaxed and supportive environment for which those who reside there lead active and fulfilling lifestyles. What the service does well: Service users clearly have a quality lifestyle promoted within the home. The environment is domestic, homely, clean, well equipped and furnished. The complaints procedure is available in the Service User guide and an appropriate pictorial format is displayed on the notice board. Service users follow individual programmes of daytime activities, and day services staff work in partnership with the residential staff. Independent living skills are developed and encouraged within the home environment with regular times for household tasks. Service users enjoy going out in the minibus and take part in leisure activities with staff. Encouragement and support is given to maintain relationships with families. Service users spoken with, confirmed choice and autonomy within the home. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 6 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 Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 8 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 Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 9 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): 2,3 Prospective service users needs are assessed, and these are reviewed and kept up to date as required by regulation. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: . Two support plan files were examined in detail and two others were sampled with staff. There is an assessment and admission procedure that includes professionals from multi disciplines on a panel chaired by an independent clinical psychologist. Service user case files contain assessment material the views of relatives are taken into account. There is an emphasis on the placement being able to meet individual needs, and initial care plans have been drawn up in accordance with assessed needs. The support plans seen were in the process of transition to a new format, many sections were not yet completed. The files had some old information, [some dated 1999] and extra sheets for individual approaches etc the files were somewhat disjointed and therefore not easy to audit trail the support and lifestyle of service users in a clear way. The documentation should be formalised and completed with priority and used more effectively for monitoring and evaluating of service users support and personal goals and aspirations. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 10 There was however sufficient evidence by the methodology used to identify that service users needs are well met. Staff was generally knowledgeable about individual service users needs and observation of practice demonstrated that service users rights were promoted and upheld by staff. Service users were dressed in their individual style and appropriate to the season. Service users were asked what they preferred from the combination of food cooked for the evening meal and support plans reflected individual needs and preferences and were well documented in how these needs were being met. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 11 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): 6,7,9 Service users are involved in their support plans. The plans are generally up to date and new formats are in the development process. Independence and risk taking is clearly promoted both in the home and out and about in the community. Consolidation of the documentation and attention to dates and signatures is advised. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” EVIDENCE: Care/ support plans are drawn up based on initial assessments, and cover aspects of both personal and healthcare. Communication needs are clearly addressed. There is evidence of some reviews conducted by the local authority, each service user’s plan is thoroughly reviewed and updated at least six monthly. On some documentation such as strengths and needs assessments there was not always dates of when completed or signatures of the author of these sheets within the support plans and no indication of whether they are still applicable or whether the individuals needs have changed. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 12 As indicated at the last inspection the format of the support/care plan structure has been be reviewed and is under development to current National Minimum Standard expectations and include service users preferred term of address. There did not appear to be much progress in this since the last inspection. Staff reported that time was a factor and there had been some staffing changes which had contributed to the support plan transition being delayed in completion somewhat. The inspector recommends that dedicated time be allocated within the homes resources to ensure that support plans are consolidated and contain up to date and current information. There was no evidence seen in the current support plans in relation to whether the service user is to be issued with a key to their bedroom door, front door and lockable facilities etc. Some service users have requested keys and one service user did have a declaration statement that she did not wish to have a lockable facility, however this documentation had not been implemented in the support plans for other service users. One service user told the inspector that he did not have a key to his bedroom door, but confirmed staff always respected his privacy and that as his room is at the top end of the house no-one tends to go up there and agreed with the staff member who said that when service users are away at weekends and go on holiday that staff lock their rooms during this time. The provision of door keys and lockable facilities should be covered within the support plan process for all service users. A service user told the inspector that he was able to make decisions in his life and reported that he had made the decision he would like wooden flooring in his room and that the manager had agreed to look into this for him. Staff were observed to prompt service users in an appropriate way, which respected their choices and decisions throughout the inspection. One service user went independently to have his hair cut. Another was consulted about opening the dining room windows wider and in relation to the inspector viewing their rooms and observing tea time. There was evidence of service user consultation and signatures of service users, with photographs and a personal profile. Despite a system being in place for service user consultation it did appear that this was not working fully in practice as a service user had complained that consultation in relation to building work at the home had not been carried out as they would have liked. There was also no documentation available within the support plans in relation to consultation and agreement with service users of the intercom system installed in some rooms or for the use of the monitor alarm sited on the landing. On speaking with staff, they did not appear to see these measures as possible limitations on freedom or possible restrictions to privacy. Whilst the inspector has no doubt that the measures have been put into place in the interests of service certain service users the documentation did not provide evidence of any discussion or consideration of these factors, neither was there any authorisation documentation/consent for use. The staff team need to be Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 13 mindful when discussing implementing any such measures that appropriate discussion and documentation is in place to support this. Appropriate risk assessments were seen for daily living and going out and about within the community. Some of these were noted to be dated in 2004 and a review date of these should be at least 6 monthly. Service users were observed taking responsibility for setting the table for tea and clearing away and told the inspector about their involvement in certain household tasks. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 14 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): 12,13,15,16,17 Service users clearly live a busy and fulfilled lifestyle, where their rights are respected. Service users enjoy their food. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service.” EVIDENCE: Service users follow individual programmes of daytime activities, and day services staff work in partnership with the residential staff. A separate education centre is used and a local college. One service user told the inspector that he works one day a week and attends a recycling centre. Cookery and music are available. Communication systems are used effectively, and speech and language therapists are consulted. Some service users have been involved in a gardening project. Independent living skills are developed and encouraged within the home environment with regular times for household tasks. Holidays are arranged, and some risk assessments for these were seen. Recent holidays included Skegness and a trip to Edinburgh is planned. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 15 [NORSACA are confident that their risk assessments regarding one to one staffing arrangements are sufficient to protect service users and staff where only one service user and one staff go on holidays abroad.] Service users go out in the minibus and take part in leisure activities with staff. Most leisure activities are individual, or in small groups to meet specific needs of the service users, though this is not clear within care plans. Regular swimming and bowling take place. One service user expressed to the inspector she particularly enjoyed shopping for new clothes and that a shopping trip was being arranged with her key worker at the end of the month. Encouragement and support is given to maintain relationships with families, and weekend visits and telephone contact are recorded in daily notes. There was a detailed family birthday dates list on service users files. The provider organisation is, led by parents. Service users have access to all communal areas including the rear garden. Some building work was however in progress which restricted safe access at the time of the inspection. When at home, service users choose whether to stay in their own rooms or the lounge. On the day of the inspection service users were observed to move freely around the home and spend private time in their room as they wished. Service users were noted to have varying responsibilities within the home from laying the table to their own bedroom cleaning. Service users spoken with confirmed that they went to bed and got up when they wanted and that they were happy living in the home, they said that they generally got on well with each other and knew how to make a complaint should they have one. Service users also confirmed that staff treated them respectfully and always knocked and waited to be invited into their bedrooms. There is an 8 weekly cyclical menu, which demonstrated cooked breakfasts are provided at weekends. The menu only offers one choice of main meal but improved evidence is advised, that service users can take alternatives in the form of records kept of who ate what. There was no evidence that a recommendation made at a previous inspection that alternatives are offered as a menu item for instance a meat item and a vegetarian option and menus that were said to be being typed up ready had not been implemented. The meal options offered appeared nutritious and varied, however the inspector recommends that nutrition be covered within then care plan process alongside weight evaluation. The cook works in the daytime, and prepares the main meal for the afternoon care staff to reheat and serve. As service users are out most of the day and take their main meal on an evening the inspector recommends that the catering hours be reviewed. The evening meal was pasta bolognaise, salad and garlic bread with apple crumble and custard or ice cream for sweet. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 16 The portions served were generous and everyone complemented the chef on the meal. One service user prefers Soya mince and this was provided. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 17 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): 18,19,20 Service users receive personal support in the way they prefer and require; Service users healthcare needs are met. Medication management was found to be overall satisfactory. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Health care is well monitored, and notes are kept of advice given by medical professionals. There were notes of frequent consultations with a General Practitioner on the files sampled. Staff reported that accidents are recorded in line with data protection, but there was no record of accidents in the service users files. The manager has been asked to provide a summary of accidents in the home to CSCI, as the records were not available on the day. Service users are encouraged to have an annual well-person check, and other checks such as regular smear tests, breast screening and hearing checks and these are evidenced within the care plan structure. Service users wishes for the end of life are obtained and recorded. Weight charts were completed well, one file seen did identify issues regarding weight gain and weight loss but this was not so in another that was examined. The weight records should be part of a section for nutrition, which should Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 18 include nutritional assessments and which can be used to identify significance of changes in the service user’s weight, including well being and mental health or used in conjunction with a nutritional assessment and care plan. Staff members spoken with reported that there were no service users currently with issues or problems with taking nutrition. Behaviour management plans were seen. Staff reported that incidents of challenging behaviour are rare. The manager has been asked to provide copies of incident reports since the last inspection to CSCI, as these were not available for inspection on the day. Equality and diversity is promoted within the home, this was evidenced by the documentation within support plans and by speaking with staff and service users. There was information regarding medication in the service users’ files and this is to be further developed into a medication profile section, and include details of medication reviews and changes of medication. Consent forms for medication should also be part of this section. The Boots blister pack system is used. The drug errors policy includes a prompt to report medicine errors under regulation 37 to CSCI. It is recommended that a copy of this be displayed in a prominent position that is accessible for staff in an emergency. Photographs are used for identification on Medicine administration sheets and a sample of staff signatures was seen. Medication record sheets were completed satisfactorily. The BNF [British National Formulary] was noted to be more than twelve months old and therefore in need of updating. There was evidence of storage temperatures being taken regularly [some gaps were noted] and a medication administration and management was observed and assessed as overall safe and appropriate. There was no evidence that staff had undertaken accredited training or that the manager was documenting competency assessments for staff, however staff reported that medication training had been undertaken by the pharmacist and that the manager works alongside staff and observes their practice. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 19 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): 22.23 Complaints procedures are accessible to service users. Service users are protected from abuse, neglect and self-harm. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure was displayed in the hallway; there are additional copies in pictorial/symbol formats. The procedure states that complaints will be responded to within three weeks. Three service users spoken with confirmed they knew how to make a complaint. Records of complaints were not accessible. The manager reported on the telephone that there had been one complaint from a service user in relation to lack of consultation and a copy of the complaint and response was agreed to be forwarded to the Commission There is a comprehensive set of policies and procedures relating to protection of service users. Staff have been trained in handling challenging behaviour and in using safe methods of intervention. Staff confirmed that the induction and training programme for staff that includes adult protection training, however there was no evidence in the form of documentation and records as these were not accessible in the managers absence. Staff demonstrated a good awareness of safeguarding Adults protocols and whistle blowing policy. Service users financial records were not examined at this visit due to their unavailability. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 20 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): 24-30 Beechwood provides a homely, comfortable, clean and well furnished environment for service users. There are some minor issues identified to address but overall the home is well maintained. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All areas of the premises are accessible to current service users. The home is well maintained, furnished and decorated in a domestic style. The lounge and dining room have ceiling fans. There is a small garden, consisting of a lawn and paved area. [The garden area was restricted temporarily due to some building work being undertaken] No changes have been made to sizes of bedrooms. The service users have single rooms. The downstairs shower room has a damp/condensation problem, which requires investigation and repair to the ceiling. A plastic garden chair was observed in this room. Staff said it was not actually used. The inspector advised that the use of plastic garden chairs in bathrooms is not safe practice and where service users require these to be in place an appropriate OT Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 21 assessment is needed for the provision of appropriate aids and adaptations for this purpose. Staff said the chair would be removed after discussing this with the manager. Bath mats are used and these were observed to be ruffled in bathrooms on both floors and which present a trip hazard, particularly as some service users are at risk of falls. There were no risk assessments seen for their use. The inspector appreciates that the mats provide a more homely appearance and are for stepping on to out of the bath etc, placed around toilets. The issue again needs to be addressed and safer options explored. Two bedrooms were seen as part of this inspection. Bedrooms are clean and well personalised. There are individual nameplates on all bedroom doors. Service user’s spoken with were satisfied with their bedroom and all had the furniture and equipment to meet their needs, the inspector observed the pillows in both rooms were flat and in need of replacement. A lounge to the front of the building is well furnished and comfortable with CD player and television. There is a pleasant dining room with sufficient seating for service users and staff and there is a serving hatch from the kitchen. New chairs have been recently purchased in the dining room. The premises were found to be very clean upon inspection. Kitchen facilities were observed to be satisfactory apart from one fridge temperature was observed to be recorded above the safe temperature for several days with no apparent action taken by staff or the manager. With staff co-operation it was eventually ascertained that the thermometer was faulty and not the fridge, however the problem appeared to have been undetected or not responded to for some time and this may have posed a serious food safety risk to service users. Staff need to have clear guidance of what action to take where fridge temperatures read within unsafe limits and to ensure that any action taken is fully documented. Staff were observed to appropriately wear aprons when cooking in the kitchen but did not wear an apron when serving food in the dining room and this was discussed with staff who were advised to discuss the issue raised with the manager/in a team meeting and if necessary to consult with the Environmental Health Officer as to how the balance of the requirements of food safety practice and attending to service users needs can be maintained. The laundry area was not inspected but it was reported that the electrician had been contacted in relation to equipment tripping out when all being used at the same time. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 22 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): 32,33,34,35 Service users are supported by a well supported and supervised, committed staff team. Evidence of training provision and recruitment practices were not seen, as records were not available on the day. The standards in relation to these therefore cannot be fully assessed as met. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” EVIDENCE: The staff rota was examined at this inspection. There is always two residential staff on duty at all times. This is supplemented with day staff to meet individual needs and activities throughout Monday to Friday. There is a waking staff member and another sleeping in usually but on the night of the inspection two staff were on sleep in duty. It was explained that this arrangement only happens on occasions where staffing numbers dictate, at holiday times etc. Staff confirmed that service users do not generally need attending in the night and would alert staff if they needed assistance. A further member of the management team for all NORSACA homes is available on call for support. Although support staff are expected to undertake some cooking duties domestic and catering staff, are employed in addition. The manager works supernumery. The rota indicated that a staff member on induction was on duty, but staff reported that the said staff member was actually on sick leave. The staffing rota therefore did not accurately reflect the staffing arrangements for that day. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 23 The manager reported over the telephone that a recent recruitment drive resulted in staff being successfully recruited in minimal timescales within limitations of CRB Disclosure returns. The manager confirmed that robust recruitment practices were maintained and relayed the procedures followed. As the manager was not available in person on the day of the inspection the staff personal files could not be examined. Staff spoken with confirmed that the training programme, includes mandatory training subjects and other specific identified training is provided for staff. LDAF Training is provided. All staff are said to receive mandatory training in Infection Control, fire safety, first aid, food hygiene, manual handling and health and safety. [Medicines management training is also provided]. NORSACA provide an induction plan, which is reported to meet skills for work standards. Documentary evidence was not available to support this. Other training provision includes challenging behaviour, physical intervention, adult protection and learning disability training specifically for autism. Staff reported that supervision and appraisal is routinely provided and evidence was seen of minutes of team meetings. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 24 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): 37,39,41,42 Service users benefit from a generally well run home. Some records were not available for inspection as required by regulation. Attention is also needed to ensure that staff remember to undertake fire safety tests weekly, which has not improved despite this being raised at the previous inspection. Service users views appear to be part of the self- monitoring review and development by the home, but more evidence needs to be provided to meet the standard fully. The health and safety and welfare of service users is generally promoted and protected, again there are some areas to address to meet the standards completely. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” EVIDENCE: The manager is experienced and qualified in social care. He has completed the Registered Managers Award. Staff spoken with reported that the manger was very approachable, committed and that they had total faith in his leadership. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 25 Quality monitoring was said to be in place and was somewhat evidenced by observation of Quality network and Quality Tree literature and regulation 26 visits reports sent to CSCI. The Quality Network folder had not however been updated and there was no evidence of service user surveys. Further evidence is therefore needed for this standard to be fully met. Support plans are kept secure and protocols are in place for confidentiality The service and maintenance records were not fully available for inspection. The fire safety records were available but these were once again not satisfactory as some weeks had been missed and attention to this is required. Records regarding water outlet temperatures were also seen; some temperatures were recorded in service users rooms and communal areas above 43 degrees. There was no indication of what if any action had been taken to reduce the temperature to within the safe zone and this should be addressed. Evidence of generic risk assessments was seen, but there was no evidence of the fire risk assessment required by the Fire Authority Regulations in the home. Accident and incident records were not examined, as these were not accessible on the day of the inspection. The minutes of the team meeting reported that the Environmental Health Officer made a visit in March 2006 and there were no issue raised from the visit. A requirement is set in relation to ensuring that records, as required by regulation are available for inspection [excludes confidential information on staff files] and in relation to the issues identified throughout the report for food safety and risk hazards] Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 26 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 Standard No Score 1 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 X 2 X 1 2 X Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 27 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 Standard YA24 YA33 YA41 Regulation 23 17 17 Requirement Resolve the damp/condensation problem in the ground floor shower/bathroom Ensure that information on the staffing rota is accurate. Ensure records required by regulation to be kept are available at all times for inspection at the home. (1) The registered person shall ensure that the care home is conducted so as— To promote and make proper provision for the health and welfare of service users. 04/09/06 Timescale for action 04/10/06 04/10/06 04/08/06 4 YA42 12 04/09/06 (a) 5 YA42 23[4] (4) Subject to paragraph (4A) the registered person shall after consultation with the fire and rescue authority — (a) Take adequate precautions against the risk of fire, including the provision of suitable fire equipment; Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 28 (b) Provide adequate means of escape; (c) Make adequate arrangements— (i) for detecting, containing and extinguishing fires; (ii) for giving warnings of fires; (iii) for the evacuation, in the event of fire, of all persons in the care home and safe placement of service users; (iv) for the maintenance of all fire equipment; and (v) for reviewing fire precautions, and testing fire equipment, at suitable intervals; (d) (e) to ensure, by means of fire drills and practices at suitable intervals, that the persons working at the care home and, so far as practicable, service users, are aware of the procedure to be followed in case of fire, including the procedure for saving life. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA6 YA6 Good Practice Recommendations Consolidate and complete the support plans and address the issues identified within the report Include capacity for consent and address issue of keys, use of lockable facilities, within the support/ care plan format. Review the menus to provide at least two options and include vegetarian options meals Further develop care plans and risk assessments on nutrition. 3. 4. YA17 YA19 5 6 7. YA20 YA39 YA42 Purchase an up to date BNF and post a copy of the drug error policy in an accessible position Improve service user consultation and quality assurance systems Review the catering arrangements to minimise food having to be reheated and address the other foods safety issues identified. Beechwood Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Care Home DS0000002245.V302258.R01.S.doc Version 5.2 Page 31 - 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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