Inspection on 13/07/05 for Beechwood House

This inspection was carried out on 13th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beechwood House 29/01/07

Beechwood House 05/12/05

Beechwood House 18/10/04

Beechwood House 12/05/04

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 House Devon Drive Brimington Chesterfield S43 1DX Lead Inspector Susan Richards Unannounced 13 July 2005 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 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 Stationary 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 House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Beechwood House Address Devon Drive, Brimington, Chesterfield, Derbyshire, S43 1DX Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01246 476444 01246 477111 Elm Care Limited Ms Alison Jane Colledge Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection Brief Description of the Service: Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Beechwood House seeks to provide high standards of care and service provision promoting O’Brien’s Life Accomplishments for service users, which is delivered by a competent staff group within a safe and homely environment, that is well maintained and decorated and furnished to a high standard. The outcome of the inspection, including feedback from service users and staff indicated that overall this was properly achieved. What the service does well: What has improved since the last inspection? The Responsible Individual for Elmcare Limited is carrying out consistent visits to the home in accordance with Regulation 26 of the Care Homes Regulations. Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 6 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 House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, & 5 Prospective service users are able to ‘test drive’ the home and are provided with the information they need about the home and its services. There are good and proper arrangements are in place to ensure that the home can meet the needs of service users admitted and that it does not offer accommodation to anyone whose needs it cannot meet. EVIDENCE: Discussions took place with some service users and staff about the arrangements for service users admissions to the home. This included the examination of information provided for both the service user and manager to enable the service user to make an informed choice and for the manager to assess their suitability and compatibility with existing service users. Information about the home and its key service provision was provided for service users in a suitable format, including key terms and conditions of their accommodation. One service user spoken with had been supported via an outside advocacy service in making this decision, which was facilitated via specialist medical health care services in respect of their discharge from there to the home. Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 9 The Inspector spoke with a prospective service user who was visiting the home as part of a series of planned visits. This service user spent the morning looking at the accommodation offered, joining in a small group activity session and having lunch with existing service users. These visits were organised by the manager and agreed with them in order for a decision to be made as to whether the home could meet the needs of that service user and as to whether the service user choose to live there. In respect of the above, a copy of the single assessment had been provided by way of care management arrangements for the purpose of the proposed placement. The Manager advised that a copy of the care manager’s single care plan summary had been requested. The Manager was undertaking a full assessment of the service users needs, which included the collation of information via outside specialist health care professionals in order to determine the suitability of the home for that service user. For those service users case tracked and who was permanently accommodated, their individual needs assessment records were examined. These were comprehensive and up to date and were based on a recognised model of assessment. Assessments were undertaken within a framework of risk management and where relevant, included assessment information from State Registered healthcare professionals. Families and carers interests were also accounted for. Discussions with service users and staff and examination of the arrangements for staff training and support indicated that staff was able to meet the needs of service users accommodated. Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 10 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 standard(s) 6, 7, 8, 9 & 10. Service users were involved in the planning of their care, the level of which was properly determined by their individual mental capacities and risk assessed needs. EVIDENCE: Care plans were documented for each service user case tracked, which were formulated within a framework of risk management. These were regularly and properly reviewed. Specialist requirements and planned/therapeutic interventions were detailed in accordance with individual’s risk assessed needs. Individual restrictions on freedoms were properly accounted for, which for one service user case tracked was in accordance with the legal requirements of the Mental Health Act 1983. Discussions with service users and staff and the examination of records evidenced the involvements of those service users who were able in their care plans, with advocacy inputs recorded as applicable. Service users spoke with the Inspector about how they made decisions about their lives and how staff helped and supported them. Information was Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 11 provided for both staff and service users about confidentiality, both written and verbal. Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 12 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 standard(s) 11, 12, 13, 14, 15 16 & 17 There were established arrangements in place to enable service users to engage in social, educational/occupational and recreational activities, both in and outside the home in accordance with their risk assessed needs and individual choices. EVIDENCE: Discussions took place with individual service users and staff, about the arrangements for occupation and leisure both in and outside the home and records were examined. At the time of the inspection many service user were engaged in various activities, some within and some outside the home. Many service users had been on their annual holiday with further booked for September. Service users spoken with talked about activities they regularly engaged in with enthusiasm. There is no computer provided for service users to access. Although this was not raised by service users as a particular problem, some had lost access to Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 13 computers due to changes in arrangements made by the local college in terms of their access to courses there. Lunch was served during the inspection. Dining tables were attractively set and lunch was served in a relaxed manner, with service users who required receiving the support they needed. Copies of were provided by way of the preinspection questionnaire, which matched the menus in the home. These indicated the provision of a balanced diet. Service users said they liked the food provided and were able to choose and were also involved in some food preparation and cooking. Drinks and snacks were said to be available between meals and there was provision for service users who were able to make these. Documented risk assessments were in place for each service user in relation to their nutrition and kitchen access. These had regularly recorded reviews and care planned accordingly. Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 14 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 standard(s) 18, 19 & 20. There were satisfactory arrangements in place to ensure that service users personal and healthcare needs were properly met. EVIDENCE: The personal and healthcare needs of service users were properly recorded and written care plans were formulated in relation to individual’s identified needs. For those service users case tracked, these were reflective of evidence based practise and detailed service users lifestyle preferences. Records were properly kept in relation to inputs from outside healthcare professionals, including those for the purposes of routine healthcare screening, for which there were satisfactory arrangements. Where necessary there was a recognised approach in place in respect of individual’s capacities to consent to health care treatment by way of a trigger tool. The arrangements for the management and administration of medicines in the home were examined and were satisfactory. Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 15 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 standard(s) 22 & 23 There were suitable arrangements in place to enable service users and their representatives to raise any concerns and to make a formal complaint and to protect service users from abuse, neglect and self-harm. EVIDENCE: Information on how to complain was provided for service users and their representatives both in standard format and in a format more suitable for service users to understand. There was a recognised system in place for the reporting and recording of complaints, including details of action taken and outcomes. Service users spoken with said they were able talk to staff and the manager about any worries or concerns they had. There had been no complaints since the previous inspection. Recognised policy guidance and information was in place for staff in relation to the protection of vulnerable adults and the prevention of abuse. This included local joint agency procedures. The Manager advised that all staff, including her, had attended training via Derbyshire County Council in relation to these and also recognised training in respect of dealing with violence and aggression and personal safety. Examination of individual staff training records sampled and discussions with staff on duty also confirmed this. The arrangements and practises regarding service users monies and financial affairs were examined and discussed for two of the service users case tracked, one of who managed their own monies. These were satisfactory. There was Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 16 suitable policy and procedural guidance in place in relation to the management and handling of service users monies. Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 17 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 standard(s) 24, 25, 26, 27 28, 29 & 30 Service users are accommodated within a safe, well-maintained and homely environment, which is decorated and furnished to a high standard and properly equipped. EVIDENCE: The Inspector carried out an inspection of the building accompanied by the Registered Manager. All areas seen were clean, well lit and ventilated, were properly maintained and were furnished and equipped to a high standard. The Inspector was invited by some service users to see their own room. Service users confirmed that these were decorated and furnished to their personal choice and all were personalised. There is a central kitchen and separate laundry and staff facilities are provided. There is a small garden and also patio/seating areas with garden furniture, which were used by service users to sit out at various times during the inspection. Service users who wished were supported to help with the garden maintenance. Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 18 The Fire Officer had visited the home in April 2005 and confirmed in writing all items appertaining to fire precaution were satisfactory. Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 & 36. There were suitable arrangements in place to ensure that service users are safely supported by a qualified and competent staff group who are properly supported and supervised. EVIDENCE: Each staff member had their own personal/training file kept in the home for their access. These were sampled. Information kept in these included records of their training and development, induction, supervision and appraisals, and certificates of attendance, together with written information on their code of conduct, job descriptions and staff grievance and disciplinary procedures and other key policy and procedural guidance for the home. Staff spoken with was familiar with these. Details of staff training undertaken over the previous 12 months (including NVQs) together with training planned were provided by way of a pre-inspection questionnaire completed by the manager. Records examined and discussions with staff were reflective of this. Details of staff employed and copies of staff duty rotas for weeks commencing 27.06.05 to 18.07.05 inclusive were provided. Records kept in relation to individual staff recruitment were examined in respect of two staff employed Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 20 and discussions held with them about the recruitment process. These were satisfactory. Care is planned, monitored, reviewed and delivered via a key worker system. Service users spoken with knew how their key worker was and indicated that they were well supported by staff and had good relationships with them. Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 40, 41, 42 & 43. The home is very well run and managed and credible systems are in place, which seek to promote the safety, rights and interests of service users. EVIDENCE: The registered manager had recently completed the Registered Manager’s Award/NVQ level 4 in management and care. Details of training undertaken by her over the last 12 months were discussed and records were kept in relation to this. There were clear strategies and operational systems in place to promote leadership, continuity of care and the aims and objectives of the home within an established framework of communication. Staff was conversant with these. There was a comprehensive set of policies and procedures in place in the home to which staff have access. Details of these were provided within the preBeechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 22 inspection questionnaire together. A number of key policies were seen and were signed and had recorded review dates. A number of records, which are required by legislation to be kept in the home, were also sampled. These were safely stored and properly maintained. Details of the arrangements for staff training in relation to safe working practises were discussed and records examined and were satisfactory. Details of the arrangements for the annual maintenance of equipment in the home were provided and were also satisfactory. There was a suitable system in place for the reporting and recording of accidents and untoward incidents, together with details of action taken and outcomes. There was proper insurance cover in place for the home, which was evidence by way of up to date certification. The home’s business and financial plan was not requested for inspection. However, there were no indicators found during the inspection to suggest that the home was not financially viable. Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 23 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 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beechwood House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 3 3 C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 24 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA14 Good Practice Recommendations The registered persons should continue to review with serivce users the need for the provision of a computer in the home for their use. Beechwood House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby, DE1 3QT 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 House C52 C02 S19935 Beechwood House V234350 120705 Stage 4.doc Version 1.30 Page 26 - 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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