Inspection on 23/11/05 for Cloughton Beeches

This inspection was carried out on 23rd November 2005.

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

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

Other inspections for this house

Cloughton Beeches 08/05/07

Cloughton Beeches 06/06/06

Cloughton Beeches 05/10/04

Cloughton Beeches 21/04/04

Cloughton Beeches 21/01/04

Similar services:

Snydale Care Home

Abbey The

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Cloughton Beeches Mill Lane Cloughton Scarborough North Yorkshire YO13 0AB Lead Inspector Mavis Pickard Unannounced Inspection 23rd November 2005 09.50a 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 Cloughton Beeches DS0000007637.V266227.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. Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cloughton Beeches Address Mill Lane Cloughton Scarborough North Yorkshire YO13 0AB 01723 870017 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) Mr James Pratt Lawson Mrs Susan Clare Kennedy, Mr Nigel Jeremy Lawson, Mrs Doreen Lawson, Mr Michael Ian Lawson Ms Susan Joan Pudney Care Home 8 Category(ies) of Old age, not falling within any other category registration, with number (8) of places Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th June 2005 Brief Description of the Service: Cloughton Beeches is a care home providing care for up to 8 older people. The premises is situated in the village of Cloughton and has has been extended since its original use as a private dwelling built in the early 1900’s. Residents accommodation situated on the ground and 1st floors. Access to the upper floor is facilitated by a stair lift. There is a mezzanine area that is accessible only by people who are able to negotiate steps. The home is set in a pleasant garden with an abundance of established plants and mature trees. Car parking is available at the front of the property. Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken over a 2-hour period in the morning. The home presented as running well. There are presently 7 people accommodated and 1 person who attends the home for day care 7 days each week. Most residents were in the home during the inspection, although 1 resident was out visiting the local hairdresser. The registered manager was not on duty, however the 2 care workers on duty ably assisted the inspection. One of the providers visited briefly. What the service does well: What has improved since the last inspection? The registered manager who was spoken with by telephone during this visit said that some care staff have completed the National Vocational Qualification [NVQ] at level2 or above and that others will complete in the near future. The manager who was registered as such in July 2005 is presently undertaking the NVQ in Management and Care at level 4. Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 & 5 The home provides comprehensive information to prospective residents and their representatives designed to inform people that the home will be able to meet their needs. People can visit the home prior to being accommodated. Not all people are appropriately assessed. Residents have a copy of the home’s Terms and Conditions of residence. EVIDENCE: From the examination of documentation provided to prospective residents and/or their representative it is clear that people concerned are provided with the information they need to make an informed choice about where they live. The information given to residents and/or their representative would generally ensure that they knew that the home could meet the assessed needs of the resident. Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 9 The care worker on duty who has worked at the home for some time said that people have the opportunity to visit the home prior to admission. However a concern was highlighted that although a current resident’s preassessment documentation that gave written evidence that they may have a dementia type illness, there is no record that resident was assessed by a mental health professional prior to admission. The home is not presently registered to accommodate people with a dementia type illness nor has the home applied for or been granted a variation to their current registration with respect to evidencing that they can meet this residents mental health needs. A copy of the home’s Terms and Conditions of residence was examined, the carer on duty said that all residents have a copy in their personal file, which is signed by them or their representative. Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 10 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 &11 People accommodated have appropriate care plans. Physical health care needs are met. Mental health care needs may not be wholly met The home maintains an appropriate death and dying policy. EVIDENCE: The care plans and daily notes of 2 residents were examined. These documents give evidence that resident’s health, personal and social care needs are set out in individual, detailed and comprehensive care plans which are reviewed regularly. The resident, their representative or the reviewer had not signed the review documents examined. From direct observation and from the documents examined it is clear that in the main peoples needs are being met. Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 11 However the continuation notes examined gave evidence that the behaviours of a resident who from time to time becomes confused, may be detrimental to themselves or to others. [Please refer to standard 1-6] These issues were discussed with the care worker on duty who said that the registered manager is aware of the situation and is currently seeking professional advice and guidance about the management of these issues. The home’s death and dying policy was examined and found to be appropriate. Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 12 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, 14 &15 Residents have control of their lives and have the lifestyle they expect in the home, maintaining wherever possible contact with their family and friends. Residents said that they enjoy the food provided. EVIDENCE: Residents spoken with said that they enjoy their lifestyle at the home. One resident a keen gardener undertakes gardening at the home and has set out pleasant window boxes that all residents and staff enjoy. Staff spoken with said that as far as is possible and practicable residents are enabled to exercise choice and have control of their lives. From speaking with residents and staff and from direct observation during this visit it is clear that residents maintain contact with relatives and friends whenever this is possible. The lunch was being prepared during this visit. Residents spoken with about the food provided said that its excellent and that they have choice. Menus were examined that showed the home maintains a 4-week rotating menu. Staff said that the menus are routinely kept to and only where an item is not available would they be changed. Staff confirmed this would be an unusual occurrence. Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Not inspected at this visit. EVIDENCE: Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 &26 Residents live in a clean, safe, well-maintained and comfortable environment, are provided with the specialist equipment they need and have their own possessions around them. EVIDENCE: A tour of the home was undertaken which gave evidence that the home is clean and comfortably furnished. Residents are accommodated in single occupancy bedrooms with the exception of 1 person who is accommodated in what is shown on the register as shared accommodation. The resident is presently the only occupant of this bedroom. The provider spoke briefly about this situation saying that the room would only become a shared facility should the present resident vacate it of her own will and should two people wishing to share with each other be accommodated. The home provides day care facilities including the provision of personal and intimate care for 1 person who is not a resident, across a 7-day period. As the Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 15 home presently has 7 residents and is registered to accommodate 8 the numbers of people being provided with care is not presently exceeded. The premises have a toilet facility on the ground floor and the first floor and a bathroom with a hoisted bath seat on the first floor. A number of bedrooms have private facilities. All hot water outlets have appropriate regulators fitted that ensure the provision of hot water at about 43°C. Rooms 1,4 and 6 were tested along with the bathroom and found to be providing water at a safe temperature. All radiators accessible to residents are fitted with covers designed to minimise the risk of burning. Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 & 29 There is sufficient experienced and competent staff employed to meet the needs of residents. EVIDENCE: From direct observation it is clear that the numbers of staff on duty is sufficient to meet the numbers of people accommodated. There are two carers on duty during the day and the home employs 1 waking staff member at night [10pm8am] and 1 sleeper across similar hours. This is sufficient for the numbers of people accommodated and gives provision for the night time supervision of a resident who, records show is prone to wander at night and who may exhibit some challenging behaviours. [Please refer to Standards 7-11] The home needs to keep this situation under review and to ensure that the ‘sleeper’ is available to perform waking duties should they be needed. Staff records were not examined however a newly appointed day carer gave evidence that appropriate procedures for the recruitment of staff are followed. The manager spoken to by telephone said that no one is employed prior to the home having received satisfactory Criminal Records Bureau [CRB] and Protection of Vulnerable Adults [POVA] disclosures or in cases where staff need to be employed quickly a POVA first disclosure. Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 17 Spoken with about training for care staff the manager said that the majority of staff have either completed or are about to complete a National Vocational Qualification [NVQ] in care at level 2 or above. The manager said that not all night staff is considering this type of training. The carer on duty confirmed that all staff undertakes appropriate induction to the role they are employed to perform. It is not clear that care staff have undertaken training with respect to the care of people with a dementia type illness. The staff roster was examined. The registered managers, management hours are not detailed although staff pointed out that the hours she undertakes a caring role are. Cloughton Beeches DS0000007637.V266227.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): 33,36 &38 The home is run in the best interest of residents. Staff are supervised. The home is safe but fire a safety issue was raised. EVIDENCE: The registered manager who was not in the home during this inspection is newly appointed in her role, although she has worked in another capacity in the home for some time. Residents and staff spoken with clearly feel that the home is run in their best interests and say that management and staff value them and treat them well. From speaking with a staff member who has worked at the home for some time it is not clear that formal supervision is undertaken as recommended by Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 19 the National Minimum Standards although staff have appraisals at least twice a year. The carer said that she has 1-1 working with the registered manager regularly and finds that this is the time when they discuss care practice, training and development and the philosophy of care provided by the home. These discussions are not planned nor are notes taken as far as she is aware. It was concerning to note that although in the main the home is safe and the health safety and welfare of residents and staff is promoted. On the day of inspection a door wedge was being used in a fire door. The door was held open by a device designed to close the door should the fire alarm be activated, however it was also ‘jammed ‘ open by the use of a wedge. Carers said that this was because the device closed the door when the vacuum cleaner was in use. Cloughton Beeches DS0000007637.V266227.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 3 3 1 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 3 X 1 Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 21 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 OP3 Regulation 14(1)(a) Timescale for action The registered person must 23/11/05 arrange that a comprehensive assessment of prospective residents needs, including where identified by the home’s assessment as being necessary, mental health needs, is undertaken by a person trained to do so. Prior to any admission. The registered person must 23/11/05 ensure the containment of any fire by ensuring that identified fire doors are kept closed or if necessary kept open only by a device that will close automatically should the fire alarm be activated. Requirement 2 OP38 23(4) (c)(i) 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 Standard Good Practice Recommendations Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Cloughton Beeches DS0000007637.V266227.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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