Inspection on 21/11/05 for The Beeches

This inspection was carried out on 21st November 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 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 11/10/07

The Beeches 04/10/06

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Beeches 16 Lakes Lane Newport Pagnell Bucks MK16 8HP Lead Inspector Barbara Mulligan Announced 21 November 2005 9:30am st 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 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Beeches Address 16 Lakes Lane, Newport Pagnell, Bucks, MK16 8HP 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) 01908 210650 Brancaster Care Homes Limited Ann-Marie Sweeney Care Home 32 Category(ies) of Dementia (2), Old age, not falling within any registration, with number other category (30) of places The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Dementia (2), Old age, not falling within any other category (30) Date of last inspection 3rd April 2005 Brief Description of the Service: The Beeches is a two-storey residential care home providing care for up to 32 older people. The home is comprised of both old and modern buildings and offers 24 rooms, six of which are shared and nineteen are single. Eleven rooms offer en-suite facilities. The home is divided into three areas, these are the old extension, the house and the new extension. Service users bedrooms are located on the ground floor and the upper floor. Access to the first floor is via a stair lift.The home has a variety of lounges and a dining room and offers facilities for receiving visitors in privacy.A chef and kitchen assistants provide freshly cooked meals on site and special diets can be catered for.The home is located close to the town centre of Newport Pagnell, which offers a variety of shops, restaurants pubs and other amenities. Service users are able to use taxis and the dial a ride service to access the town centre. The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on the 21st November 2005. The visit consisted of discussions with the manager, service users and care staff and a tour of the home. Records, policies and procedures were also examined. A preinspection questionnaire was sent to the home prior to the inspection with comment cards to distribute to service users, relatives and health care professionals. The inspection officer was Barbara Mulligan. The registered manager is AnnMarie Sweeney. What the service does well: What has improved since the last inspection? Storage for medication systems in the home have improved since the previous announced inspection. Lockable medication trolleys have been purchased that enables staff to transport medicines around the home in a safe manner. There is a recruitment policy in place and all staff files are accurate and contain all relevant documentation. A requirement was made following the previous announced inspection for care and ancillary staff to be recruited in sufficient numbers to meet the needs of the home. It is pleasing to see that this has been complied with. The home now has regular maintenance staff and appropriate measures are in place to resolve any maintenance problems that may arise. Two requirements were made following the previous announced inspection for 1) the home to implement a staff training and development programme, which The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 6 meets National Training Organisation workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users and 2) that all members of staff receive induction training within six weeks of appointment. This has been complied with and the registered manager is to be commended for this. There has been extensive redecoration and maintenance work carried out in the home since the new provider took over. This has greatly improved the living environment for service users providing a homely warm and safe environment for service users to live in. Formal staff supervision is now taking place on a regular basis. New contracts of terms and conditions have been drawn up and the registered manager said that these were to be given to care staff shortly. A requirement of the previous announced inspection was made that the registered manager has immediate access to a petty cash float. The figure is to be determined by the manager and the organisation, but sufficient to cover any eventuality. It is pleasing to see that this has been complied with. Weekly testing of the fire alarm system is now undertaken weekly and recorded. All staff mandatory training is up to date and recorded in staff files. Regulation 26 visits have recently recommenced and these are received by the Commission. Health and safety matters have improved, with generic risk assessments now in place and there is evidence that COSHH information is reviewed and updated. The cupboard where chemicals and cleaning materials were kept has now been moved to a more appropriate storage area. What they could do better: Care plans require a detailed action plan that sets out the action needed to be taken by staff, to ensure that all aspects of the service users needs are met. There was no evidence of personal development, further learning or how services will meet aspirations and goals of service users. Following the previous announced inspection a requirement was made that an effective quality assurance and quality monitoring system in place to measure success in meeting the aims, objectives and statement of purpose of the home. This has not been put in to place yet due to other priorities of the home. This will be a requirement of this report. Inspection of medication records show numerous signature omissions. There are also cases of non-administration where there is no documented reason. It is a requirement of the report that staff sign to record all medicines administered and the date they were administered. All procedures relating to the administration of controlled medicines are in place. However the controlled drugs register shows that there is not always two signatures obtained when administering controlled medicines. This is a requirement of the report. The kitchen is need of new cupboards and work-tops and this is a recommendation of the report. The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 7 The registered manager undertakes all staff supervision. This is a big task and to do this the manager has to undertake group supervisions rather that individual supervisions. It is recommended that formal staff supervision is undertaken by the registered manager and the senior staff in the home, to allow for individual staff supervisions to take place. Evidence of staff training is in the form of certificates that are stored in individual files. This makes it a difficult and lengthy process to assess all training that has been undertaken by staff. It is recommended that the home implements a matrix of training undertaken by all staff employed by the home. The home need to implement a policy/procedure for the safe keeping of service users money. 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 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5. The homes Statement of Purpose and Service Users Guide provide service users and prospective service users with details of the services the home provides. Each service user has an individual written statement of terms and conditions that is signed by service users or relative or relevant third party and the registered manager. Service users needs are thoroughly assessed prior to admission ensuring that staff are prepared for admission and have a clear understanding of the service users requirements. Service users receive care services from staff who have the skills and competencies to meet their care needs. Prospective service users have the opportunity to visit the home on an introductory basis, before making a decision to move there, ensuring that service users are able to make an informed choice about where they live. EVIDENCE: The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 10 The Statement of Purpose contains all the necessary information as detailed in Schedule 1. The Service Users Guide has been completed since the following announced inspection and is informative, detailed and contains all the necessary information detailed in Standard 1. All service users are given a contract that details the terms and conditions of occupancy. It is the responsibility of the manager to carry out the initial assessment of need. The manager stated that she will visit a potential service user either in the hospital or occasionally in their home to undertake the initial assessment of needs. On some occasions potential service users are invited into the home for the day where the initial assessment can take place. The home uses an assessment tool that covers, present medical history, past medical history, medication, mobility, allergies, pressure area care, nutritional status, personal hygiene needs, continence needs, mental health, and a section for any other significant information. Potential service users are then invited to visit the home. This procedure is used for individuals referred through care management arrangements and for individuals who are self funding. Prospective service users and family members or representatives are included in the assessment process if this is appropriate. Specialist equipment is in place around the home. The home has a good working relationship with the district nurses and this enables the home to satisfactorily meet the health needs of service users. The home has catered for service users from different social, cultural and religious back-grounds, and the manager felt that this had been successful. The home works closely with families to ascertain the service users preferences and needs and to ensure these are understood and met by the home. Most potential service users are admitted from hospital, but occasionally they are admitted from home and the staff will visit them in their own home. The prospective service user is invited to spend time at The Beeches. If the visit is successful then an admission is planned. It is at this time that a key-worker is allocated. The potential service user has a review after the first 4 – 6 weeks to assess their stay in the home. The home does not accept emergency admissions. The home has an admission policy and service users and relatives are encouraged to visit the home prior to admission. A trial period after admission is agreed with a review at the end of this period that can be extended if necessary. The home does not admit service users for intermediate care so this standard was not assessed during the inspection. The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 11 The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 12 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 and 11. Not all care planning documentation adequately provides staff with the information they need to satisfactorily meet service users needs. The health care needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication policies and procedures are clear and informative, but there is no consistent implementation of the policies, that could result in unsafe working practices. The manner in which personal care is delivered ensures service users are treated with respect and dignity and that their right to privacy is upheld. Service users and their families are treated with respect and sensitivity at the time of their death. EVIDENCE: The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 13 A random selection of service user plans were looked at. These show that a variety of health and social care needs have been identified. However, there is not always a detailed plan of care to meet each identified need and this is a requirement of the report. There is evidence of preferred daily living routines and all care plans looked at contain the individuals likes and dislikes. Risk assessments are in place for pressure area care, nutritional screening, prevention of falls and manual handling. Levels of recording varied between files looked at. The home needs to promote continuity of practise and the inspectors felt that training in report writing and care planning would be beneficial to the home. This is a recommendation of the report. The district nurse completes an initial assessment to identify those service users who have developed or are at risk of developing pressure sores. There were no service users with pressure sores at the time of the visit. Staff use the water-low assessment tool to determine if service users are at risk of pressure sores. Other risk assessments observed are for mobility, nutritional status, prevention of falls and manual handling. Specialist equipment for the prevention of pressure sores and mobility aids are in pace around the home. The home can access the continence advisor via the district nurse if this service is required. . Service users can retain their own G.P. if they wish to, or they can register with the local practise. Each service user is encouraged to keep their own optician, however if this is not possible then a domiciliary optical service is accessed. Referrals for hearing tests are accessed via the service user’s G.P. and are carried out on a needs only basis. The home carry out music and movement classes, however these are not carried out on a regular basis. Weight monitoring is recorded care plans, along with action plans for service users who require extra care with eating/feeding. Dental services are accessed on a needs only basis. There are no service users who are able to administer their own medication. Medication is kept in three secure trolleys and these are attached securely to the walls. Medication is administered via a monitored dosage system and the home uses a local pharmacy. The manager said that there have been no problems encountered with the supplying pharmacy. Inspection of MAR charts show numerous signature omissions. There are also cases of non-administration where there is no documented reason. It is a requirement of the report that staff sign to record all medicines administered and the date they were administered. The home has suitable systems now in place to transfer medication around the home. The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 14 All medication coming into the home is recorded on the Mar sheet and signed for by staff. When medication is returned, it is recorded in a separate book and stamped by the pharmacist. All procedures relating to the administration of controlled medicines are in place. However the controlled drugs register shows that there is not always two signatures obtained when administering controlled medicines. This is a requirement of the report. There is a controlled drugs policy and a general administration of medicines policy. These are accessible to staff. All senior staff have undertaken a twelve-week course regarding the safe handling of medication. The manager was aware of the need to retain medication for a period of seven days after the death of a service user. Single rooms ensure service users receive care from staff and health care professionals in complete privacy. At the time of the inspection there were six shared rooms in use. Adequate screening observed ensures complete privacy for the service user. Staff were observed during the inspection to knock on service users bedroom doors before entering. The home’s Statement of Purpose includes information about maintaining the privacy of service user’s. Service users can have a key to their rooms if they wish. Preferred terms of address are recorded in service users care plans and likes and dislikes are recorded in most service users plans. The home has a policy and procedure regarding death and dying. This includes information about the needs of service users from different religions and cultures. The wishes of service users regarding death are recorded in some of the service users personal files. Every effort is made to ensure that service users stay in the home, and importance is placed upon the comfort and care of a service user who is dying. The home involves the service users and their families, if appropriate, when trying to ascertain an individuals wishes regarding dying and death. This information is gathered as soon as is feasible. The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 15 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) 12, 13, 14 and 15. Systems in the home ensure that where appropriate service users are supported to exercise choice and control over their lives. Service users are able to receive visitors at the home and there are no restrictions imposed on visiting unless requested by the service user. Service users are encouraged to bring personal possessions in with them allowing personal space to reflect the character and interests of its occupant. The presentation and standard of food is of a high standard and meets the nutritional needs of service users. EVIDENCE: The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 16 Service users are offered a choice of menu and the inspector saw examples of these. Activities for service users are carried out every afternoon and these were seen being carried out during the visit. There are no restrictions on visiting to the home and service users can meet friends or family in the privacy of their own room. This is detailed in the Statement of Purpose and the Service Users Guide. The manager stated that service users daily routines are flexible and this was confirmed during discussions held with service users. The home has a monthly church service in-house that service users can attend if they wish to. Service users are able to receive visitors in the privacy of their own rooms, and are able to choose whom they see and do not see. There are no restrictions on visiting, and this is documented in the Service Users Guide. The manager stated that relatives are invited to stay for meals with their relative if they wish. There are no service user who deal with his or her own financial affairs. A small amount of personal allowance is held at the home for one service user. There are no service users with an advocate but the manager stated that she would be able to advise individuals about this if the need arose. Service users are encouraged to bring in their own belongings to personalise their own rooms and evidence of this was observed around the home. An invitation to bring in personal items of furniture and other belongings is included in the service user’s guide. The manager stated that if service users wished to look at their own records then this could be facilitated. The menus show that service users are offered a choice at every mealtime and these run on a four weekly rotation. The main meal is served at lunchtime with a choice of main meal and sweet. The inspector sampled a meal during the inspection, which was well presented, and of a high standard. Discussions held with service users confirmed that the meals served were usually of this standard. The chef is to be commended on the high standards of the meals in the home. The home employs a full time chef and when the chef has time off a carer undertakes the role of cook. This carer has obtained her basic food hygiene certificate. The manager and the chef informed the inspector that they would be able to cater for different cultural and religious dietary needs and had done so in the past. Evidence is recorded in care plans of nutritional screening and the home has input from the dietician. If the need arose for a service user to have a special therapeutic diet, the home will liaise with the dietician for advice. During the previous announced inspection service users and relatives were not happy with changes made to the dining areas. This has now been satisfactorily resolved. The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 17 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, 17 and 18 The home has effective complaints procedures to ensure that service users or their representatives are listened to. The legal rights of service users are protected by the homes policies, procedures and protocols. Staff have a good knowledge and understanding of Adult Protection issues which protect service users from abuse. EVIDENCE: The home has a complaints procedure. This includes timescales for responding to complaints and includes information regarding contacting the Commission for Social Care Inspection. The home has received five complaints since February 2005. These are well recorded and responded to within timescales. A summary of the complaints procedure is included in the Statement of Purpose and Service Users Guide. Voting can be facilitated for any service user that requests to do so. Postal votes are arranged and individuals can be taken to the polling stations by car if they wish to vote that way. The manager is aware of the POVA register and stated that she would submit staff for inclusion if it became necessary. The home use Milton Keynes Area Adult Protection policy called “Protecting Vulnerable Adults from Abuse ” in conjunction with their own adult protection The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 18 policy. Milton Keynes Council offer training for care staff and this is accessed by the home. There is a whistle blowing policy in place. The registered manager does not act as appointee for any service users. Valuables can be stored in the homes safe but the manager stated that service users tend to keep their valuables in their own rooms, which are lockable. Adult Abuse Awareness training is covered in the homes induction policy. The inspector also looked at a policy regarding aggression towards staff from service users and was informed that this is covered during induction. The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 19 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, 20, 21, 22, 23, 24 25 and 26 Standards of cleanliness at the home are good ensuring that service users live in an environment that is clean and hygienic, protecting their health, safety and welfare. The standard of the environment within this home is good providing service users with an attractive and homely place to live. The overall quality of the furnishings and fittings is good ensuring the safety and comfort of service users. The garden is regularly maintained to keep it safe and accessible for service users. EVIDENCE: The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 20 The Beeches is situated close to the town centre of Newport Pagnell, where shops and other amenities can be found. The fabric of the home incorporates both new and old buildings and is divided into three areas. These are the old extension, the house and the new extension. Following the previous announced inspection numerous requirements were made regarding the environment. It is pleasing to see that extensive redecoration work has been undertaken by the new provider, and this has greatly enhanced the environment, in particular the bedrooms of service users. Bedrooms are situated on the ground and first floor and access to the upper floor is via a stair lifts. During a tour of the environment bedrooms seen were personalised with service users own furniture and personal belongings. Storage space for service users clothes was spacious and suitable for the storage of clothes. All rooms had locks and some service users chose to use this facility. Double rooms have adequate screening facilities. The home has three spacious lounge and dining areas. These are decorated tastefully and there are many personal touches around the home. These include flowers, plants, a piano, books and pictures. There are quiet areas around the home where service users can meet visitors in private. The dining room is spacious, bright and overlooks the gardens. The kitchen has broken cupboards and drawers and worktops are worn. A requirement was made following the last two inspections that the kitchen cupboards and worktops are replaced. This will be a requirement of this report. The manager informed the inspector that the District Nurse advises the home regarding appropriate disability equipment. A range of hoists, grab rails, assisted toilets and baths and other aids were observed in place throughout the home. All doorways appear to be wheelchair accessible and many parts of the building are open plan, making it easy for wheelchair users to manoeuvre around. The home has a call system in place with accessible facilities and this was installed in all service users rooms. A church service is held in the home on a monthly basis. The furnishings observed in communal areas are of good quality and suitable for the range of interests and activities preferred by service users. Information is available regarding infection control and staff have undertaken training in this area. The laundry room is sited so that soiled articles, clothing and infected linen do not have to be carried through areas where food is stored, prepared cooked or eaten. The laundry contains two washing machines both fitted with a sluicing facility. Laundry floors are impermeable and wall finishes readily cleanable. A tour of the home showed that cleanliness in the bedrooms and the communal areas is well maintained. The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 21 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, 28, 29 and 30. Staffing numbers are adequate to ensure that the assessed needs of the service users are met. Service users benefit from a staff team who are up to date with their training, to ensure that staff are competent to do their jobs. There are effective recruitment procedures in place to ensure service users are protected from harm. Service users benefit from clarity of staff roles and responsibilities that results in a good quality care service being delivered. EVIDENCE: Rotas demonstrated that appropriate levels of staff are on duty across a twenty-four hour period. Ancillary staff are recruited in sufficient numbers to meet the needs of the home. Progress is being made with NVQ training with care staff undertaking this training following the completion of the TOPPS Training. There is evidence to demonstrate that all staff undertake mandatory training and this is updated as needed. A random selection of staff files were made available for inspection purposes. All files looked at contained the necessary documentation as detailed in The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 22 Schedule 2. There is evidence that all staff CRB checks had been obtained. The home do not employ any volunteers. There is a policy regarding staff recruitment and this was found to cover all areas as detailed in standard 29. All new staff receive the TOPPS training within the first six weeks of appointment. There is evidence to demonstrate that all staff undertake mandatory training and this is updated as needed. Evidence of training is copies of training certificates that are stored in individual staff files. This makes it difficult and a lengthy process to assess exactly what training has been undertaken by staff. It is recommended that the home implement a matrix of all staff training undertaken. Other training made evident includes Dementia Training, Continence Training, Nutritional Training and Diabetes Training. All staff receive a minimum of three paid days training per year. The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 23 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, 33, 34, 35 and 36. The registered manager has a good understanding of the areas in which the unit need to improve. The systems for service users consultation are not adequate with no evidence that indicates that services users’ views are both sought and acted upon. Policies and procedures are consistently implemented and monitored, thereby safeguarding the service users rights, health and best interests. Health and Safety procedures are in place ensuring the safety of service users, staff and visitors to the home. EVIDENCE: The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 24 The manager for the home has been in post since 13th September 2004. Prior to this she was managing a domiciliary care agency. Previously she was a support services manager for SCOPE for fourteen years. The manager’s portfolio was not available for inspection purposes but the inspector was informed that training undertaken in the last twelve months includes safe handling of medicines, POVA training and she has obtained a certificate in care management and a degree in organisational management. The home operates regular monthly staff meetings for all staff. The manager tries to meet and talk to all service users on a daily basis. There is an equal opportunities policy in place and this was looked at during the inspection. Occasionally the home are required to look after personal money for service users and it is a requirement of the report that the home implements a policy/procedure regarding the safe keeping if service users money. Following the previous announced inspection a requirement was made that an effective quality assurance and quality monitoring system in place to measure success in meeting the aims, objectives and statement of purpose of the home. This has not been put in to place yet due to other priorities of the home. This will be a requirement of this report. Accidents, pressure sores and complaints are monitored regularly and there is evidence of this. There is a folder containing compliments and thank you letters, mainly from the relatives of service users. Notices were observed about the announced inspection. Regulation 26 visits by the proprietor are undertaken on a monthly basis. Insurance certificates for the home are on display in the main reception area. The manager does not undertake the role of appointee for any service users. Secure facilities are available for the safekeeping of valuables if required. There is evidence to demonstrate that staff receive formal supervision at least six times a year. However, the manager undertakes all staff supervision and is only able to manage this by undertaking group supervisions. It is recommended that formal staff supervision is undertaken by the registered manager and the senior staff in the home, to allow for individual staff supervisions to take place. Staff spoken to confirm that annual appraisals take place. Service users can have access to their records if they wish to. The records maintained for health and safety are in good order. The homes policies and procedures cover a wide range of issues. All confidential information is kept in secure areas of the home. Records for fire safety and are comprehensive and up to date. A fire manual covers the homes fire procedures, practice fire drills, fire prevention, maintenance of escape routes, fire alarm testing, emergency lighting testing and door maintenance. A generic fire risk assessment for the home is in place and there is evidence that this has been agreed with the fire officer. Service reports are in place for the maintenance of the lifts, hoists, electrical appliances and for gas safety, and kitchen hygiene. COSHH sheets are up to date and accurate. The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 25 Risk assessments for the use of cot sides and service users who smoke are in place and observed by the inspector. Infection Control guidelines are available for staff. The homes incident and accident book is completed legibly. The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 26 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 2 3 3 3 x x The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 27 yes 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 7 Regulation 15 Requirement The registered manager is required to ensure that care plans set out in detail the action to be taken by care staff to ensure that all aspects of the health, personal and social care needs of service users are met. The registered provider is required to ensure that all staff provide a signature for medicines administered and the date the date they were administered. The registered manager is required to ensure that two staff provide signatures for the administration of controlled medicines. The registered manager is required to ensure that an effective quality assurance system be implemented with service users who receive care in the home. . The registered manager is required to ensure that a policy/procedure is in place for the safe keeping of service users money. Timescale for action 30/01/05 2. 9 13(2) 30/11/05 3. 9 13(2) 10/12/05 4. 33 12 30/05/05 5. 35 16 30/02/05 The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 28 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. Refer to Standard 19 36 Good Practice Recommendations It is recommended that the home has the kitchen cupboards and worktops replaced. It is recommended that formal staff supervision is undertaken by the registered manager and the senior staff in the home, to allow for individual staff supervisions to take place. It is recommended that the home implements a matrix of training undertaken by all staff employed b ythe home. 3. 30 The Beeches 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 29 Commission for Social Care Inspection 8 Bell Business Park Smeaton Close Aylesbury Buckinghamshire HP19 8JR 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 20052111 The Beeches X00015 AI Stage 2S64534 V248550 H53.doc Version 1.40 Page 30 - 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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