CARE HOMES FOR OLDER PEOPLE
Beechy Knoll 378 Richmond Road Sheffield South Yorkshire S13 8LZ Lead Inspector
Janis Robinson Unannounced Inspection 10th November 2005 09:00 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 DS0000065505.V265561.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. DS0000065505.V265561.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Beechy Knoll Address 378 Richmond Road Sheffield South Yorkshire S13 8LZ 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) 0114 239 5776 0114 264 6063 Pearlcare (Richmond) Ltd. Post Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places DS0000065505.V265561.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The minimum numbers of care staff on duty must comply with that required by the `Reidential Forum - Care Staffing in Care Homes for Older People`. Date of last inspection Brief Description of the Service: Beechy Knoll is a fourty bed home providing personal care for older people of both sexes. It is situated in a residential area of Sheffield, close to local amenities and bus routes. The home is built over two floors, all areas of the home are accessible to residents and a passenger lift is provided. 33 of the homes bedrooms are single and 3 bedrooms are double. 22 bedrooms have ensuite toilet facilities. The home has communal lounges and a communal dining space. Appropriate bathing facilities are provided. A central laundry and kitchen serve the home. Seating is provided in the homes gardens. The home has a car park. DS0000065505.V265561.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Since the last inspection the home had changed ownership. An acting manager was in place, who had applied to become the registered manager of the home. This inspection was unannounced and took place over 4 hours from 12.40 pm to 4.40 pm. An inspection of the environment was undertaken, and records were sampled, including; staff training, health and safety, care plans, rotas, complaints and fire records. Interactions between residents and staff were observed. The inspector spoke with two visitors to the home, a proportion of staff on duty and thirteen residents. Discussions with the homes acting manager took place. What the service does well:
All of the comments made by residents were positive. Residents said the home was ‘very good’, ‘can’t be better cared for’, and`lovely and comfortable’. Contracts were undertaken with residents to inform them of their rights and obligations. Assessments prior to admission were undertaken to ensure the home could meet the needs of the prospective resident. Trial visits to the home, to enable prospective residents and their representatives to make an informed decision, were encouraged by the home. Staff undertook a range of training to keep them up to date and ensure they were able to meet residents’ needs. Each resident had a care plan, which outlined all personal, social and health care needs. Access to health care professionals was available, to maintain residents health. Residents confirmed that the staff were respectful towards them. The routines at the home were flexible, some activities were available, and residents were able to choose how to spend their day. There was an open visiting policy, to encourage contact with family and friends. There was a complaints procedure, each resident had been provided with a copy to inform them of their rights. All spoken with said they had confidence in the staff at the home, who would listen to any concerns and take them seriously. Adult protection procedures were in place. The environment was well maintained. The majority of the home was clean and free from odours. Homely touches were provided in communal areas to create a comfortable environment. Bedrooms were well decorated and individually personalised with possessions residents brought in with them.
DS0000065505.V265561.R01.S.doc Version 5.0 Page 6 Agreed levels of staff were being maintained. The home had a commitment to National Vocational Qualifications (NVQ), to ensure staff had the skills needed to meet the needs of residents. Staff undertook a range of training and individual training records were kept. Residents finances were safely managed. Health and safety systems were in place at the home, fire equipment had been checked and serviced. Mandatory training took place. What has improved since the last inspection? What they could do better:
Care plans did not contain sufficient detail relating to personal care needs to ensure staff were fully informed in relation to the staff action required to ensure assessed needs were met. The majority of residents spoken with said that they would like more activities and trips out of the home. Records of complaints did not consistently record the outcome of the complaint. Whilst the home had a written adult protection procedure, copies of local multiagency procedures were not available at the home. The corridor and some communal rooms had stained carpets. The recommended 50 of the staff team trained to NVQ level 2 by 2005 had not been achieved. Staff recruitment records did not contain all of the required information. Staff supervision, to support and develop staff, did not take place at the required frequency. Records of staff training were difficult to navigate, a clear system to monitor staff training needed to be developed. Some refresher training in food hygiene was required. DS0000065505.V265561.R01.S.doc Version 5.0 Page 7 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. DS0000065505.V265561.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection DS0000065505.V265561.R01.S.doc Version 5.0 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 the following standard(s): 2, 3, 4 and 5. Standard 6 does not apply to this home. Contracts had been undertaken with residents to inform them of their rights. Assessments of needs were undertaken prior to admission to ensure that the needs of prospective residents could be met. Staff undertook periodic training to keep them up to date and access to specialist services was arranged, in order that all assessed needs were met. Trial visits were encouraged to enable prospective service users to look around the home, meet residents, staff and give them the information needed to make informed choices. EVIDENCE: Contracts had been undertaken with all residents. Those sampled contained the full range of information required, and included information on the fee charged, the rights and obligations of both parties and the period of notice. The resident or their representative had signed the contracts. Assessments of needs were in place, and copies of social workers assessments were obtained prior to admission, if available, so that a decision could be made about whether the residents’ needs could be met.
DS0000065505.V265561.R01.S.doc Version 5.0 Page 10 All of the residents spoken with felt the home met their needs. One resident said ‘I couldn’t be better looked after’, and a further resident said ‘The home is wonderful, the staff are very kind’. Access to specialist services was supported. One resident said that staff supported them to maintain contact with their skin specialist. Residents confirmed that they had been able to look around the home, stay for a meal and meet residents and staff, who provided them with the information they needed before choosing to move in. DS0000065505.V265561.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 10 and 11 Each resident had a care plan, to give staff the information needed to ensure all care needs were met. The plans required more detailed information in some sections. Health care was monitored, assessed and met. Staff respected residents privacy and appeared respectful towards residents. Each care plan contained a section on death and dying, to ensure residents wishes were sought and carried out. EVIDENCE: Care plans contained information required on all aspects of personal, social and health care needs. However, information on the staff action required to meet personal care needs was not specific. The two plans checked stated that `full assistance’ was required. The plans did not specify how this assistance was to be given. Residents spoken with were aware of their right to access their records, but chose not to do so. The plans contained detail of all health care contacts, appointments and treatments, and the home supported access to these to ensure health was maintained. Access to dentists, chiropodists and opticians was available. A
DS0000065505.V265561.R01.S.doc Version 5.0 Page 12 chiropodist was visiting the home at the time this inspection took place. Moving and handling, and falls risk assessments had been undertaken for all residents to keep them as safe as possible. Staff were observed respecting privacy by knocking on doors before entering. The interactions between staff and residents appeared respectful and caring. Staff took time to respond and reassure confused residents. All of the staff displayed a high level of commitment to the residents and to maintain the high standards of care. Residents spoken to made very positive comments about their care. One resident told the inspector `I am very happy here, I have made friends and the staff are good’. Residents said `the home is very good, you could not wish for more’ and `I can’t think of how I could be better cared for’. The wishes of residents were sought regarding death and dying, which were recorded in plans to ensure these were carried out. Plans also recorded where residents did not want to discuss this sensitive issue. DS0000065505.V265561.R01.S.doc Version 5.0 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 the following standard(s): 12, 13 and 14. Residents were able to make choices about how they spent their time. Some of activities were offered to residents, to improve choices and maintain interests. However, the range of activities and outings offered needed to be extended. There was an open visiting policy. EVIDENCE: Residents said they were able to get up and go to bed when they chose, and were seen to use different areas of the home according to their preference. The home had a domestic worker who helped to provide a range of appropriate social opportunities both in and outside of the home. Residents were free to join in any organised activities. Residents said they enjoyed the range of activities offered. However, most of the residents spoken with said that they would like more varied activities, and further trips out of the home, to be provided. Residents confirmed that they were able to see their visitors in private. The residents spoken with said their visitors could come at any time, and the home helped them maintain contact. One resident informed the inspector that a family member visited every other day, and the home was supporting visits out of the home with family. Two visitors spoken with said they were always made to feel welcome, and staff kept them informed.
DS0000065505.V265561.R01.S.doc Version 5.0 Page 14 Residents were able to bring personal items with them into the home. All of the bedrooms were individually personalised and very homely. This was important to residents as it helped them retain control over their immediate environment. Whilst the standard relating food was checked at the last inspection, several residents commented that the new cook employed at the home since the last inspection had greatly improved the quality of the meals provided. DS0000065505.V265561.R01.S.doc Version 5.0 Page 15 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 and 18 The home had a clear and accessible complaints procedure, to ensure residents’ rights were protected and any concerns listened to and taken seriously. The system to record complaints required some improvement to ensure all relevant information was recorded. The home had an adult protection procedure, some additions to the written procedure were required. EVIDENCE: Each resident and representative had been provided with a copy of the homes complaints procedure. This contained relevant detail and informed the reader of who to contact outside of the home to make a complaint, should they wish to do so. All of the residents said they had no concerns and could go to the acting manager and staff to sort out any worries they had. The home had a comments and complaints box in the entrance area. The record of complaints set out the nature of the complaint and the action taken, however, records did not consistently state the outcome of the complaint. The home had a written procedure for adult protection. Staff had undertaken training on abuse and were aware of the procedure to follow if an allegation was made. A copy of local multi-agency adult protection procedures was not provided, to ensure full information was available to staff. Residents said that they felt very safe at the home.
DS0000065505.V265561.R01.S.doc Version 5.0 Page 16 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, 20, 24 and 25. The majority of the home was well maintained. The home was clean, in the main, and free from odours. Appropriate facilities were provided to meet residents needs. All areas of the home were accessible to residents. Homely touches had been provided to create a comfortable environment. Communal areas were well maintained, and residents’ bedrooms were well decorated and personalised. EVIDENCE: The home was well decorated. Communal areas were attractive, comfortable and the furniture provided was of a good standard. The home had a pleasant conservatory, and garden seating was provided for residents’ enjoyment. All of the bedrooms were well decorated and highly individual, reflecting the residents personal taste. All bedrooms had door locks to promote residents privacy, if required. All of the residents said that they were very happy with the accommodation provided. One ground floor lounge and the corridor area had stains to the carpets. A fault with the hot water supply to four bedrooms identified at the last inspection had been rectified shortly after that date.
DS0000065505.V265561.R01.S.doc Version 5.0 Page 17 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 and 29. Agreed levels of staff were being maintained to ensure the safety of residents and enable assessed needs to be met. Some staff undertook NVQ training. Recommended levels of NVQ trained staff had almost been achieved. Staff recruitment procedures required some update. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained to meet the needs of residents. Residents and the visitor spoken with felt that enough staff were provided. Of the 25 care staff, 10 staff were undertaking NVQ levels 2, 3 or 4 in care. Three staff had achieved level 3 in care. This nearly met the recommended 50 of the care staff trained to NVQ level 2 in care by 2005, once these had been completed the home will have over and above the recommended levels of trained staff. Staff recruitment records were sampled. A system to undertake CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks was in place, to promote safe and efficient recruitment procedures. However, one cook and one night staff had commenced employment before CRB checks had been returned. Whilst the inspector acknowledges that written references had been obtained, staff must not work unsupervised before the completion of all relevant checks. Staff files did not contain all of the required information. Records did not evidence that gaps in employment history had been identified, or explored, as two files sampled did not include the dates of any previous employment. One file checked did not contain copies of proof of identification or a photograph.
DS0000065505.V265561.R01.S.doc Version 5.0 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, 35, 36, 37 and 38 The acting manager had been in post a few weeks prior to this inspection taking place. Formal systems to support the acting manager with the complexities of her role needed to be put onto place. Residents’ finances were safely managed. A system of staff supervision was in place. Supervision was not taking place at the required frequency. Records were stored securely, to respect residents’ rights. Policies and procedures for the smooth running of the home and care of residents were in place and accessible to staff. Staff undertook mandatory training. Staff training records required updating in order that they could be monitored efficiently. Some updates were required. Fire systems were checked and serviced. Fire practice drills had taken place for all staff. DS0000065505.V265561.R01.S.doc Version 5.0 Page 19 EVIDENCE: The acting manager was familiar with the home and had been a team leader prior to her promotion. The acting manager displayed a high level of commitment to residents, as did the staff team. Whilst the previous manager made visits to the home, the acting manager was receiving no formal handover or guidance regarding the complexities of her new role. The acting manager must be formally supported to undertake and become familiar with her managerial duties. The acting manager had applied to register with the Commission for Social Care Inspection. Records of residents’ monies were inspected. These were accurate and up to date. Monies were stored securely. Whilst staff supervision took place, to support and develop staff, these did not take place at the required frequency of a minimum six times each year. All records were stored securely in the home. There were health and safety systems in place, to protect staff and residents. On the day of the inspection fire exits were clear from obstructions and hazardous substances were securely stored. All staff undertook mandatory training. Records were difficult to navigate and the training matrix to enable the acting manager to monitor staff training had not been kept up to date. Staff fire training records indicated that staff had participated in a fire drill at the recommended frequency. DS0000065505.V265561.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 3 X X X 3 3 x STAFFING Standard No Score 27 3 28 2 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X X 3 2 3 2 DS0000065505.V265561.R01.S.doc Version 5.0 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 OP7 Regulation 15 Requirement Care plans must contain specific detail on the staff action required to ensure residents identified needs are met. Residents must be consulted regarding the variety of activities offered. Further activities and trips out of the home must be provided. The record of complaints must clearly detail the outcome of the complaint. A copy of local multi-agency adult protection procedures must be made available at the home. The stained carpet in the ground floor lounge must be cleaned to eradicate marks. Where this is not possible, the carpets must be replaced. (Previous timescale of 01/08/05 not met) The ground floor corridor carpet must be cleaned to eradicate marks. Where this is not possible, the carpet must be replaced. New staff must not commence employment until all relevant
DS0000065505.V265561.R01.S.doc Timescale for action 31/01/06 2 OP12 16 31/01/06 3 4 5 OP16 OP18 OP19 22 13 23 31/01/06 31/01/06 31/01/05 6 OP29 18 31/01/05 Version 5.0 Page 22 7 OP29 18 8 OP31 12 9 10 OP36 OP38 18 18 checks, including Criminal Records Bureau, have been completed. Staff files must contain all of the required information, including: Proof of identity; Photographs; Dates of all previous employment; Evidence that gaps in employment history have been explored. The acting manager must be formally supported to undertake and become familiar with her managerial duties. Staff supervision must take place a minimum of six times each year. An audit of staff mandatory training must be carried out and where gaps are identified, training must be provided. A system to monitor the staff training provided must be developed. 31/01/06 31/01/06 31/01/06 31/01/06 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 Refer to Standard OP28 Good Practice Recommendations 50 of the care staff must be trained to NVQ level 2 in care by 2005. DS0000065505.V265561.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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