Inspection on 19/04/05 for The Beeches

This inspection was carried out on 19th April 2005.

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 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

The Beeches 18/05/06

The Beeches 29/09/05

The Beeches 09/11/04

The Beeches 06/05/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

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

CARE HOMES FOR OLDER PEOPLE The Beeches Forty Foot Road Leatherhead Surrey KT22 8RN Lead Inspector Janet Daulton UnAnnounced 19 April 2005 13:00 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 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 H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Beeches Address Forty Foot Road Leatherhead Surrey KT22 8RN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01372 227540 01372 374564 Anchor Trust Mrs Linda Ryan CRH Care Home 52 Category(ies) of DE(E) Dementia - over 65 - 24 registration, with number LD(E) Learning Disabilities - over 65 - 12 of places OP Old Age - 16 PD(E) Physical disability - over 65 - 6 The Beeches H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Of the 16 (sixteen) service users in the category OP up to 6 (six) may also be in the category PD (E) - implemented The age/age range of persons to be accommodated will be: OVER 65 YEARS OF AGE - implemented 1 April 2002 That the Manager completes level 4 NVQ in Management by June 2005 implemented 7 January 2005 That the Manager attends a vulnerable adults training organised by Social Services specifically for senior staff within four months of registration implemented 7 January 2005 Date of last inspection 9th November 2004 Brief Description of the Service: The Beeches is a purpose built care home providing care for up to 48 older people.It is owned by Anchor homes, and is situated close to Leatherhead town centre. The home consists of five separate units, four of which have a separate kitchen area, and all units have sepatrate dining and lounge facilities. All bedrooms are for single occupancy,with ensuite facilities. A courtyard area is situated in the centre of the home,with wheelchair access. There is ample parking to the front of the building. The homes manager has registered with the Commission for Social Care Inspection since the last inspection. The Beeches H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the first inspection for 2005-2006. the inspection lasted 4 hours and was a positive one. Service users and staff were involved in the inspection process, and spoke about life within the home. During the inspection process evidence was gathered in the following ways • Discussion with the Deputy Manager. • Discussions with the service users. • Observation of the interaction between staff and service users • Examinations of service users and the homes records. • Tour of the home. What the service does well: What has improved since the last inspection? What they could do better: Although training in the home is comprehensive, more staff should be encouraged to attend training such as learning disability training and infection control training. The Beeches H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 6 The home must ensure that the stock ordering and the return of medication is well controlled to ensure that the home is not overstocked with medication. To ensure confidentiality at all times, when discussing anything to do with service users, this should not take place in the communal reception area. The manager should collect and examine information about the number of falls within the home to determine whether there is a pattern to the falls, and what action can be taken to minimise this wherever possible. The residential staffing tool should be used to ensure that at all times the home has sufficient numbers of staff on duty. 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 H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Beeches H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 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 standard(s) 2,3 Each service user has adequate information about their terms and conditions of accommodation and care, and their needs are assessed before they are admitted in order to ensure that the home can meet the assessed needs. EVIDENCE: Statements of Terms and conditions were evidenced on the service user files that were sampled and examined. The service user or their representative signed these. All the service users files sampled had a full assessment by social services, or if privately funded, had a detailed assessment completed by the home staff. There were records of one-day assessment visits and reviews were held and recorded. The Beeches H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7, 8, 9 10 The care needs of the service users were clearly set out to enable the care staff to provide the care identified. Medication was administered safely, and records generally well maintained Service users were treated with respect, however the arrangements for discussion between staff and health professionals meant that the service users right to confidentiality of personal information was compromised. EVIDENCE: Care plans examined set out in detail the needs of the service users and the actions to be taken by staff to meet those assessed needs. There was evidence of regular visits from health care professionals, and equipment, such as pressure relieving mattresses, were available from the Community Nursing team. There were records of visits from the Chiropodist, and continence advisor. The service users were seen to be well dressed and presented. Staff were observed to treat the service users in a respectful way and personal care was carried out in private, in the service users room, or in the bathrooms, which were locked when in use. The Beeches H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 10 The inspector observed confidential information about a service users condition being openly discussed between staff and the visiting GP in the communal reception area, whilst a visitor was also there. The telephone in the reception area was also used to communicate confidential matters about service users. There was evidence of over ordering of medication for the service users. The policy for self-administration of medication could not be evidenced on the day of the inspection. The accident books revealed a significant number of falls within the home. This matter was discussed with the deputy manager and recommendations made to audit this on a regular basis. The Beeches H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 11 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 standard(s) 13,14 Service users are able to maintain contact with their friends and relatives at any time, and are encouraged to exercise control over their lives. EVIDENCE: Two relatives who were visiting on the day of the inspection were positive about the arrangements for looking after their relatives, and stated that they always felt welcome at the home. One gentleman who visits his wife regularly was so impressed that he was hoping to move in himself when a room became available. Many of the service users have families who visit regularly. All the rooms visited showed evidence of personalisation, with lots of photographs and personal effects in the rooms. Service users informed the inspector that they were able to get up and go to bed at a time that suited them. Service users were encouraged to manage their own financial affairs for as long as is possible. The Beeches H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16,18 The home has satisfactory systems in place to deal with complaints and protect service users from abuse. EVIDENCE: Commission for Social Care Inspection have received no complaints about this home. The home had a detailed complaints monitoring file, which contained action notes. Staff demonstrated their knowledge about the complaints procedure, and service users felt confident that they could express concerns without fear of retribution. Several staff have had specific vulnerable adults process training, and all have covered vulnerable adults in their rights and responsibilities training. Staff demonstrated an awareness of the procedure to follow in the case of an abuse allegation. The home had not yet obtained the recently updated Surreys multi agency procedure for vulnerable adults investigation. The Beeches H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19,26 The standard of the environment throughout the home is good providing a safe and attractive place to live. EVIDENCE: The home is situated in a quiet residential area. The home was spacious, comfortable and clean on the day of the inspection. There were no malodours in any of the communal areas or bedrooms that were viewed. The level of heating was satisfactory for the time of year. The grounds were maintained in a tidy way; there were no service users sitting out at this time of year. The laundry facilities were satisfactory, and there were sluice facilities on each unit. Staff were observed to carry out procedures to minimise the risk of cross infection, including hand washing and wearing of gloves and aprons. The Beeches H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The staffing arrangements at night need reviewing to ensure the staffing arrangements are sufficient to meet the needs of the service users. Overall the training arrangements in the home were satisfactory. EVIDENCE: A staff rota was maintained. There were 3 staff members on duty at night for the home. The home must complete the Department of Health staffing guidance tool to ensure that the home is adequately staffed at night. Domestic staff were employed in sufficient numbers. New staff files were examined. References had been obtained and CRB clearance check had been submitted to CRB. The deputy manager informed the inspector that the POVA check had been completed and staff were not working unsupervised until the CRB clearance had been received. All staff spoken with confirmed that they had received terms and conditions of employment. Training records were seen at inspection. Overall training opportunities were good, and staff confirmed this. However only 9 members of staff had received training in learning disability, and 7 staff were detailed as receiving training in infection control. The Beeches H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 38 Service users live in a home that is run by a competent manager. The Policies and procedures of the home ensure the safety and wellbeing of the service users. EVIDENCE: The manager has successfully been registered with the Commission for Social care Inspection. From discussion with the service users and staff it was clear that there was an atmosphere of openness and respect, in which the service users and staff felt valued. The registered manager ensured safe working practices with appropriate Health and safety training, and regular maintenance of equipment. Service records were sampled at inspection. Accident records were maintained. Records were kept of day-to-day events, and communication systems were in place to ensure a good handover between shifts. The Beeches H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x x x 3 The Beeches H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 17 no Are there any outstanding requirements from the last inspection? 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 10 Regulation 12(4) Requirement The registered person must ensure that confidential information is dicussed in an appropriate environment There must be a policy for service users self administering their medication. The home must use the residential forum guidance and staffing tool to review its staffing levels at night. Timescale for action Immediate. 2. 3. 9 27 13(2) 18(1)(a) May 31st 2005 June 30th 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 9 18 30 10 Good Practice Recommendations As good practice the home should avoid overordering medication stock The home should obtain the new copy of the Surrey Multiagency procedure for vulnerable adults investigations.19 More staff should attend specialist training such as learining disability training and infection control training. as good practice a regular audit of falls should be carried out to deternine if there is a pattern. H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 18 The Beeches Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 H58 s13565 The Beeches v286500 190405 Stage 4.doc Version 1.30 Page 19 - 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!