Inspection on 10/02/06 for The Beeches

This inspection was carried out on 10th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

The Beeches 13/09/07

The Beeches 25/04/07

The Beeches 04/01/07

The Beeches 03/08/05

The Beeches 29/03/05

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Beeches 59 Ferrybridge Road Castleford West Yorks WF10 4JW Lead Inspector Patricia Pedley Unannounced Inspection 10th February 2006 12:15 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 The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 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. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Beeches Address 59 Ferrybridge Road Castleford West Yorks WF10 4JW 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) 01977 517685 01977 517685 Care Care Care Ltd Ms Caroline Wicks Care Home 23 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (23), Old age, of places not falling within any other category (23), Physical disability over 65 years of age (23) The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate in the care home. Date of last inspection 3rd August 2005 Brief Description of the Service: The Beeches is a care home providing accommodation and personal care for up to 23 Older persons who may have additional physical disabilities or enduring mental health problems. The enterprise is privately owned through a limited company. The accommodation is on two floors that has a passenger lift between the floors. Not all the rooms are single and few have en-suite facilities. It is sited on a main road close to the centre of Castleford. The accommodation has a garden to the front and a car park to the side and rear of the building. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the care home taking place over a 4hour period. The manager who is not yet registered was not on duty at the time of inspection. The nurse on duty was new to the home therefore the inspector was assisted by the home’s administrator who has worked in the home for a number of years and knows the homes procedures well. Whilst carrying out this inspection, the inspector met with residents, visitors, spoke with staff, examined records and looked around some bedrooms and communal areas of the home. The inspector would like to take this opportunity to thank residents and staff for their assistance and hospitality during this inspection visit. What the service does well: What has improved since the last inspection? Care planning and risk management processes have improved and contain much more individualised information about how to meet needs than in the past. Service users have received updated copies of their terms and conditions of occupancy. A new set of “sit- on” weighing scales has been purchased. The manager’s application for registration has been received and a fit person interview has taken place. A decision is pending as the Commission is awaiting receipt of further information in respect of the application. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 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. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 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 The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 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 The home’s Statement of Purpose requires amendment to include details of any restrictions to residents. Service users needs are assessed prior to admission. EVIDENCE: In the previous two inspection reports a requirement has been made that the home’s Statement of Purpose be amended to include details of restrictions used in the home such as use of guards on the homes main staircase. At this inspection the guards were still in place but no amendment to the Statement of Purpose has been made in this respect. The Statement of Purpose and Service user Guide have been amended to include details of the new manager. Signed copies of the terms and conditions of occupancy were seen. The home’s administrator said that all residents or their family had been provided with their own copy. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 9 The funding authority assessment and care plan for those service users whose files were examined. The manager visits potential service users to carry out a pre-admission assessment. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 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, 9 & 10 Some care planning and risk assessment processes are very but improvements are necessary to ensure they are in place for all service users to ensure their safety and wellbeing. There needs to be improvements to the record keeping for the administration of medication. Residents are supported in a respectful and dignified manner. EVIDENCE: Two care plans were examined. One showed that a holistic approach had been taken with plans in place for communication, personal care, falls, pain, continence, eating, mobility etc. There was a lot of good information on the care plan but the information was untidily kept on the sheet therefore was` more difficult to follow. The care plan was seen to have been updated regularly. Risk assessments and associated care plans were in place for moving and handling and tissue viability. Daily records gave an indication that care needs were being met. The care plans seen did not include a photograph of the resident nor had they been signed by the resident or their representative. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 11 The second care plan had care plans only for sleeping and continence although the resident had been in the home since the beginning of October 2005. The file, as did the other included pre-admission assessment, handling and sleep assessments. Records showed that healthcare needs are attended to including consultation with other healthcare professionals as the need arises. The home’s administrator said that the home now has some sit on weighing scales so that all residents can be weighed regularly. An examination of the medication administration record (MAR) sheets showed some gaps on the record of administration and that responsible staff did not always sign in medication as received into the home. It was also noted that staff do not always sign to say they have administered prescribed creams and eye drops. Some records showed that the code “O” (not required) had often been used on the MAR sheet. These areas of concern were discussed with the nurse on duty and it was recommended that if medication is not required for some time then this needs to be discussed with the GP, as there may be a need to review the need for the medication. Residents spoken with said that staff treated them very well. They said that staff attended to their personal care in a dignified manner. This was confirmed through observing staff carrying out their duties. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 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): Although activities do take place it would be beneficial to provide a regular programme suitable to the needs of those living in the home. Although residents are satisfied with the meals on offer it would be beneficial to discuss a choice of menu with them. EVIDENCE: Residents and staff said that an entertainer had visited that morning to carry out activities with residents. He reads the newspaper, does exercises, plays games and quizzes. The hairdresser visits weekly. The home does not have a regular activities programme, the activities book demonstrates that arrangements for activities are somewhat ad hoc. The home’s administrator said that they used to have a visiting vicar but he does not come anymore. One service user has her own arrangements for receiving communion. One of the staff holds a small service regularly for interested residents. Residents said that they were satisfied with the meals provided. The record of menus was seen. This does not indicate much choice at lunchtime although residents said that they are generally pleased with what is on offer. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 13 One of the visitors said that he was pleased with how his relative was being cared for. He lives locally and said he was always made welcome. He said that the home discuss any problems with him. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Residents feel that their concerns are listened to. Recording of complaints needs to show improvement. Any restrictions on choice must be fully addressed. Staff would benefit from training on adult abuse and protection. EVIDENCE: From discussion with the home’s administrator two complaints had been received. A record of the complaint was not seen for one but was for the other. The details of the investigation and outcome were available for neither. The home’s administrator said that she would ask the manager to address this. Residents and visitors said that should they have any concerns that they feel they are listened to and things would get sorted out. The last two inspection reports have pointed out concerns about the home’s staircase having restraining devices at the top and bottom. Although these have been in place for a number of years their use has not been justified through risk management processes and the restrictions are not included in the Statement of Purpose. This issue has not been addressed as yet. The home’s administrator showed the inspector around some bedrooms. At the last inspection it was pointed out that bedroom doors could not be locked from the inside, as the lock was missing or broken although the door can be locked from the outside. This restriction on choice was discussed since this needs to addressed in a satisfactory manner. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 15 A recommendation was made in the last report that the homes adult abuse procedure be amended to include details of how to use the local authority (lead agency) policy and procedure for the Mistreatment of Vulnerable Adults. The home’s policy does not include this information as yet although the relevant policy is available in the care home. The home’s administrator said that some staff had attended adult abuse training in the past but no one had attended the training recently. She thought it possible that the registered provider was planning to provide some training sessions to cover this training. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 23, 24 & 26 Those areas of the home, which have been refurbished, are very pleasant and bright. The registered providers plan to continue with their programme of refurbishment as funding becomes available to them. EVIDENCE: The home’s administrator said that the registered providers were continuing with their programme of refurbishment although this had been delayed because of the bed vacancies. Since the last inspection some bedrooms had been redecorated and re-carpeted. The stair carpet and office carpet are also earmarked for replacement as it is becoming thin in places. As previously mentioned, a number of bedrooms were examined. These had lots of homely and personalised touches. Some bedrooms are smaller and would it be difficult to manoeuvre a hoist in them. Bedroom door locks need to be replaced as mentioned previously in the report. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 17 The home’s bathrooms were seen to meet the needs of current service users but there are few adaptations for less able service users and this need to be monitored. The home was found to be clean and tidy throughout. There is still a lot of wheelchair damage to doors and frames. It is recognised that this will take some time to address fully. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Staffing levels are sufficient and will need to increase when new admissions take place. Mandatory training arrangements are in place to ensure the safety of residents. Although staff recruitment practices are generally good there needs to be formal arrangements for checking references more thoroughly. EVIDENCE: The home’s administrator said that the home has gone through a difficult period as they have had six vacant beds. This has meant a reduction in staffing levels although they have been sufficient to cover care needs. She said that things are improving, three of these vacancies have been filled and staffing increased accordingly. A new admission was expected later in the day. The home’s manager now has some supernumerary time but this is dependent on staff absences, as she has to cover if qualified staff are absent. Three staff files were examined. All contained the information required by regulation. One reference in one of those files showed that there were concerns in the previous workplace. The home’s administrator said that the member of staff had been very open about what had occurred. There was no formal evidence that this reference had been followed through verbally with the referee or through formal discussion with the applicant at interview to confirm fitness for the post. The home’s administrator said that they were The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 19 more than satisfied with the standard of work delivered by the member of staff concerned. The home’s administrator said that a few staff had attended stoke awareness training which was provided by the local authority. She said that 8 staff are NVQ Level 2 qualified, 4 staff are currently enrolled. Advice was given about changes in the National Induction Standards and how to obtain advice from Skills for Care. The home’s administrator said that current induction standards met TOPPS guidance. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 20 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): The manager is a qualified nurse and has been developing her skills appropriate to her role and responsibilities but needs to undertake the Registered Managers Award. Staff are aware of how to assure the safety and wellbeing of service users. EVIDENCE: The homes administrator said that the manager has completed the moving and handling facilitators course and is currently undertaking the NVQ assessor’s course. She has not yet registered for the Registered Managers Award. The lunchtime staff handover was observed. It was pleasing to see that each resident was discussed highlighting any problems they have in respect of their health and wellbeing. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 21 It was noted in the accident records that a resident had been to hospital. The Commission had not been informed of this event as required in Regulation 37. It was pleasing to see from records that falls are monitored on a monthly basis. According to the home’s service history a copy of the monthly report has not been received by the Commission since October 2005. The home’s administrator said that meetings have been held but there hasn’t been a report, she also said that the registered provider visits the home weekly. Staff supervision records were not checked therefore this recommendation has been carried forward from\the last report. The maintenance certificates for portable appliance, water chlorination, gas appliances, passenger lift, hoists and extinguishers were seen to be in date. The fire alarm and emergency lighting had been tested recently but the certificate had not been received yet. The home’s administrator said that a training provider was coming the week following the inspection to train six staff so that they are competent to train other staff in fire safety. The records for fire safety showed that this needs updating. However, the administrator said that there are arrangements are in place to update staff before the end of February. The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 22 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 1 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X 3 X 1 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X X 2 X 3 The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1)(2) Requirement Care plans must be fully prepared as soon after admission as possible. Care Plans must be signed as agreed by the resident or their designated representative. Care plans must include a current photograph of the resident. There must be no gaps in regard to the daily administration of medication on the medication administration sheet. Prescribed creams and eye drops must be signed off as administered. Designated staff must sign that medication has been received into the home. Medication must be reviewed by the GP if not required on a regular basis. Individual risk assessments must be prepared and available in service user’s files in relation to DS0000060847.V283589.R01.S.doc Timescale for action 31/05/06 2 OP9 13(2) 07/03/06 3 OP1OP14O P18OP23 4(1) & 13 (4) 30/04/06 The Beeches Version 5.1 Page 24 4 OP31 5 OP31 6 OP16 the use of restraining devices on stairs and service user’s doors, which restrict freedom of choice. Any restriction must be noted in the Statement of Purpose. Locks on bedroom doors must be repaired or suitably replaced. 26(4)(c) & A copy of the registered (5)(a) providers monthly report must be forwarded to the Commission with a copy being prepared for the home. 37(1)(c) The Commission must be informed in writing of any event, which affects the wellbeing of service users, including admission to hospital for treatment. 22(3)(4) Details of any complaint received, including detail of the investigation and outcome must be fully recorded. 30/04/06 07/03/06 07/03/06 The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations Service users need to be more actively involved in care planning processes. Care plans need to be clearly set out to better inform staff of the action they need to take to meet individualised care needs. It would be beneficial for a regular activity programme to be in place. It would be beneficial for meal choices to be discussed with residents and for there to be a better indication of the choices on offer at lunchtime. The home’s adult abuse procedure should contain reference as to how staff should use and refer any concern to the funding authority through using the local authority joint agency adult abuse procedure. Staff would benefit from training on adult abuse and protection. Consideration should be given as to repairing wheelchair damage on doors and doorframes and replacement of the stair carpet. There should be more formal procedures for addressing any concerns about references received for new staff including formal recording of discussion with the referee and with the applicant. The manager should register for the Registered Managers Award before June 2006. Supervision should take place six times a year. 2. 3 4 OP12 OP15 OP18 4 5 OP19 OP29 6 7 OP31 OP36 The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 The Beeches DS0000060847.V283589.R01.S.doc Version 5.1 Page 27 - 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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