Inspection on 17/09/07 for Beverley Court Residential Home

This inspection was carried out on 17th September 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beverley Court Residential Home 06/12/06

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Beverley Court Residential Home 334-336 Beverley Road Hull East Yorkshire HU5 1LH Lead Inspector Pam Dimishky Key Unannounced Inspection 17th September 2007 09:10 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 Beverley Court Residential Home DS0000067853.V350136.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. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beverley Court Residential Home Address 334-336 Beverley Road Hull East Yorkshire HU5 1LH 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) 01482 449296 Hestan Court Limited Dawn Marguerite Jones Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Date of last inspection 6th December 2006 Brief Description of the Service: Beverley Court Residential Home is a purpose built home comprising of 3 floors and registered to care for 30 residents. It is situated on the corner of Sculcoates Lane and Beverley Road, which is one of the main roads leading into the centre of Hull. The Home is well served by public transport. Nearby there is a good range of shops and a local park. On the ground floor there is one dining area, a lounge and a small number of single rooms. On the first floor there is a further lounge / dining room and additional bedrooms. The remaining bedrooms are situated on the second floor. Access to the first and second floors is via two staircases or a passenger lift. To the rear of the Home is a car park and to the side and front, overlooking Beverley Road, are garden areas. The weekly fees stated by the manager during this visit range from £334.50 to £347; this does not include the provision of newspapers, hairdresser, private chiropody and personal toiletries etc that must be paid for separately. The home changed ownership in July 2006. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection on 6th December 2006 including information gathered during an unannounced site visit to the home. The unannounced site visit was undertaken by one inspector over one day; it began at 9.00 am and ended at 3.00. On the day of the site visit the inspector spoke with residents, staff and the manager and observed practice in the home both directly and indirectly. Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The manager submitted information about the service in advance of the site visit by completing and returning a pre-inspection questionnaire. Survey forms were sent out prior to the inspection; five were returned from staff, one from a care manager, two from relatives and seven from residents. Some of the comments from these surveys are reflected anonymously throughout the report. The inspector would like to thank residents, staff, relatives, and the manager for their assistance on the day of the site visit and to everyone who spoke to the inspector or responded to a survey. What the service does well: The home has been completely redecorated and refurbished since the new owner took over in July 2006; a record is kept indicating that the home is keeping up with routine maintenance and replacement of equipment. Care plan documentation is very comprehensive and is compiled from the initial assessment prior to the resident moving into the home. All staff receive one days induction training prior to coming to work in the home and the home is making the appropriate checks when recruiting new staff to safeguard the residents. Training is recognised as an important factor in providing staff with the skills to undertake the care needed to meet the individual needs of the residents. Contact with relatives and friends is encouraged and visitors are made welcome at the home at any reasonable time. At the time of this visit, lunch was observed to be nicely presented and plentiful. Residents commented how good the food is and also “the staff are very good”. Comments from relatives include “understanding and consideration for all residents”, “gives the appropriate information and listen to our concerns and act accordingly”. A care manager stated, “Clients are treated as individuals, receive quality care and attention, and staff are pleasant and friendly”. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home has a statement of purpose and service user guide which includes all the information required. However, the statement of purpose is not readily available to residents or their representatives and the manager stated she is to combine both documents which will be given to residents and prospective residents or their representatives to enable them to make an informed decision about the home. The requirement at the previous inspection for the recording and storage of all medication to be carried out accurately and safely has not been met. The manager has changed the supplying pharmacist and is using a new system for dispensing medication. However, when checked, some discrepancies were found which the manager said would be addressed immediately following this inspection. The home operates a bath rota which staff and the manager stated is according to the identified choice of the resident. One resident said “I would like a bath more often” and the manager stated she would include reviewing the preferred frequency of bathing in the monthly reviews which the manager stated will be implemented before the end of the year; currently reviews have only taken place annually and as changes occur. The home does not have an activities co-ordinator and staff provide organised activities which take place approximately three times a week. A number of residents prefer to spend much of the day in their room either watching television, reading books or just doing crosswords. However, two of the five surveys returned by residents said “there are never any activities provided by the home to take part in”. The manager stated entertainers visit the home but the last time this was arranged was during May; clothes parties however, for both men and women, are held more frequently. The manager also said that Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 7 trips out of the home have been arranged but on the day the residents have changed their mind and not wanted to go. A Roman Catholic priest and representatives from the church visit one resident but there are no connections with churches of other faiths. A number of residents were asked at the time of this visit if they would like to see someone from the church or to attend a church service and the inspector was told this was not something they wanted. However, the manager offered to explore again with all residents whether individual religious needs are being met. A condition of registration for the home to increase its communal space within three years has not yet been met but the manager stated there are plans to attach a conservatory to the dining room to provide more dining space; currently only nine people can dine at any one time and meals are therefore provided in two sittings. 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. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 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 Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 and 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service have the information needed to choose a home and will have had their needs assessed to ensure these can be met by the home. EVIDENCE: Prospective residents and/or their representatives are given a copy of the service user guide which includes a copy of the homes statement of terms and conditions and complaints procedure; this document is signed and dated by the resident before coming to live in the home. A summary of the home’s statement of purpose is not included in the service user guide, but the manager stated in the future the two documents would be combined. A case record for someone coming into the home recently was examined and seen to include the manager’s initial assessment covering all the areas needed from which to develop the plan of care. Following the initial assessment, a written, formal offer of care is sent to the prospective resident stating the home can meet the individual assessed needs. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 10 The home does not offer intermediate care and standard 6 does not therefore apply. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Health and personal care that people receive is based on their individual needs and the principles of respect, dignity and privacy are put into practice. However, the medication system and review of care plans needs closer monitoring to ensure residents safety and welfare are not compromised. EVIDENCE: Six residents’ case records were examined. Each one had a comprehensive plan of care developed from the initial assessment. The home uses a standard risk assessment for all residents covering pressure areas, falls, moving and handling, nutrition etc. The manager stated a risk assessment is also undertaken for specific areas depending on the individual needs of the resident. However, a risk assessment was not in the case file for a resident who uses bed rails to prevent falls and the manager stated the assessment had not been reviewed for eighteen months. The most recent guidance and poster for use of bed rails has been obtained by the home and further guidance from the Health and Safety Executive was also left with the manager. Weight charts are being kept for residents and whilst these had been recorded regularly Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 12 earlier in the year none of the case files were seen to have further entries until September. The manager stated all residents are weighed every month and she would explore with staff why the record was not up to date. Care plans are reviewed annually with Social Services or as changes occur, but the manager was advised the home must make routine monthly reviews of the care plan and as needs change. One resident stated in their survey form “I would like more baths” and this was discussed with the manager and two members of staff, who independently stated the home operates to a bath rota which has been put together according to the wishes of the residents. However, this said, if a resident wishes to be bathed more often their wishes will always be accommodated. Two male carers are employed in the home and one male resident told the inspector he is able to choose who helps to bathe him. Staff interviewed stated residents are asked if they have a preference as to which gender of care staff provides personal care and their wishes are respected. Arrangements are in place to receive health service support to ensure health care needs are met eg general practitioner, district nurse, community psychiatric nurse, chiropodist, optician, dentist, continence nurse, physiotherapist and dietician. The manager stated the home works closely with the palliative care nurse at Dove House and in conjunction with the district nurse ensuring pain relief is regularly reviewed over 24 hours. The home has a treatment room which is designed for the purpose. The manager stated the home has changed to a new supplying pharmacist and drugs are provided in blister packs rather than the cassettes used previously. The packs are kept in a drugs trolley which is appropriately secured to the wall and a drugs refrigerator ensures medicines are being stored at the correct temperature; the temperature is generally being monitored daily although three consecutive days had been missed during September. A wash hand basin is also installed to provide staff with the means to ensure hygienic practice is taking place when dispensing medicines. Three residents medications and associated records were checked and found to have some anomalies. The pharmacy directions for the prescription is not always clear eg “Take one as directed” and one resident’s medication was still in the blister pack for two tablets signed for as given. (The manager informed the inspector in writing, she has investigated with the staff how this has occurred and found it was an error on the pharmacist’s part in providing extra tablets on these two days. She is now working with the pharmacist and general practitioners for simplified instructions on the prescriptions so these are clearer on the medical administration record). One resident’s tablets were seen in the drug trolley to have been potted up ready to be given out at a specific time. However, these were noted 45 minutes after the allotted time and had not therefore been given out. (The manager informed the inspector in writing the day following the inspection, that arrangements had been put in place to ensure the resident received the medication at the prescribed times Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 13 and staff have been instructed not to decant to separate containers unless it is for immediate administration). Staff responsible for giving out medication receive appropriate training inhouse before undertaking medication training provided through Social Services. A member of staff interviewed confirmed having undertaken the training. Residents said they were treated with respect and dignity and staff were observed treating residents entirely appropriately. Care staff were noted knocking on doors and those interviewed demonstrated how residents are supported in making choices about their daily lives. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 14 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): 12,13,14 and 15 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use this service are able to make choices about their lifestyle. However, whilst opportunities are available to participate in some activities this area needs to be individually explored further to ensure residents preferences for social, cultural, religious and recreational interests and needs are satisfied. EVIDENCE: During the morning of this site visit, there was a lively atmosphere due to a CD being played of piano music. The hairdresser was also visiting and residents requests for a weekly visit has been arranged and these are now taking place. The manager stated it is proving difficult to provide residents with stimulating and meaningful activities and the range provided approximately three times a week by the care staff, includes board games, movement to music, puzzles and reminiscing. Six residents spoken to in their rooms said they prefer to stay in their room and watch television, read books or do crosswords. When asked if they would like the church to visit or to attend a church service there was a negative response. A Roman Catholic priest and representatives of the church visit one resident weekly but there is no input from other denominations although the offer was made by the Anglican church and declined. The manager stated arrangements have been made for some Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 15 residents, who enjoy reading, to belong the library. Two of the five resident surveys received stated “there are never activities to take part in”. This area was discussed in more detail with the manager who said trips out of the home have been organised and residents have then changed their mind on the day, entertainers have been to the home but there have been none since May. However, clothes parties for both men and women are held every month and have proved to be successful. Residents wishing to go for walks are accompanied to the nearby park or shops by the care staff and families also take their relative out; one resident has recently visited relatives in America for three months. A cordless telephone is available for residents to use in private either in their room or a quiet area of one of the communal areas; two residents have their own telephone installed in their room. Relatives and friends are welcome to visit at any reasonable time and can be seen in private in one of the communal rooms or in the resident’s own room. A visitors’ book is available in the entrance to the home. The home operates to a three weekly menu which includes a choice for lunch and tea. Residents are given a copy of the menus and invited for their comments and suggestions for change. The cook talks to new residents about their likes and dislikes which are detailed, along with any food allergies, in individual care plans. The cook is able to provide sugar free diets for diabetics and any special diets. The manager said the home works with the dietician and general practitioner to meet any special dietary needs. Lunch was observed at the time of this inspection and was noted to be plentiful and attractively presented. Lunch was either Cornish pasty or corn beef hash with mashed potatoes, green beans and cabbage followed by banana cheesecake or jam and coconut sponge and custard. For tea residents were being offered egg and chips or hot dog with onions followed by scones or chocolate ice cream. The cook said she is following the menu as far as possible but one cooker is not working and they are awaiting a replacement. All the residents spoken to said how much they always enjoyed the food and this was reflected in the responses received in the resident surveys. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure and are safeguarded from abuse. EVIDENCE: A complaints policy and procedure is available in the home and is included in the service user guide given to all residents. The complaints record book was examined and there have been no complaints recorded since the last inspection. However, the Commission for Social Care Inspection had received a complaint which is currently being investigated by the registered provider. Statements have been taken from members of staff and the case record scrutinised but at the time of this report there is insufficient evidence available to substantiate the claims. Residents spoken to and those completing the survey form all indicated they knew who to speak to if they were not happy. Staff understood the complaints procedure and said the manager was informed of any concerns. The manager stated she had undertaken the manager training for safeguarding adults and that all staff have received awareness training or are scheduled to do so. Two staff interviewed, one who has only been employed a month, said they had not received training. However, they had read the policies and procedures and understood “whistle blowing”. The manager confirmed both members of staff will undergo training in the near future. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 17 The manager was advised it is good practice to keep a record of any concerns, no matter how trivial, to monitor whether any patterns emerge. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well maintained, generally clean and comfortable environment which encourages independence. EVIDENCE: Considerable investment has been made in improving the environment throughout the home. All bedrooms have been totally refurbished, including redecoration, new beds and furniture, furnishings, carpets and bedding which almost completes the upgrade of the premises; a mirror over the wash basin in residents’ rooms, shelving and towel rails are scheduled to be fitted in the near future. A condition of registration is for communal space to be increased within three years and it is planned for a conservatory to be added to the dining room within two years. Currently the dining room is not adequate, allowing only nine residents to dine at any one time. The new carpet on the ground floor corridor is soiled and the manager said that despite the cleaner’s best efforts it is proving to be a problem. A handyman is employed full-time to Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 19 work across the three homes owned by the provider and all maintenance work is now being recorded. All bedrooms have a call alarm, but the majority were noted to not have the leads in situ. Although the manager stated a number of the residents are mobile and able to activate the alarm without the lead, she will conduct an audit and replace the leads were needed. Toilets will also be assessed as to whether a lead is attached to the call facility or whether ceiling pulls would be more appropriate in emergency situations. Following the refurbishment work a number of toilets did not have soap or soap dispensers and the manager said this work will be undertaken as a priority. Two bedrooms (27 and 30) were noted to have an unpleasant odour which the manager explained is a periodic problem associated with the drains being blocked by fallen leaves. The handyman was made aware of the problem and cleared the drain at the time of this inspection. No other unpleasant odours were detected at the time of this visit. The environmental health officer visited the kitchen on 3rd April 2007 and made three requirements which have been attended to. The laundry is fit for purpose with cleanable walls and floors. A new washer with sluicing facility for soiled linen and a tumble dryer have been installed and are maintained under contract for same day repairs. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, and deployed in sufficient numbers to support the people they care for. Residents are safeguarded by the home’s recruitment practice. EVIDENCE: At the time of this inspection 26 residents were living in the home and the staff rota indicated the residents are cared for by four staff on the early and late shift and three at night. The manager stated a fifth member of staff has been appointed for the early shift and will commence in approximately two weeks time. Staff spoken to, and those completing survey forms, indicated a further member of staff is needed at busy times. Six files for staff recruited since the last inspection were examined. It is evident from the files that the necessary checks to safeguard residents are taking place, ie two references, Criminal Record Bureau (CRB) checks, POVA first checks, job application form. One member of staff commenced a month ago and is awaiting the results of a CRB check. However, evidence was seen of a satisfactory POVA first for the staff member who is only working under supervision until the CRB result is known. The manager was advised with regard to exploring the gaps in employment history dates as five of the application forms showed only years had been given. All staff complete a day’s induction before commencing work and only work under supervision whilst Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 21 completing further induction training which meets the Skills for Care specification. Fifty per cent of staff have an NVQ level II or above qualification and funding has been sourced to enable further qualifications at NVQ level III. Staff interviewed, and information taken from the staff survey forms, confirmed that training is relevant to the role of caring and in meeting the individual needs of the residents. A matrix is kept illustrating training staff have received and indicating individual gaps in training needs. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is experienced and competent to run the home and the health, safety and welfare of residents and staff is promoted and safeguarded. The home can only be sure it is being run in the best interests of the residents when the quality assurance system is up and running. EVIDENCE: The manager of the home is registered with the Commission for Social Care Inspection and is experienced in residential care. She holds a qualification in care and has enrolled to take the Registered Manager’s Award which was due to commence in approximately two weeks time. A survey form completed by care management responded positively about the home. The home holds the local authority QDS (quality development scheme) parts I and II which is due for review before the end of this year, but has not met a requirement made at the last inspection to develop an internal quality assurance process to ensure Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 23 the aims and objectives of the home are being met. The manager confirmed she is to develop a system to measure the performance of the home before the end of this year and will summarise the results for inclusion with the service user guide. The home holds small amounts of money on behalf of most of the residents and three residents’ records, receipts and amounts were checked and in order. The manager and staff confirmed individual supervision is taking place every eight weeks covering care practice and training needs. Staff interviewed and staff surveys indicate they receive manager support and are kept up to date with new ways of working. From the records examined, a requirement made at the last inspection for all records held about residents to be signed and dated has been met. Fire detection and fighting equipment was available within the home and a check of the fire extinguishers showed they had been serviced in September 2006 and are now due the annual service. The passenger lift has a thorough examination certificate dated 13/8/07, but whilst the manager was sure the mobile hoist and bath hoist has undergone a similar examination, no certificates were available and she will chase these up with the contractor. A current landlords gas safety certificate is in place and dated 3/4/07 and the employer’s public liability certificate displayed in the hall was current to 3/8/08. From interviews with staff and from examining the home’s training matrix it is evident staff are kept up to date with mandatory training for health and safety, moving and handling, fire safety, food hygiene, control of infection and first aid. Accidents are being recorded for residents and separately for staff and were seen to be adequately recorded. However, only the staff accidents are recorded on the required form and the manager stated she would obtain a supply of the forms for recording resident accidents. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 24 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 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 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 X X 3 Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4 Requirement Information regarding the home must be made available to prospective residents and their relatives, allowing them to make an informed choice. Timescale of 31/1/07 not met The service users plan must be kept under review monthly or as changes occur The recording and storage of all medication must be carried out accurately and safely An effective quality assurance process must be in place to ensure the aims and objectives of the home are being met Timescale of 31/03/07 not met Timescale for action 30/11/07 2. 3. 4. OP7 OP9 OP33 15 13 38 30/11/07 17/09/07 31/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000067853.V350136.R01.S.doc Version 5.2 Page 26 Beverley Court Residential Home 1. 2. 3 4 5 6 Standard OP7 OP12 OP16 OP19 OP19 OP19 7 8 OP19 OP29 It is good practice to monitor residents weight regularly as an indicator of their general health It would be good practice to further explore with the residents individually, their interests and preference for activities, in and outside the home, and religious needs It would be good practice to record all concerns, no matter how trivial, and whether they have been satisfactorily resolved, to monitor whether any patterns emerge The providers plans to extend the dining room by adding a conservatory, should benefit the residents by providing sufficient space to enable them to dine together The problem causing an odour in rooms 27 and 30 should be further explored and measures taken to prevent further occurrence The planned audit of leads to call alarms in bedrooms should go ahead as soon as possible and for action to be taken where appropriate. Call leads in toilets should also be in situ to aid residents to call for help in emergency situations All toilets should have soap made available at all times to ensure hygienic practice and reduce the risk of infection Staff job applications should include an accurate employment history by providing actual dates for previous employment; where gaps appear these should be explored. Beverley Court Residential Home DS0000067853.V350136.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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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