Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 14/04/05 for Beechwood House

Also see our care home review for Beechwood House for more information

This inspection was carried out on 14th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home was able to demonstrate that the assessed needs of individuals admitted to the home are being met. Service users spoken to by the inspector expressed their positive satisfaction with the care provided, and service users presented as well cared for and supported. Staff and training records indicate that the staff group has the required numbers, range of skills and abilities with which to appropriately meet the range of needs presented by the home`s service users. The management approach was found to be open and enabling, and conducive to creating a positive and inclusive atmosphere in the home. Service users expressed very positive views regarding the new manager and owners and there was evidence of a wish for continuity in the manager`s expressed wish to maintain the active involvement of service users in the running of the home. The home adheres to a clear policy and practice with regard to ensuring that service users privacy, dignity and rights are respected. Service users were observed to be treated with respect by the manager and staff, and were evidenced to have their right to privacy upheld and promoted. Service users were evidenced to receive wholesome and appealing meals in pleasant surroundings, and at times convenient to them. Service users expressed favourable views about the quality of food provided. Service users feel that they are supported by staff in enabling them to exercise choice and control in their daily routines, and were observed to have good relationships with the management and staff. Feedback from service users and relatives/friends indicates that visitors are made to feel very welcome at the home, and that service users are positively encouraged to maintain their links with family, friends and with the wider community. The home has an open and transparent complaints policy which is made known and accessible to service users and their relatives. Complaints received in the past year have been satisfactorily dealt with and there is no evidence of any unresolved concerns. No complaints have been received since the change in ownership in February 2005. The home presents as an attractive, safe and homely environment, with adequate washing, bathing and toilet facilities. Communal lounges are comfortably furnished and arranged. Service users` rooms were observed to be pleasantly decorated and furnished, reflecting individuals` identities and preferences. The home is generally well maintained and decorated, but would benefit from re-carpeting in some of the communal areas. This is being planned by the new owners.

What has improved since the last inspection?

The home received a very positive report on its last inspection, and it is the expressed intention of the new owners to maintain continuity in the philosophy of care and quality of services provided to the home`s service users.

What the care home could do better:

The home is completing initial assessments of service users prior to admission, but is failing to ensure that care management assessments and care plans are in place prior to a decision regarding admission being made. Service users were provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. Views expressed by two service users indicated that there needs to be more consultation with service users regarding their leisure interests with view to extending the range of activities on offer.Whilst appropriate recruitment policy and procedures are in place, there were some shortcomings in the completion of the home`s staff recruitment checks in the months prior to the new owners taking over. This represents a potential risk to the safety of service users and current procedures must be made watertight by the new owners so as to ensure that all recruitment checks are satisfactorily completed. The home provides a safe and caring environment for its service users, with appropriate protection policies and procedures being in place. There is a need, however, for staff awareness of adult protection issues to be raised. In this regard, training in adult protection needs to be extended to all staff at the home, and for the new providers to undertake a `Training for trainers` course in this area. The home presents as clean, pleasant and hygienic. There is, however, an outstanding requirement in regard to the need for staff to become more fully aware of infection control procedures and to complete approved training in this area. Whilst views expressed by the service users and staff were generally very positive, the home needs to demonstrate this is consistent and develop quality assurance processes. The views of service users, relatives/friends, professionals and other visitors need to be sought and an annual quality audit report compiled. Appropriate supervision arrangements are in place, but a system of appraising staff performance and development needs to be put in place.

CARE HOMES FOR OLDER PEOPLE Beechwood House 40 Beechwood Road Sanderstead Surrey CR1 0AA Lead Inspector Peter Stanley Announced Inspection 14 April 2005 09:30 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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Beechwood House Address 40 Beechwood Road, Sanderstead, Surrey, CR2 0AA 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) 020 8651 2937 020 8405 2572 Mr Hariharen Pavaday & Mrs Anjoo Pavaday Mrs Anjoo Pavaday Care Home 15 Category(ies) of Old age (15) registration, with number of places Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 21 October 2004 Brief Description of the Service: Beechwood House is a small residential home for older people situated in a quiet residential road in Sanderstead. A bus service is available to access the home. The nearest railway station is Sanderstead. The home has recently changed ownership, and is now managed by Mrs Anjoo Pavaday. The house is set back off the road and has a ramp and steps to access the front entrance. There is a large back garden that can only be reached by steps. The home accommodates fifteen elderly residents and is registered in the category of care provision for older people. The home consists of eleven single bedrooms and two double rooms. There is a smoking lounge on the first floor and a smaller lounge on the ground floor. The dining room is next to the large kitchen, with a door leading to the patio and back garden. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the home took place over one day. The new registered providers, Mr and Mrs Pavaday, were present during the course of the inspection. Mrs Anjoo Pavaday is also the home’s new registered manager. The inspector toured the premises and spoke to a number of service users and staff. Care records and other documentation were examined. Three requirements remain outstanding from the previous inspection. From this inspection a further 13 requirements and 5 recommendations are made. What the service does well: The home was able to demonstrate that the assessed needs of individuals admitted to the home are being met. Service users spoken to by the inspector expressed their positive satisfaction with the care provided, and service users presented as well cared for and supported. Staff and training records indicate that the staff group has the required numbers, range of skills and abilities with which to appropriately meet the range of needs presented by the home’s service users. The management approach was found to be open and enabling, and conducive to creating a positive and inclusive atmosphere in the home. Service users expressed very positive views regarding the new manager and owners and there was evidence of a wish for continuity in the manager’s expressed wish to maintain the active involvement of service users in the running of the home. The home adheres to a clear policy and practice with regard to ensuring that service users privacy, dignity and rights are respected. Service users were observed to be treated with respect by the manager and staff, and were evidenced to have their right to privacy upheld and promoted. Service users were evidenced to receive wholesome and appealing meals in pleasant surroundings, and at times convenient to them. Service users expressed favourable views about the quality of food provided. Service users feel that they are supported by staff in enabling them to exercise choice and control in their daily routines, and were observed to have good relationships with the management and staff. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 6 Feedback from service users and relatives/friends indicates that visitors are made to feel very welcome at the home, and that service users are positively encouraged to maintain their links with family, friends and with the wider community. The home has an open and transparent complaints policy which is made known and accessible to service users and their relatives. Complaints received in the past year have been satisfactorily dealt with and there is no evidence of any unresolved concerns. No complaints have been received since the change in ownership in February 2005. The home presents as an attractive, safe and homely environment, with adequate washing, bathing and toilet facilities. Communal lounges are comfortably furnished and arranged. Service users’ rooms were observed to be pleasantly decorated and furnished, reflecting individuals’ identities and preferences. The home is generally well maintained and decorated, but would benefit from re-carpeting in some of the communal areas. This is being planned by the new owners. What has improved since the last inspection? What they could do better: The home is completing initial assessments of service users prior to admission, but is failing to ensure that care management assessments and care plans are in place prior to a decision regarding admission being made. Service users were provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. Views expressed by two service users indicated that there needs to be more consultation with service users regarding their leisure interests with view to extending the range of activities on offer. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 7 Whilst appropriate recruitment policy and procedures are in place, there were some shortcomings in the completion of the home’s staff recruitment checks in the months prior to the new owners taking over. This represents a potential risk to the safety of service users and current procedures must be made watertight by the new owners so as to ensure that all recruitment checks are satisfactorily completed. The home provides a safe and caring environment for its service users, with appropriate protection policies and procedures being in place. There is a need, however, for staff awareness of adult protection issues to be raised. In this regard, training in adult protection needs to be extended to all staff at the home, and for the new providers to undertake a ‘Training for trainers’ course in this area. The home presents as clean, pleasant and hygienic. There is, however, an outstanding requirement in regard to the need for staff to become more fully aware of infection control procedures and to complete approved training in this area. Whilst views expressed by the service users and staff were generally very positive, the home needs to demonstrate this is consistent and develop quality assurance processes. The views of service users, relatives/friends, professionals and other visitors need to be sought and an annual quality audit report compiled. Appropriate supervision arrangements are in place, but a system of appraising staff performance and development needs to be put in place. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4 and 5 Generally service users are admitted to the home on the basis that their needs have been assessed and can be met. However this could be jeopardised if care management assessments and care plans have not been seen prior to admission. Prospective service users, their friend and relatives are able to visit to assess the suitability of the home. EVIDENCE: The home’s policy is for prospective service users to be invited to visit the home and move in on a trial basis for 4 weeks. Following this trial period a review is held with the service user and his/her relatives/advocates. A decision regarding permanent placement is then made. Unplanned admissions are avoided where possible. The inspector examined a sample of five service user files relating to recent admissions. The home completes assessments, risk assessments and service user plans that are kept for easily accessible staff reference on a separate file in a staff area of the home. A copy of this documentation must be included in the service user files. A requirement has been made in respect of this. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 10 A photograph of the service user was not included on three of the files examined. A requirement has been made in respect of this New service users are admitted on the basis of a full assessment undertaken by a person who is suitably qualified to do so. The assessment is completed with the service user, relative or delegated representative and any relevant professionals that have been party to the referral. The inspector did not, however, find any evidence of care management assessments on three files or care plans (from the referring local authority) on two of these. A requirement is made that for any care management referral made by health or social services, a copy of the care management assessment and care plan must first be obtained prior to any decision regarding admission being made. The inspector is making it a recommendation for a checklist to be compiled and kept on service users files, detailing all the documentation obtained in respect of service users who have been referred for admission to the home. This should include details of when care management assessments and care plans have been received, details of any specialist assessments, and details of when the home’s initial assessment, risk assessments and service user plan have been completed. Details of when the health history and medication details have been received should be noted together with personal information (including details of the service user’s GP and next of kin). The registered manager was able to demonstrate the home’s capacity to meet the assessed needs of individuals admitted to the home. Service users spoken to by the inspector expressed their positive satisfaction with the care provided, and service users presented as well cared for and supported. There was evidence from the service user plans that specific social and cultural needs are being addressed. Staff and training records indicate that the home has the range of skills and abilities with which to meet the needs of service users. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The health care needs of service users are being fully met, however in order to continue to provide a safe service, accredited medication training needs to be extended to all care staff. Service users are treated with respect and their privacy is maintained. Security and privacy can be improved by increasing the provision of a lockable space for storing personal valuables to all the residents’ bedrooms. EVIDENCE: Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 12 Service user plans identified the health, personal care and social needs of residents and are drawn up by the home in consultation with the service user and his/her relatives/advocates. These are based on information from assessments and are reviewed on a regular monthly basis. These included completed risk assessments on areas such as including manual handling. The health care needs of residents were being appropriately met. The GP visits the home and other medical professionals attend as and when needed. Service user records detail visits from the district nurse and GP, and include details of hospital visits and other appointments. Personal and oral hygiene, including the care of dentures, are actively encouraged. The promotion of continence is monitored with advice being obtained from incontinence advisors when required. The home has a medication policy in place. The inspector examined medication records which were in order. The home uses the Monitored Discharge system for administering medication. No controlled drugs are being used. All medications are kept in a locked cabinet in an area adjacent to the lounge. Any service user who wishes to take full responsibility for their own medication is able to do so subject to a risk assessment being carried out. Such assessments are reviewed on a regular basis and the date recorded on file. All medicines are prescribed on an individual basis. Advice from a pharmacist concerning the home’s policy on the safe handling and administration of medicines is obtained on a quarterly basis. Not all staff have received training in administering medication, and a list is kept in the medication cupboard of those staff who are qualified to do so. The registered manager indicated that accredited medication training is due to be updated for all staff. This has been supported by making this a requirement. The home adheres to a clear policy and practice with regard to ensuring service users dignity and rights are upheld in all matters associated with personal physical and medical care. Service users can see their GP in the privacy of their own bedroom and without the attendance of staff if they prefer. The service users said that staff are considerate and respectful of their privacy. Service users’ wish to spend time in their own rooms is respected, and staff were observed to knock on their doors before entering. Not all service users currently have a lockable space in their bedrooms for storing personal possessions and valuables. This needs to be addressed and a requirement has been made to address this. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Service users are provided with a varied range of opportunities for recreational and social activities that is in accord with their social, cultural and religious needs. However in order to maintain the residents continued interest and participation there needs to be more consultation with them regarding their specific interests with a view to extending the range of activities on offer. Residents are encouraged to maintain contact with their family and friends, and to maintain links with the local community. The meals provided were wholesome and appealing and served at times convenient to them. EVIDENCE: Feedback from service users regarding the range of activities on offer was generally positive. Service users are able to participate in a range of activities that include music and movement, bingo and manicure. Vocal and musical entertainment and occasional outings to places of interest are also arranged. Service users are able to exercise choice in their daily routines. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 14 Two residents expressed an interest in painting and drawing and this, together with reminiscence are therapeutic activities that the home should consider providing. A recommendation is included for service users to be consulted as to specific areas of interest and activity which they would like to pursue and for the range of activities on offer to be extended to accommodate individual needs. The inspector found that service users are assisted to exercise a fair degree of choice and control in their daily routines, but that the participation of service users in decision-making within the home is not currently being evidenced. Service user meetings are held every two months to encourage feedback regarding any issues service users wish to raise. The inspector was concerned to find that the first meeting held in March with the new providers had not been minuted so as to record the issues discussed. A requirement is made for all meetings with service users to be minuted to include an agenda, minutes of each issue discussed and the actions/decisions agreed. Service users spoken to by the inspector indicated that they felt supported in exercising some choice and control in their day-to-day activity. One service user, however, felt that there could be more choice offered in daily activities offered. Service users are allowed some flexibility with when they take their meals with breakfast being served in their rooms if they wish. There are set meal times, but hot drinks and snacks are available, when required, throughout the day. Service users generally expressed satisfaction with their daily routines, and felt that these were sufficiently flexible to meet their needs. Visitors are encouraged to visit and maintain contact with service users. From the views expressed by service users, and the feedback received (from comments cards) prior to the inspection, relatives and other visitors are made to feel welcome at the home. Links with the community are maintained with a range of visitors to the home. Service users are able to go out to the shops, or elsewhere, providing they have been risk assessed as safe to do so. Dial-a-ride is available if required. The opportunity for organised outings to places of interest were positively viewed. One service user, without any near relatives, attends a local day centre two days a week. The inspector spoke to the service user on her return from the day centre and found that she greatly valued this opportunity for social contact. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 15 The inspector observed that the meals served at lunchtime included fresh vegetables and presented as appetising and nutritious. Service users expressed very positive views regarding the quality of the food served. The inspector examined menus provided over a two-week period. These evidenced a varied choice of food with fresh vegetables and fruit being included in the diet. The dining room presented as a very pleasant area in which to have meals. The nutritional needs of service users are monitored. Any difficulties that an individual may experience are quickly identified and the appropriate action is taken. Service user’s weights are monitored where dietary concerns have been identified. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 An appropriate complaints policy and procedure is in place. Complaints received have been satisfactorily dealt with and there is no evidence of any unresolved concerns. Service users are protected from abuse and live in a safe environment. In order that this level of protection can be maintained training in adult protection must be extended to all care staff. EVIDENCE: Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 17 There is a policy and complaints procedure at the home which includes the stages and time scales for the process and notes that complaints will be responded to within twentyeight days. The procedure states that any complaint can be referred to the CSCI, local office at any time during the course of investigation. A complaints book is maintained which details the outcome of any complaint and what action (if any) was taken. One complaint has been made since the last inspection. This was addressed and resolved to the satisfaction of the complainant. No complaints have been made since the change in ownership of the home in February 2005. There is an Adult Protection and Whistle Blowing Policy in place for staff to reference should the need arise. The manager informed the inspector that five staff have attended a one day course in adult protection, and that six staff have still to complete this training. A requirement has been made to address this. The inspector discussed the need for the new providers to attend an accredited training course on adult protection such as ‘Training for Trainers’ a recognised course which can be cascaded down for the benefit of all staff. A recommendation has been made to address this. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26 Service users live in a safe, well-maintained environment, with access to safe and comfortable facilities. Sufficient bathing, washing and toilet facilities are provided with which to meet the needs of service users. Service users’ rooms were safe, comfortable and pleasantly decorated, reflecting their personal identities and suited to their individual needs. Service users are provided with the aids and specialist equipment they require to maximise their independence. The home presents as clean, pleasant and hygienic however in order to maintain this staff need to complete approved training in infection control. EVIDENCE: Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 19 The accommodation provided for the service users was found to be safe, warm and comfortable throughout. The home is in a good state of decoration and the premises have been well maintained and comply with safety requirements from the Fire Service and Environmental Health. The new owners have plans for recarpeting of the communal areas and service users rooms. The communal areas provide a pleasant, homely environment. There are two lounges, one of which is for smokers. The lounges provide adequate space for the service users to sit, and were warm, comfortable and pleasantly furnished. The dining room provides a very pleasant area in which to take meals. A number of service users who were using these areas expressed their positive satisfaction with the environment and the facilities provided. Service users bedrooms were observed to suit service users’ needs and to be pleasantly furnished and laid out. These were pleasantly decorated and reflected the personal identity and interests of their occupants. There are 11 single rooms and 2 double bedrooms, which meet the requirements for minimum size. There are two bathrooms, one with an ambu-hoist and there are sufficient bathing and washing facilities to meet service users’ needs. All the bathrooms and toilets had liquid soap and paper towels provided. Adaptations have been made to various areas of the environment to ensure the health and safety of the service users. One bathroom has an ambu-hoist and grab rails are in place in the other bathroom. There is a passenger lift in place from the ground floor to the first floor. Handrails are in place on the staircases. Any adaptations or specialist equipment that is needed for service users is assessed by an occupational therapist on an individual basis as and when needed. Central heating can be controlled in each individual room. There is an emergency lighting system. Hot water temperatures are tested daily and records showed these were within safety limits. All radiators within the home are either low surface temperature radiators or have been covered with appropriate guards. The home presented as clean and free from offensive odours at the time of the inspection. Although staff at the home have received in house infection control training from the previous manager, none of the staff have attended an ‘approved’ training course. A requirement from the last inspection for training to be provided for all staff has yet to be met (see standard 38). The new providers assured the inspector that they would ensure that this requirement is met forthwith. The home has a mechanical toilet utensil washer and disinfector. The kitchen was clean and fresh food is kept in hygienic conditions. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 29 The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. Whilst appropriate recruitment policy and procedures are in place, there were shortcomings in the completion of the home’s recruitment checks. This represents a potential risk to the protection of service users. EVIDENCE: Staffing levels are in accordance with the original agreement prior to the Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older people. This is subject to adjustment should the dependency of the service users increase or if a crisis occurs that would warrant an increase in staffing levels. The home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s service users. The home has 11 care staff and 3 ancillary staff. The deputy manager, who was not present for the inspection, is a registered nurse. The inspector examined staff rotas, which were found to be satisfactory. There are always three carers on duty in the home during the day and two (one waking, one sleep-in) at night. The home currently has 8 care staff with NVQ Level 2 and meets the 50 target for 2005. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 21 The inspector examined a number of staff files for staff recruited in recent months. One staff file did not have a new CRB (Criminal Records Bureau) check, but an old CRB check from a previous employer. The home must ensure that new CRB checks are in place for all applicants prior to being employed. This is made a requirement. Both this file and another staff file did not include any references or explanation of a gap in employment since 2002. The failure to complete the necessary checks is in breach of regulation 19 (b) and is potentially putting service users at risk. A requirement therefore has been made to address this. The inspector accepts that the new providers were not in post when these applications were being processed, but, as discussed with Mr and Mrs Pavaday, the requirements are based on a failure in the recruitment processes within the home and must nonetheless still apply. To assist the processing of applications in accordance with the information and checks outlined in Schedule 2 of the regulations the inspector discussed the need for a checklist to be included on each staff file, indicating all the checks and documentation required and the date when these are obtained. This is included as a recommendation. The training and competence of staff will be assessed on the next inspection. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37 and 38 The new registered manager has the necessary skills and experience with which to manage the home in the best interests of the service users. Staff are supported through supervision but monitoring of their future training needs should be put in place to ensure a good level of service to residents is maintained. Generally the health, safety and welfare of service users and staff are being appropriately protected. EVIDENCE: Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 23 The new registered provider/manager presents as a knowledgeable and caring person, who relates well to the home’s service users. She has a nursing background and has a range of previous supervisory/management experience which will assist her in meeting the aims and objectives in running the home. She is not qualified to level 4 NVQ in Management, but is intending to register in 2005 to undertake a course of training leading to an NVQ Level 4 management qualification. This has been made a requirement. The management approach of the registered manager was found to be an open and enabling one. The manager was observed to interact well with both staff and service users and to assist in creating a positive and inclusive atmosphere. Service users expressed very positive views regarding the new manager and owners and there was evidence of a wish for continuity in the manager’s expressed wish to maintain the active involvement of service users in the running of the home. Both staff and service users are encouraged to participate in the day-to-day running of the home, with staff and service user meetings being held on a regular basis. Staff members spoken to by the inspector expressed their satisfaction with the new owners and indicated that they were happy with the way in which the home was being managed. The home needs to demonstrate that it is being run in the best interests of service users, and that it is meeting its aims and objectives. Service users and staff are able to communicate their views to management in service user and staff meetings, though this needs to be evidenced with recorded minutes. Whilst views expressed to the inspector from service users and staff were generally very positive, the home needs to evidence its performance and develop its quality assurance processes. This is in line with a requirement from the last inspection. A questionnaire for service users has been developed but has yet to be implemented by the present providers. Questionnaires also need to be developed for relatives and friends of service users, for those who visit in a professional or voluntary capacity and for other stakeholders. The time-scale for meeting this requirement has been extended to allow the new owners to institute an ongoing quality audit system. An annual development plan has been produced, but this is not based on any quality assurance audit. The present owners will need to put in place a development plan for 2005-06 which evidences that the home is meeting its aims and objectives and is being run in the best interests of service users. This must include feedback from all sources of information, including the surveys, and must evidence a cycle of planning, action and review. The results of the surveys must be publicised and the report made available to current and prospective service users, their relatives/representatives and other parties including the CSCI (Commission for Social Care Inspection). This has been made a requirement. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 24 All requirements are in place with regard to employment policies and procedures. There is induction, training and supervision arrangements in place which are put into practice for the benefit of the service user. A requirement is made for a new supervision format to be developed. This should record agenda items, issues discussed, and agreed actions and decisions. The supervision record should be signed and dated by the supervisor and supervisee. Supervision should cover all practice issues, the philosophy of care in the home and staff members’ training and career development needs. The inspector also recommends that an annual system of staff appraisal is developed to appraise staff progress and performance over the year, to highlight learning and development needs, and to agree set objectives. To this end, the homes needs to develop an appraisal format which is signed and dated by the appraiser and the staff member being appraised. The inspector also recommends that the manager and deputy manager undertake staff appraisal training to assist in facilitating this process. Records required for regulation were generally in place and well maintained. Staff and service users’ records are kept in a locked filing cabinet in the office; this office is always staffed and is locked when not in use. The home has an access to files policy. The service provider/manager is the registered ‘controller’ for data protection purposes. Service users, relatives and carers are fully involved in the drawing up of care plans and other documents placed in their individual files. Records in the home indicate that the new registered providers are continuing to ensure that there are safe working practices in the home and that the health, safety and welfare of service users is being protected. All Accidents and incidents are recorded in an appropriate manner. Safety procedures are in place. All staff receive induction training in health and safety and training updates are facilitated. Service users spoken to by the inspector indicated that they felt safe in the home, and no concerns were raised. Protection with regard to Fire Safety training is carried out every three months by an ‘approved company’ to ensure that all staff are clear of what actions to take should such an event occur. Fire awareness and training have been seen as paramount at this home, and this vigilance must be maintained by the new owners. The fire risk assessment was last updated in May 2004 and will need to be updated by the new providers. The inspector noted that inspection and servicing of the home’s hoists was last carried out in February 2004. An up to date servicing inspection is made a requirement, with a copy of the servicing certificate to be forwarded to the CSCI. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 25 The home last received a health and safety inspection in March 2003. A requirement has been made for an up-to-date inspection to take place. A copy of the report must be forwarded to the CSCI. Risk Assessments for safe working practices are in place and should be updated on a regular basis. While techniques for the manual handling of service users is in place, practical training in moving and handling is required and must be arranged for all care staff. This has been made a requirement. Food and hygiene procedures are in place to ensure the safety of staff and service users. A requirement from the last inspection, for staff to undertake ‘approved’ infection control training has yet to be met. The time-scale for meeting this requirement has been extended to allow the new providers to comply with this. Evidence of PAT testing and the five yearly electrical certificate has been previously noted. A check of the gas installation has been recently completed. The home has undertaken a risk assessment of the homes water system in relation to Legionella on 23rd July 2004. Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 3 1 x x 2 3 2 Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 27 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 OP3 Requirement The registered manager must ensure that a copy of the homes assessments, risk assessments and service user plans are kept on service user files. A photograph of the service user must be included on all service user files. The registered manager must ensure, that for all care management referrals, a copy of the care management assessment and care plan is obtained prior to any decision regarding admission being made. The registered manager must ensure that accredited medication training is updated for all staff. A lockable space for storing personal valuables must be provided in those bedrooms where this is not currently being provided. The registered manager must ensure that all meetings with service users are minuted to include an agenda, minutes of each issue discussed and the actions/decisions agreed. The registered manager must Timescale for action 1 May 2005 2. 3. OP3 OP3 1 May 2005 1 May 2005 4. OP9 1 October 2005 1 July 2005 5. OP10 6. OP14 1 May 2005 7. 12 (1)(a) & OP18 1 October Page 28 Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 (b), 18 (1)(a) 8. 19 (b), Schedule 2 OP29 9. 19 (b), Schedule 2 OP29 10. 24 (1)(a) & (b) 24 (1) OP33 11. OP33 12. 18 (2) OP36 13. 13 (4)(c) OP38 14. 13 (4)(a) & (c) OP38 15. 12 (1)(a) & (b), 13 (4)(c) OP38 ensure that all staff have attended a one day course in adult protection. The registered manager must ensure that all documentation listed in Schedule 2, including references, are evidenced on staff files. Any gaps in employment should be explained. The registered manager must ensure that new CRB checks are in place for all applicants prior to their being employed in the home. A quality audit system must be in place to assess whether the aims and objectives of the home have been met. The registered providers must ensure an annual development plan is implemented for the home and send a copy of the plan to the CSCI, local office. The registered manager must evidence that care staff are being appropriately supervised by developing a more comprehensive supervision format. This should record agenda items, issues discussed, and agreed actions and decisions. The supervision record should be signed and dated by the supervisor and supervisee. An up to date servicing and inspection of the homes hoists is required. A copy of the servicing certificate must be forwarded to the CSCI. The home requires an up to date health and safety inspection. A copy of the report from the inspectorate must be forwarded to the CSCI. Up to date training in moving and handling must be arranged for all care staff. 2005 1 May 2005 1 May 2005 1 October 2005 1 January 2006 1 May 2006 1 June 2006 1 September 2006 1 July 2006 Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 29 16. 13 (3) OP38 The registered person must ensure staff undertake infection control training, (standard 38.2) 1 September 2006 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 OP3 Good Practice Recommendations The registered manager must ensure that a checklist is compiled and kept on service users files, detailing all the documentation obtained in respect of service users who have been referred for admission to the home. The registered manager must ensure that there is consultation with service users regarding their interests with view to extending the range of activities on offer. The new providers should attend an accredited training course on adult protection such as ‘Training for Trainers’ a recognised course which can be cascaded down for the benefit of all staff. An annual system of staff appraisal should be developed to appraise staff progress and performance over the year, highlight learning and development needs, and agree set objectives. To this end, the home needs to develop an appraisal format which is signed and dated by the appraiser and the staff member being appraised. The inspector recommends that the manager and deputy manager undertake staff appraisal training to assist in facilitating this process. 2. 3. OP12 OP18 4. OP36 5. OP36 Beechwood House G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 Page 30 Commission for Social Care Inspection 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 G53 S62807 Beechwood V211342 140405 Stage4.doc Version 1.20 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!