Inspection on 13/09/07 for The Beeches

This inspection was carried out on 13th September 2007.

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 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 25/04/07

The Beeches 04/01/07

The Beeches 10/02/06

The Beeches 03/08/05

The Beeches 29/03/05

Similar services:

Abbey The

Snydale Care Home

Whiteley House

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

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 Tony Railton Key Unannounced Inspection 09:00 13 September 2007 th 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.V342618.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. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 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 carecarecareltd@btconnect.com Care Care Care Ltd Mrs Karen Elaine Smith 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.V342618.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2007 Brief Description of the Service: The Beeches provides accommodation and personal and nursing care for up to 23 older persons who may have additional physical disabilities or enduring mental health problems. The accommodation is on two floors with a passenger lift between the floors. Ground floor accommodation can accommodate those with a physical disability. Not all the rooms are single and only a few have en-suite facilities. The home is sited on a main road close to the centre of Castleford. The home has a garden to the front and a car park to the side and rear of the building. The Deputy Manager informed the Commission for Social Care Inspection on 13 September 2007 that fees at the home range from £380 to £385 per week and there are extra charges for hairdressing (from £3) and for chiropody (from £10). Information about the home and the role of the CSCI is available within the Statement of Purpose and the Service User Guide, both of which are available on request from the home. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit to the home commenced at 09.00 hours and ended at 15.45 hours. During this visit there was the opportunity to speak to people using the service, the Deputy Manager, the Nurse on duty, two care staff, the cook, the domestic and visiting hairdresser. On the day of the visit, the registered manager was not available. Six people’s records were seen and included assessments, care plans, activities, medical and daily records. Six staff files were also seen and included application forms, references, police and POVA checks, training and supervision records. Other information also considered included the home’s Improvement Plan and Business Plan for 2007 and 2008 and twelve of the home’s returned quality assurance surveys. Other information ,such as the home’s returned Annual Quality Assurance Assessment, was also considered and the service history. The comments of four returned CSCI relatives’ surveys were also considered. This was a very positive visit where a number of improvements to the quality of services provided were found. The inspector would like to take the opportunity to thank the people using the service, the Deputy Manager and her staff team for their hospitality and cooperation throughout the visit. What the service does well: People experience a comfortable and homely atmosphere and have their needs met in a relaxed and unhurried manner. There are positive relationships fostered between people using the service and those caring for them. One person said that the staff are “great” and another that they are “very good and helpful”. People are offered a varied and balanced diet and one person said that the food is “excellent” and that they “get plenty to eat”. Another said that the food is “very good”. People have their personal and healthcare needs assessed to make sure the home can meet their needs. The care plans contain a narrative to reflect people’s choices, preferences, likes and dislikes. People’s needs are met by a trained and qualified staff team and they are protected by the way staff are recruited and employed. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 6 People using the service have access to a robust complaints policy and procedure and people said that they know how to make a complaint or raise issues of concern. People live in a well maintained home that is safe. The Local Authority Environmental Health Department has recently awarded the home Four Gold Star Certificate for the good standards of hygiene within the kitchen. What has improved since the last inspection? What they could do better: People’s care plans are not reviewed on a minimum monthly basis to make sure people’s care needs are being met and to reflect their changing care needs. To protect people further, a clear record needs to be maintained of all medicines to be disposed of. People using the service do make decisions about their lives and have choices and preferences, however, descriptive words are not used in the daily records to reflect this. People do not have the opportunity to enjoy activities of their choice on a regular basis. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 7 Staff meetings are not held regularly to give staff the opportunity to comment on the way the home runs and the quality of services provided. Although the views of people using the service and their relatives is sought through quality assurance surveys, their comments are not collated or a report reflecting what they say provided reflecting what they have said and any actions taken by the home as a result. 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. The Beeches DS0000060847.V342618.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 The Beeches DS0000060847.V342618.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): 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. To make sure the home can meet people’s personal and healthcare needs, these are assessed before they are offered a service. The home does not provided specialist intermediate care facilities. EVIDENCE: Previous information, including the Annual Quality Assurance Assessment, shows that people’s needs are assessed before they are offered a place, to make sure the service can meet their personal and healthcare needs. Discussion with the Deputy Manager, and the assessment documentation, confirmed this. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 10 The Deputy Manager said that the home does not provide intermediate care or specialist equipment for rehabilitation. Previous information, including the Annual Quality Assurance assessment and service history, confirmed this. The Beeches DS0000060847.V342618.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): 7,8,9,10 People using the service experience adequate outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. People’s care plans show how they want to be cared for but need to be checked regularly to make sure people’s changing needs are met. People are protected by the way medicines are dealt with. EVIDENCE: A sample of six people’s records showed that their care plans have improved and now contain a narrative to describe their personal and healthcare needs. There is also a description of what staff need to do to make sure people are cared for the way they want to be cared for. It was noted that none of the care plans seen had been reviewed to check and see if people’s needs had been met. The Deputy Manager said that the plans were to be reviewed in three months. This was confirmed by the care plans. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 12 People are protected by the way medicines are given, stored and recorded. A number of people’s medicines were checked and found to be correctly administered, recorded and the balance correct. The Deputy Manager said that now there is a new system of checking medicines that includes a daily and weekly audit. The medicine audit records confirmed this. It was found that there was not a proper record kept of medicines to be disposed of. People’s records show that their health care needs are met and they are supported by local General Practitioners, Chiropodist, Optician and Dentist and some by the Community Mental Health Team Nurses. This was confirmed by the Deputy Manager and Qualified Nurse. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 People using the service experience adequate outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. People enjoy a varied and balanced diet, however, there was little evidence of their social and recreational interests being met. EVIDENCE: People were observed enjoying their lunchtime meal in relaxed and pleasant surroundings. A sample of the lunchtime meal found it to be well presented, well cooked and tasty. The Deputy Manager said that people enjoy fresh meat and vegetables from a local provider and that they have a varied and balanced diet. This was confirmed by the menu and through discussion with the cook. One person said that the food is “great” and that there is “plenty to eat”. Another said that they had enjoyed their meal and it was “excellent”. Although the new assessments and care plans show people’s choices and preferences, likes and dislikes, there was little documented evidence that these were being considered or met. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 14 The Deputy Manager said that two staff have received training in providing ‘Activities for Older People’. This was confirmed by the training records. However, there was little evidence in the daily records or reviews of people attending regular organised activities. The weekly activities’ white board in the hallway was blank and there were no organised activities observed on the day of the visit. Throughout the visit, people were observed being treated with dignity and having their wishes respected, however, this was not reflected in the daily records. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. People have access to a robust complaints policy and said they know how to make a complaint and they are protected from abuse. EVIDENCE: People are protected from abuse as the Deputy Manager said that all staff have received safeguarding training. This was confirmed by the staff training records and discussion with care staff. The service history shows that the home has had two safeguarding referrals since the previous inspection. Discussion with the Deputy Manager, and the minutes of the safeguarding meetings, show that these were appropriately dealt with. People have access to the complaints policy and procedure that is displayed around the home and forms part of the Service User Guide. Staff said that they know how to make a complaint. Two people using the service said that they know who to complain to but have never had to do so. One returned CSCI relatives’ survey shows that they know how to make a complaint but have never had a reason to complain. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 16 The service history shows that the home has received one complaint since the previous visit. Discussion with the Deputy Manager and the record of complaints show that this was properly dealt with. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 17 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 using the service experience good outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. People live in a safe and well maintained home and have comfortable bedrooms surrounded by their own possessions. EVIDENCE: To make sure people live in comfortable surroundings, the service provides an improvement plan. A tour of the premises found that there has been a number of improvements to the home since the previous visit to improve the quality of life of people using the service. These improvements include the redecoration of the hallways and corridor. New carpets have been provided in three bedrooms and the corridors. Five bedrooms have been decorated and three have new furniture. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 18 The Deputy Manager said that one new bedroom carpet was already stained and needed to be cleaned. One person said that they “liked their new bedroom”. The manager said that new bed linen and towels have been provided throughout. This was confirmed by a tour of the bedrooms and the linen store. To keep the home maintained to a good standard, as well as redecorating the corridors, protective plates have been added to all the doors to protect them from wheelchair damage. To make sure people are moved safely, a new hoist has been provided. To make sure people’s food is stored correctly there is a new refrigerator in the kitchen. The kitchen, in May 2007, was awarded Four Gold Star Certificate by the Local Authority Environmental Health Department. The certificate is displayed at the front entrance. The Deputy Manager said that a good standard of hygiene is maintained for the people using the service. A tour of the premises found it to be clean and hygienic. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 19 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 using the service experience good outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. People’s personal and healthcare needs are met by trained and qualified staff. EVIDENCE: People’s care needs are met by trained and qualified staff as staff training records show that all care staff, with the exception of two, have a National Vocational Qualification Level 2 or above. The health and safety of people using the service is promoted as staff records show that they are trained in Basic First Aid, Food Hygiene, Moving and Handling, Infection Control and Health and Safety. People using the service are protected by the way staff are selected as six staff records show that police checks, POVA (Protection of Vulnerable Adults ) and references are taken up before they are employed. Discussion with the Deputy Manager, and staff records, also show that all staff receive safeguarding training. Throughout the visit, there were enough staff on duty to meet people’s care needs in a relaxed and unhurried manner. Discussion with the Deputy The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 20 Manager, nurses and care staff found that they feel there are enough staff available to meet people’s care needs. This was confirmed by the duty rota. One person using the service said that the staff are “great”, another said staff are “very good” and “very helpful”. The visiting hairdresser said that she has been coming to the home for a number of years and the staff are “very caring” and “patient”. One returned relatives’ survey does not raise any issues in this area. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 21 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): 31,33,35,36 and 38 People using the service experience adequate outcomes in this area. We have made this judgement using a range of evidence including this visit to the service. People live in a home that is safe but people using the service and their relatives should have a say in how the home is run and the quality of the services provided. EVIDENCE: Through observation, it was clear that there is a positive relationship between staff and those using the service and people’s care needs do appear to be met. There were no care plan reviews to show and document that people’s personal care needs are met. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 22 There are no descriptive words in the daily records to reflect and show people’s choices, preferences, or any decisions they make about their daily lives. There is a lack of organised activities to reflect that people’s social and recreational needs are met. The home’s returned satisfaction surveys show that the home does seek the views of people using the service, however, this information is not collated or a report provided to reflect people’s comments about life in the home. Records show that only two staff meetings have been held this year to give staff the opportunity to comment on the running of the home and the quality of services provided. People’s financial interests are safeguarded; this was confirmed through discussion with the Deputy Manager and sample of people’s records. People live in a well maintained home. The monthly Health and Safety reports confirmed this. Previous information shows that regular service to the passenger lift and hoists make sure people are safe. Staff training records show that staff receive training in First Aid, Moving and Handling, Food Hygiene and Health and Safety. The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 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 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 2 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 2 x 2 x x 3 X x The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 25 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 OP9 Regulation 13(2) Requirement The Registered Person shall make sure that all medicines to be disposed of are properly recorded and signed for. Timescale for action 01/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP7 OP12 OP14 Good Practice Recommendations People’s care plans should be reviewed on a monthly basis to show that their care needs are met and their changing needs are reflected. People’s involvement and choices with regard to activities should be reflected in the daily records. The daily records would benefit from the use of descriptive words to reflect and show people’s choices and preferences and any decisions they make about how they live their daily lives. The stained bedroom carpet should be cleaned as soon as is practicable. The information gathered through quality assurance surveys should be collated and a report provided to reflect the outcomes for people using the service. 4 5 OP24 OP33 The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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. Extracts may not be used or reproduced without the express permission of CSCI The Beeches DS0000060847.V342618.R01.S.doc Version 5.2 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!