Inspection on 19/05/08 for Beechy Knoll

This inspection was carried out on 19th May 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Beechy Knoll 24/05/07

Beechy Knoll 05/06/06

Beechy Knoll 10/11/05

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Beechy Knoll 378 Richmond Road Sheffield South Yorkshire S13 8LZ Lead Inspector Sue Turner Key Unannounced Inspection 19th May 2008 07:45 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 Beechy Knoll DS0000065505.V362369.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. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 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 beechyknoll378@yahoo.co.uk Pearlcare (Richmond) Ltd Mrs Wendy Barnes Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following category: Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 40 24th May 2007 2. Date of last inspection Brief Description of the Service: Beechy Knoll is a privately owned care home that provides care and accommodation for forty 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 and all areas of the home are accessible to people via the use of ramps and a passenger lift. Private accommodation is provided in thirty-three single and three shared rooms; twenty-two bedrooms have en-suite toilet facilities. Communal accommodation is provided in a variety of lounges, dining areas and a conservatory. Seating is provided in the home’s gardens and there is a small car park available for staff and visitors to the home. A copy of the previous inspection report was available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. The manager confirmed that accommodation fees from April 2008 ranged from £318 - £351 per week and there is an additional charge for hairdressing, diala-ride and private chiropody. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This was an unannounced key inspection carried out by Sue Turner, regulation inspector. This site visit took place between the hours of 7.45 am and 3:30 pm. The registered manager is Wendy Barnes, who was present during the site visit. Avi Markovic the Regional Manager and Cath Whitehead the Clinical Manager were also present for part of the visit and to receive feedback. Prior to the visit the manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. Questionnaires, regarding the quality of the care and support provided, were sent to people living in the home, their relatives and any professionals involved in peoples care. We received eight from people living in the home, four from relatives and four from staff. Comments and feedback from these have been included in this report. On the day of the site visit opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home and check the homes policies and procedures. Time was spent observing and interacting with staff and people. Six staff, two relatives and eleven people living in the home were spoken to. The inspector checked all key standards and the standards relating to the requirements outstanding from the homes last key inspection in May 2007. The progress made has been reported on under the relevant standard in this report. The inspector wishes to thank the people living in the home, staff, and relatives for their time, friendliness and co-operation throughout the inspection process. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 6 What the service does well: People living in the home said that the care they were receiving was good. They made comments such as: “Staff are very busy but always do their best”. “All the staff are special”. “We’re all quite happy here”. “The staff are lovely, there’s no problems with any of them”. “It’s all right here, if it wasn’t I wouldn’t live here”. “There’s nothing I don’t like, I wouldn’t change a thing”. “It couldn’t be better. The cleaners go in my room every day and clean it”. Comments received from questionnaires and from talking to relatives were in the main positive and included: “We think you all do your best”. “We feel our relative is reasonably well cared for in her circumstances”. “I could not be happier with the care given by all the staff at Beechy Knoll”. “Beechy Knoll have looked after my mum for sixteen months, through good and bad times. The excellent care provided gives me peace of mind”. “My sister always seems happy and content when I visit her”. Care plans were in place for all. They set out all aspects of personal, social and health care needs. People’s health care was monitored and access to health specialists was available. People and relatives said that staff were always respectful towards them. People said that they had a choice of food and that the quality of food served was “good”, “appetising” and “I can’t fault it”. There was a complaints procedure and adult protection procedure in place, to promote peoples safety. People said they had confidence in the homes manager and staff, who would listen to any concerns and take them seriously. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 7 People said that they felt safe living at the home. Training took place, to equip staff with the essential skills needed. Systems were checked and serviced to maintain a safe environment. What has improved since the last inspection? What they could do better: The information in the homes AQAA was brief. They did not tell us very much about the views of the people living at the home, how the manager finds out what they want or what they are doing to make sure their service provides good outcomes for them. The clinical manager said that she was going to spend time with the manager looking at how they could provide better evidence within the AQAA. Information that was necessary to ensure that people’s individual needs were consistently met had not been reviewed and updated. Examples of this were care plans and the service user guide. Out of date information could mean that staff did not know how to best care for people which could result in people’s health, safety and welfare being put at risk. People and/or their relatives were not being asked to contribute to the care planning and reviewing process. The manager was not carrying out monitoring of medication administration. This meant that mistakes in medication records were not being rectified. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 8 Some staff had not undertaken training in adult safeguarding procedures. Up to date training would make sure people were offered safe support and consistent care practices. Asking people who had an interest in the home their opinions and then forming a development plan could improve the quality of care offered to people. There was a lack of organisation and management of records in the home. This did not promote peoples safety. Staff should have ensured peoples safety by making sure their wheelchair footplates were in place when moving them. Equipment and tools that could pose a hazard to health should be kept safely locked away. 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. The summary of this inspection report can be made available in other formats on request. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 9 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 Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A statement of purpose and service user guide was available. So that people considering living at the home were fully aware of the services available, these should be kept up to date. People’s needs were assessed prior to admission. EVIDENCE: The homes Statement of Purpose (SP) and Service User Guide (SUG) were available, both in the entrance hall, for anyone visiting the home and a copy was also in each persons room. These included useful information about the home and the services offered. Some information in the SOP and SUG was out of date. The clinical manager said that they were in the process of reviewing and updating the documents and these would be available within the next few weeks. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 11 When someone showed an interest in the home the manager carried out a pre assessment. This meant that they could be assured that they could meet the person’s needs. People were invited to visit the home, try out the meals and spend time meeting the staff and seeing the services available. People said: “I’d heard good things about the home so my daughter came and looked around. She knew it would be OK for me”. “I came for the day and liked it so I came to live here straight from hospital”. This home does not provide intermediate care services. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were happy with the way staff delivered their care however lack of adequate recordings could put people at risk. The arrangement for the administration of medication was not robust and could pose a risk to people. The health and personal care needs of people were met in a way that respected their privacy and dignity. EVIDENCE: People living in the home had an individualised plan of care. Three peoples plans of care were checked. Care plans contained a full range of information. These contained specific information on all aspects of personal, social and health care needs. The care plan was developed at the time of the person’s admission. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 13 Staff completed daily records. These were done once a day and not at the end of each shift, as recommended at the last inspection. There was very little information in the daily records. Those seen were short, brief comments that were repetitive. Records didn’t detail how people had spent their day, what meals they had taken, if any visitors were seen, any personal care tasks undertaken and any activities they had joined in. Daily records did not link with the information recorded in peoples care plans. One care plan seen stated that the person upon admission to the home had requested through friends, that they would like to continue to follow their vegetarian diet. On the day of the site visit the person was given steak pie for lunch. Records of food eaten confirmed that they were also given meat on other days. The manager said that this person had decided they weren’t vegetarian and was requesting meat. The manager was asked to ensure that peoples care plans were up dated accordingly. Care plan reviews and dependency profiles were updated monthly. Staff completed a form that gave a score and from this it could be seen if peoples care needs had changed. These were not person centred and the outcome of these reviews was not passed onto all staff. Two relatives said that they had not been invited to contribute to their relatives care plan or review. One relative survey said: “I am kept informed about everything to do with my mum”. Care plans identified that a range of health professionals visited the home to assist in maintaining peoples health care needs. All contact with health professionals was recorded in a separate book People said that GP’s, dentist, opticians and chiropodists visited the home as requested. When visited by a health professional any changes made to a person’s health needs wasn’t always transferred into the persons care plan. People said: “Staff are very quick to call the doctor if they think I’m not very well”. “The nurses come and change my dressing every other day”. Medicines were securely stored in locked trolleys. Medications were supplied by the pharmacist in monitored dosage. This was a new system and the manager said that there were “teething problems” that were being sorted out with the pharmacist. Controlled drugs (CD) were kept in a separate room and within a double locking cabinet. Two people were taking CD’s these were checked. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 14 There was a CD register, which two staff signed when administering. The number of CD’s in stock tallied with the number recorded in the register. Staff undertook an in-house training programme and were not allowed to administer medication until they were considered to be competent by the person assessing them. At the last inspection it was recommended that all staff that administered medication should attend accredited medication training. This had not happened. There was no evidence that the manager was auditing medication administration procedures. Some medications given had not been signed for on the MAR (Medication Administration Records) sheets. People and relatives spoken with, and via their questionnaires, confirmed that the carers treated them with respect and provided personal care and support in a way that maintained their dignity and privacy and was sensitive to their individual needs and wishes. Staff were observed speaking to people in a respectful way and showed empathy and patience when providing personal care to them. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People had a choice of lifestyle within the home and were able to maintain contact with family and friends ensuring that they continued to be involved in community life. A range of activities was on offer, which promoted choice and maintained interests. Meals served at the home were of a good quality. EVIDENCE: People were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. We saw that everyone coming to the home was made to feel comfortable whilst visiting their loved one. Care plans seen included details of a person’s previous lifestyle and interests. People were proud to have their own TV in their bedroom so that they are able to watch programmes of their choice whenever they wished to do so. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 16 The home employed an activities worker who worked three days each day. Examples of the activities available were crafts, quizzes and reminiscing sessions. Outside entertainers visited the home and shopping trips were occasionally organised. The activities coordinator recorded all activities undertaken and which people had taken part in an activities record book. It was recommended that this information should be cross-referenced to care planning records to provide a full picture of how people spend their day. People said: “We have a singer that comes each month. Last week we had a magician, he was very good”. “We make some nice things, this is a tissue holder we made, and its lovely isn’t it”. “The activities worker sits and reads to us. She’s reading Fred Passes book about old Sheffield, we really enjoy that”. “She even gets us doing exercises”. “We used to get out to Meadowhall, but we don’t get out as much now”. Staff said: “The residents ask to go out but there aren’t enough staff to take the residents on an outing. We used to go out but cost of transport and staff to accompany seem to be a problem”. Relatives said: “More time should be spent with the residents and there should be more entertainment. When I have visited after they have had a sing a long or some kind of entertainment their spirits seem to be lifted. Most of the time everyone is falling asleep”. “There is a lady who does activities with the residents, which she does well but she only works part time and has a lot of residents to see to. I would like to see more activities and more chance for people to go out”. “I would like a vicar or member of the local church to take an active part in the residential home. I feel spiritual aspects of care are very much neglected”. “The home could improve by providing more entertainment for people”. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 17 On the day of the site visit, we observed lunch being served and noted that people had a choice of two main meals. People said that they were asked each morning what they would prefer for lunch, and that there is also a choice of meal at breakfast time and teatime. People said that they had ample amounts of food to eat, that they were offered fresh fruit on the tea trolley every day. On the day of the site visit the choice for lunch was either steak pie or sausage roll. On another day the choices were fish or fish cakes. We talked to the manager about these not being real choices. The clinical manager said that they were looking at changing menus and implementing more balanced and nutritional options. Tables were set with cloths, paper napkins, cutlery and plastic beakers. The dining room was quite crowded, although two sittings had been introduced to allow more space. Staff were seen assisting people in a caring and supportive way. Staff didn’t rush people but the dining room experience was one of getting the task over with. It was apparent that staff didn’t see this as an important social event for people living in the home. One person didn’t eat their lunch and said it was because they didn’t like chips and chips were on their plate. Minutes from the residents meeting recorded that they had said they didn’t like chips. The manager said that this was an oversight and staff were aware of the persons likes and dislikes. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures were in place and people felt confident that any concerns they voiced would be listened to. The majority of staff had received adult safeguarding training. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure that people were protected. EVIDENCE: People and their families had been provided with a copy of the homes complaints procedure, which was also on display in the entrance hall and bedrooms. This contained details of who to speak to at the home and who to contact outside of the home to make a complaint should they wish to do so. Relatives spoken to said that they felt very comfortable in going to any member of the staff or management team, knowing that any concerns they may have would be addressed without delay. The home kept a record of complaints, which detailed the action taken and outcomes. The home had not received any complaints since the last inspection. We had not received any complaints about the service. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 19 People said they would go to the staff or the manager if they had any concerns or complaints. They were also aware that there was a suggestion box in the entrance hall where they could post anonymous information if they wished. The eight people that returned surveys all said that they knew how to make a complaint. Minutes from the last residents meeting said that people had been reminded about how and who to complain to if they were unhappy about anything. An adult protection policy and procedure was in place. The majority of staff had undertaken training on adult protection. Two staff said they had not completed adult protection training; this was brought to the attention of the manager who said she would arrange this immediately. In conversation with members of staff, we noted that they had an understanding of safeguarding adults and whistle blowing policies, procedures and practices. People said they felt safe living at the home. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean and generally well maintained, providing a homely environment for people and their visitors. EVIDENCE: Since the last inspection some areas within the home had been redecorated. The AQAA stated that the maintenance and renewal programme for the home would continue. Some bedrooms and communal areas had new fitted carpets and new lighting had been fitted to the corridors. We found that the furnishings, in communal areas were looking very tired and worn. Chair seats and arms were discoloured and side tables were scratched Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 21 and damaged. In some of the small lounges the carpets were stained and marked. The manager said that they had recently bought a new carpet shampooer. There were no unpleasant odours in the home. In one lounge there was a wide screen television. The picture was difficult to see because the aerial reception was poor. Bedrooms checked were comfortable and homely. People said their beds were comfortable and bed linen checked was clean and in a good condition. People said they “liked their bedrooms” and some said they “had lots of space”. People said that they were satisfied with the laundry service provided by the home. Relatives said: “The home is clean and mostly sweet smelling”. “Mum has everything that she needs in her room”. Controls of infection procedures were in place. Staff were observed using protective aprons and gloves. The homes laundry was sited away from food preparation areas. There were no separate hand washing facilities provided for staff in the laundry room; this could result in the risk of cross infection. Some staff had undertaken training on infection control and a training pack had been purchased to enable the home to offer training or refresher training for staff. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff were provided to meet the needs of people. Recruitment information obtained for staff was sufficient to protect the welfare of people. Newly employed staff had completed induction training. EVIDENCE: Staff interviewed said that they enjoyed working at the home and got a lot of job satisfaction. They said that there was usually enough staff on duty and when people were sick other staff were called in. On the day of the site visit staffing numbers were at an acceptable level. The registered manager said that staff were paid at ‘time and a half’ if they work additional shifts and that they received a bonus at the end of the month if they achieved full attendance; this is good practice. When staff were asked if they thought that there were enough staff to meet peoples individual needs, three said “usually” and one said “always”. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 23 Eight people retuned surveys. When asked are staff available if you need them, five said “always”, one said “usually” and two said “sometimes”. Fifteen care staff had achieved NVQ Level 2 or above in care. A number of care staff had also commenced the training. This met the required minimum of 50 of the staff team trained to NVQ Level 2 in Care. Staff interviewed said that when they started work they received induction training in the first two months of their employment. Three staff files checked identified that the member of staff had received induction training when they commenced work. When staff were asked if their induction covered everything they needed to know to do their job they all said “Yes, very well”. A relative said: “A number of carers have now left the home including two male carers (which I thought were quite valuable) having to transfer most residents from chair to wheelchair. They have not been replaced”. Staff were able to talk about the various training courses that they had attended, which included all of the mandatory training, for example, Moving and Handling, Food Hygiene, First Aid and Fire. Further training in specialised topics for example diabetes had been delivered by the Sheffield Partnerships for Older Peoples Projects (POPP’s) team. The recruitment records of three staff members were checked. The staff had provided employment histories and the home had obtained two written references for each of them. These were satisfactory. POVA checks had been made and CRB checks had been obtained for the staff members. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35, 36, 37 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were overall, benefiting from the leadership and management approach of the home. Record keeping did not safeguard people’s rights and best interests. People’s health and safety had not been promoted and protected in some areas. EVIDENCE: The registered manager has completed both NVQ Level 4 in Care and the Registered Manager’s award. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 25 Everyone spoken to and information from questionnaires confirmed that people, staff and relatives were all happy to approach the manager at any time for advice, guidance or to look at any issues. They all said that they were confident that she would respond to them appropriately and swiftly. Resident and relative forums had taken place. The AQAA stated that following consulting with people more activities had been arranged and menus had been amended to include their meal suggestions. Regular staff meetings were held. Staff said they were able to put items on the agenda and following the meeting minutes were circulated. Staff said: “I have been here for four years and I’m very happy with my job, I can always go to the manager if I need advice”. “If I am in any doubt I always ask the team leader”. Formal staff supervision, to develop, inform and support staff took place at regular intervals. Staff said that they found this useful and beneficial. Monthly monitoring visits by the responsible individual took place. Records of these visits covered all aspects of the home. The manager said she had not carried out a quality assurance review for some time. The company had employed a clinical manager. She was working with the registered manager to look at ways of improving the quality of the service. She had put in place action plans to address any shortfalls already identified. She informed us of her plans for enhancing the care offered to people. Some people held their own money and they had a lockable drawer in their room where they could hold this money safely. Personal allowances were held on behalf of some people. We checked the records held for three people against balances of monies held and all were correct. Receipts were given to friends and relatives when they handed over money to the home, and receipts were obtained for any monies spent on behalf of people. Records kept at the home were securely stored. As previously reported care planning information was in many different places and some information was out of date. The recording of accidents was monitored via the use of a separate monitoring form; these were not fully completed. Other records for example staff recruitment information was not organised in an orderly way. This could mean that records are misplaced or invalid and would not be available to use Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 26 as evidence. Robust record keeping would assist in ensuring that peoples health, safety and welfare was promoted. Equipment at the home was serviced and maintained. Fire records evidenced that weekly fire alarm checks took place. This was in line with the fire services recommended ‘weekly’ check. Staff said fire drill training took place on a regular basis and we saw evidence of this. During the site visit we observed concerns relating to the health, safety and welfare of people: • • People were being moved around in wheelchairs that had footplates fitted but which were not being used. Power and manual tools, for example a drill and hammer had been left unattended in a room that could not be locked. The handyman was asked to move these to a safe place. This places people, visitors and staff at risk. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 27 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 2 2 Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO 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 OP1 Regulation 6 Requirement The Statement of Purpose and Service User Guide must be reviewed and updated so that it provides accurate information to people. People and/or their representative must be involved in the care planning and reviewing process. Care plans must be updated so that they reflect people’s current needs and wishes. When changes are made to care plans all staff must be informed of this. This will ensure that they are able to care for the persons changing needs. To ensure peoples health and welfare, MAR sheets must be fully completed and signed at the time of medication administration. There must be regular monitoring of the medication administration procedures. Following this any appropriate action must be taken to ensure that people are kept safe. To ensure the protection of DS0000065505.V362369.R01.S.doc Timescale for action 01/07/08 2. OP7 15 01/08/08 3. 4. OP7 OP7 15 15 01/07/08 19/05/08 5. OP9 13 19/05/08 6. OP9 13 19/05/08 7. OP18 18 01/08/08 Page 29 Beechy Knoll Version 5.2 8. OP33 24 9. OP37 17 10. OP38 13 people all staff must be trained adult safeguarding procedures. There must be a system in place to review the quality of care with the aim of making any improvements that are highlighted. So that people are protected, records required by regulation must be maintained, up to date and accurate. The health, safety and welfare of people must be promoted and protected at all times, therefore: • Wheelchairs must have footplates fitted and these must be put in place whilst people are being transferred. • Equipment and tools that could pose a hazard to health must be kept locked away. 01/08/08 19/05/08 19/05/08 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. 3. 4. 5. 6. Refer to Standard OP7 OP7 OP9 OP12 OP15 OP19 Good Practice Recommendations Any visits from health care professionals should be crossreferenced to care plan records. Diary notes should include an entry for each shift, rather than each day. All staff that administers medication should undertake accredited training. Any activities undertaken by people should be crossreferenced to their care plan, in addition to being recorded in the activities record book. Mealtimes should be a more social event that people look forward. A planned programme of maintenance and refurbishment should continue. DS0000065505.V362369.R01.S.doc Version 5.2 Page 30 Beechy Knoll 7. 8. OP19 OP26 The picture reception on televisions should be improved. Hand washing facilities should be available for staff in the laundry room. Beechy Knoll DS0000065505.V362369.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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