Inspection on 25/07/06 for Beechwood House

This inspection was carried out on 25th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beechwood House 06/10/09

Beechwood House 14/07/09

Beechwood House 13/10/08

Beechwood House 19/06/08

Beechwood House 22/05/07

Beechwood House 04/10/05

Beechwood House 22/09/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Beechwood House Front Street Earsdon Whitley Bay Tyne & Wear NE25 9JU Lead Inspector Jackie Burke Unannounced Inspection 25th July 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beechwood House DS0000061572.V295716.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 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 DS0000061572.V295716.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechwood House Address Front Street Earsdon Whitley Bay Tyne & Wear NE25 9JU 0191 252 4840 0191 252 4840 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) Redcote Homes Limited Mrs Bernadette Bell Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The increase from 27 to 28 beds is to change one room to double usage. This only applies for use by married or partnership couples sharing bedroom 10 4th October 2005 Date of last inspection Brief Description of the Service: Beechwood House is a residential care home for older people situated in the village of Earsdon. There are two public houses in the village and a local bus service. Accommodation is provided over two floors. Access to the first floor is via a passenger lift. There are 27 bedrooms, none of which are en suite. Toilets are located throughout the building and commodes are provided in bedrooms overnight. There are five bathrooms three of which have assisted baths and one incorporates a roll in shower. One bathroom is used as a storage area and this must be cleared and assisted bathing facilities provided to improve choice for residents. There is a mobile hoist available in the home. Beechwood House has a large lounge and conservatory on the ground floor and two dining rooms. There is a smoking area on the ground floor and a quiet lounge on the first floor. The home is pleasantly decorated and furnished throughout and there is a private garden to the rear. Plans are under consideration to extend the size of the home using existing buildings adjacent to Beechwood House in order to provide care for a further nine residents if planning is approved. Nursing care is not provided at Beechwood House The cost of services provided by Beechwood House range from £336 to £385 per week. Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is of an unannounced key inspection. The inspection took place over two days on the 25th and 26th July 2006 and lasted for 8 hours. I spoke with two visitors, seven residents and four staff during the inspection. I also spent time with the manager and the owner during the inspection. Four care files were case tracked during this inspection. Four staff files were examined during this inspection. The manager has handed in her notice and leaves Beechwood House at the end of July 2006. The owner Mrs Sitharanjan is planning to manage the home in the short term and hopes to appoint a new manager as soon as possible. She has agreed to inform CSCI as to appointment and to apply to register the new manager when he /she is appointed. What the service does well: Beechwood House provides a pleasant homely environment for people who live there. There is a good standard of décor and cleanliness throughout the home and families and friends are encouraged to visit. People who live in the home said “I am very happy here. The staff are understanding and thoughtful. I like to do things in my own way and they know just to let me get on with it.” “I am well suited and I have a lovely room” The food in the home is good and cooked fresh daily. There is a choice of meals at lunch and teatime. Beechwood House DS0000061572.V295716.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 contacting your local CSCI office. Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are given a copy of the contract for Beechwood House. Needs are assessed and assurances given that needs will be met before service user’s move into Beechwood House. EVIDENCE: The service user contract currently reads “Beachwood House” and should be changed to the correct spelling of the home. Assessments are done before service users move into Beechwood House. In some cases the assessment is undertaken by a care manager and supplemented by the manager’s assessment of need. Where individuals arrange care privately the manager makes the assessment. Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Health, personal and social care needs are set out in an individual care plan for each service user. Health care needs are met. There is a medication policy and procedure in place and staff administering medication are provided with appropriate training. Service users are treated with respect and privacy is upheld. EVIDENCE: Four case files were examined during this inspection and the overall standard of information in care files care files was good. Care plans and daily recording sheets provide evidence that health and personal care needs are being addressed. Records confirm that GP, District Nurse, Chiropodist and other health care professionals are involved in the primary care of residents in Beechwood House. Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 10 Two people had dirty spectacles during the inspection and staff should be reminded to check on and deal with the personal hygiene and personal care needs of service users. An action plan has been developed relating to a service user whose first language is not English. This includes translations of phrases, which have been written on cards, and the manager agreed to laminate and use to promote effective communication between staff, other service users and the individual. Family members provide culturally specific foods and work should be done to develop ways in which the home can meet dietary needs for the service user. There is a medication policy and procedure in place at Beechwood House and checks made of controlled medication during the inspection confirmed that records are accurately maintained and medicines are stored appropriately. Staff who administer medication within the home are trained to do so and the policy is followed. Medication, which is no longer required, is returned to the pharmacy. There is a fridge in the medicine room, which is used to store eye drops. Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have expressed concern that there is not a range of suitable activities available at Beechwood House. Visitors are welcomed to the home. Service users are enabled to exercise choices within their lives There is a varied balanced diet provided at Beechwood House. EVIDENCE: A new activities coordinator has been appointed at Beechwood House. The activities coordinator is employed to provide 20 hours of activities per week but also covers some care hours as required. Activities are available but are often compromised by care needs within the home and staff shortages. Some people spoke of taking walks around Earsdon village. Armchair exercise and games provided in house, a yoga teacher visits the home each month and provides a yoga and relaxation session. On the second day of inspection two people and the activities coordinator played a game of quoits in the garden. Service users who played the game said that they had enjoyed the opportunity to go out in the garden and had Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 12 enjoyed the game, which they had not played previously. Care staff helped service users with nail care in the afternoon. Visitors were observed during both inspection days and service users and visitors said that visitors are welcomed to Beechwood House. There is a pet cat living in the home, which provides companionship and affection to a number of people. Meals are provided on the premises and are cooked fresh daily, on the first day of inspection a choice of smoked cod or toad in the hole was provided with potatoes, vegetables and a dessert of ground rice or jelly & ice cream. The food was hot and portions of an ample size and served according to individual preference. One person had chosen a salad and the cook will provide alternatives as requested. Breakfast is offered at times to suit individual tastes and a choice of cooked breakfast or cereal and toast is on offer. Choices are offered at teatime and suppertime and tea and coffee is offered during the day and evening. Cold drinks are available and people are encouraged to drink fluids to maintain hydration during hot weather. Fresh fruit is available on request. Kitchen staff are experienced and have received appropriate training in nutrition and food hygiene. Special dietary requirements may be catered for including diabetic diets and low fat options for people with high cholesterol levels. Family members provide specific cultural foods for one service users however it is recommended that staff address the cultural dietary needs of service users in Beechwood House. Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a complaints policy at Beechwood House; which is to be reviewed and all comments and complaints recorded. Service users are protected from abuse. EVIDENCE: There is a complaints policy at Beechwood House and since the last inspection seven complaints have been recorded. Information relating to a complaint about a medication error has not been dated or signed and this was discussed with the manager. Outcomes of complaint investigations have not been included within the complaints file and this was discussed with the manager who agreed that this information would be included. The complaints procedure should be further reviewed and all complaints whether verbal or written should be recorded and responded to within the timescales of 28 days indicated in the policy. Residents spoken to stated that they would speak to the manager if they had a complaint. There is awareness in the home of the protection of vulnerable adults; staff spoken to during the inspection were aware of the rights of individuals and the vulnerability of the people in their care. POVA training has been provided to management and half of the staff group. Further POVA training is planned to take place for remaining staff members. Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Work is underway to ensure that service users live in a safe well-maintained environment The home provides sufficient lavatories but there are less bathing facilities than required Specialist equipment is provided but maintenance checks are overdue The home is clean pleasant and hygienic EVIDENCE: There are five bathrooms in Beechwood house one of which is a combined bath/shower facility. Three bathrooms are not in use. The bathroom on the first floor used for storage has yet to be cleared and assisted bathing facilities provided. Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 15 Maintenance checks for the hoist and bathing equipment were last done in May 2005 and are overdue. Bedroom 10 is not in use and has an unpleasant smell. Soft furnishings and a soiled mattress must be replaced and the carpet cleaned in order to address this. Carpets in some rooms need to be replaced as they are soiled and worn. The carpet outside room 25 is frayed and must be dealt with to prevent a trip hazard. A corridor fire door is propped open with a glass vase and represents a risk in limiting fire prevention and the risk of causing a cut injury. Automatic door closure systems should be fitted to fire doors. A programme of refurbishment and redecoration is underway and the provider is committed to making changes necessary to improve standards in Beechwood House. The cleaning cupboard on the first floor was unlocked and the key in the door during the inspection, staff should be reminded to lock the door. COSHH guidelines are displayed on both storage cupboard doors and cleaning materials are clearly marked and correctly stored. The home is clean and pleasant. Domestic staff are working hard to cover cleaning duties. Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are not met in full by numbers and skill mix of staff. Service users are protected by the homes recruitment policy and practices Staff are trained and competent to do their jobs EVIDENCE: There are some vacancies in the home, staff have been recruited and Criminal Records Bureau checks applied for. On the days of inspection there were three care staff and the manager on duty, two domestic staff and two kitchen staff. The handy man was also busy in the garden. The owner of the home Mrs Sitharanjan was also in the home during both days of the inspection. Shifts are covered: 8am-3pm Manager Senior Care Two care staff 3-10pm Senior Care Two care staff 10pm-8am Two care staff The manager has resigned from her post and leaves Beechwood House at the end of July 2006. Interviews are underway to recruit a new manager and in Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 17 the meantime the service provider has arranged to cover managerial tasks and has asked senior staff to continue to take part in out of hours duty rota. There is a commitment to training and development within Beechwood House. The majority of care staff are qualified to NVQ level 2 or above and there are a number of staff who are pursuing further NVQ level awards. Training records show that training has recently been provided for staff in Fire Awareness, POVA, Dementia Care, Moving and Handling and Health and Safety. Two staff are currently receiving training in medication. Induction training and COSHH training should be provided to new domestic staff. Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a vacancy for the manager’s post. The home is run in the best interests of service users Service users financial interests are safeguarded Staff are not appropriately supervised. The health, safety & welfare of service users and staff is compromised. EVIDENCE: The manager has resigned and leaves a vacancy at the end of this month. The owner will oversee management of the home in the short term and is currently recruiting a new manager. Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 19 Quality assurance systems within the home are poor and should be developed to seek the views of service users, staff and families; to measure whether aims and objectives of the home are being met. This may include manager’ s daily rounds, meetings with service users families and staff and handover meetings with staff as well as a comments and suggestions book. Policies relating to the financial interests of service users are in place and records relating to individuals financial transactions maintained. Staff records show that staff have not received supervision and the management of staff within the home has been poor resulting in resignations and staff changes. Four files were examined and indicated that supervision had been provided to one staff member and a brief record made. Supervision should be provided to all care staff at least 6 times per year. Two staff files did not contain any records of supervision; one staff member was appointed in November 2005 and had not yet had any supervision. Two staff files contained appraisal records one of which is dated 2002. The manager said that the deputy manager had provided supervision to staff and he has now left Beechwood House. The manager had not had time to give supervision to staff as she was too busy with other tasks. Staff files are in disarray and records and organisation should be improved Policies and procedures are in place to safeguard the well being of people who live in the home and the health and safety of service users is maintained by the provision of mandatory training, risk assessment and record keeping. Systems should be developed within Beechwood to ensure that routine safety and maintenance checks are anticipated and undertaken. Portable appliance testing was done in May 2006. Systems should be developed to ensure that maintenance checks are anticipated and flagged up and that the home has a development plan. Fire records confirm that equipment checks are up to date and testing is undertaken on a regular basis. Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 x X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 2 X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP12 Regulation 16(1)(2) m, n Requirement Work must continue to improve the range of activities on offer and to enable people to exercise choice and control Outstanding Requirement 4/10/05 The complaints policy should be reviewed and all complaints should be recorded and investigated within the timescales. Outstanding Requirement 4/10/05 Routine maintenance and renewal of the fabric and decoration of the building is implemented and records kept. The building complies with requirements of the fire service and environmental health department. Assisted bathing facilities should be provided to meet service users needs Hoist Aids and bathing equipment should be checked and maintained to safely meet the assessed needs of service DS0000061572.V295716.R01.S.doc Timescale for action 31/10/06 2. OP16 22 (3) (5) (8) 31/10/06 3. OP19 23 (2) (b) (c) 31/10/06 4. OP19 23 (4) (a) (c) 23 (2) (j) 23 (2) (c) 01/09/06 5. 6. OP21 OP22 31/10/06 01/09/06 Beechwood House Version 5.2 Page 22 7. 8. OP27 OP31 9. 10. 11. OP33 OP36 OP38 users. Staff numbers and skills should meet the assessed needs of service users. 8 (1) (a) A manager should be appointed who is qualified competent and experienced to run the home and to meet it’s stated purpose, aims and objectives. 24 Effective quality assurance and (1) (a) (b) monitoring systems should be developed. 18 ( 2) Staff should be provided with formal supervision at least six times per year. 12 The Registered Person should (1) (a) (b) ensure the health, safety and 13 welfare of service users and (4) (a) staff. 18 (1) (a) 01/10/06 01/09/06 31/10/06 31/10/06 01/09/06 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 OP2 OP4 Good Practice Recommendations Spelling errors in the service users contract should be corrected. The cultural, and social needs of specific minority ethnic individuals should be understood and met. By providing laminated cards with translations & symbols By providing for specific cultural dietary needs Beechwood House DS0000061572.V295716.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 DS0000061572.V295716.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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