Inspection on 24/08/06 for The Beeches

This inspection was carried out on 24th August 2006.

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 11/11/08

The Beeches 07/08/07

The Beeches 04/10/05

The Beeches 14/06/05

The Beeches 08/02/05

The Beeches 06/08/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Beeches Beech Road Armthorpe Doncaster South Yorkshire DN3 2DZ Lead Inspector Janet McBride Key Unannounced Inspection 24thAugust 2006 10:20 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 DS0000007985.V302148.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 DS0000007985.V302148.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Address Beech Road Armthorpe Doncaster South Yorkshire DN3 2DZ 01302 300312 01302 835980 thebeeches@highfield.care.com 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) Southern Cross Care Centres Limited Post Vacant Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2005 Brief Description of the Service: The Beeches is a registered care home providing personal care and accommodation for 32 older service users. The home is located in the village of Armthorpe and is surrounded by shops, pubs, churches and a library all within walking distance of the home. The home was purpose built in 1990, set in its own grounds with a pleasant garden area and seating for residents and visitors to the front and rear of the home, car-parking area at the rear of the home. The two-storey home has 32 single rooms, 9 bedrooms on the ground floor, three of which have patio doors to the garden, 23 bedrooms on the first floor, which can be accessed via a passenger lift or stairs. Fees range from £385:00 to £430:00per week, as at August 2006,and additional charges are made for hairdressing, Chiropody, toiletries, magazine, newspapers and transport/taxi. The Statement of Purpose and the Service User Guide, which is available on request, this as information about the services available to residents and their families. The home last published inspection report was also available on request. The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector from the Commission for Social Care Inspection carried out this unannounced inspection at The Beeches, which took place on the 24th of August 2006 for 6:45 hours. The home is registered for 32 beds; at the time of Inspection all beds were occupied, but with one resident in hospital. Pre-Inspection work was carried out for example, analysis of notifications and any other relevant documentation. During the Inspection various documentation and records were examined for example, medication records, staff rotas, staff training files and case tracking of two-service users care plans, which were cross-referenced with medication records and any other relevant documentation. This Inspection also included individual interviews with members of staff, talking to most of the residents within the home and feedback from relatives and visitors on the day. Since the last Inspection a new manager as been appointed, but as not put her application for Registration with the Commission for Social Care Inspection at the point of the Inspection visit, this was discussed and the manager informed the inspector that all documentation was now ready and she was going to put this into action this week. Tour of the premises and direct and indirect observation of staff interaction with residents throughout the visit and information was gathered from as many different individuals as possible that had contact with the residents in their environment. The Inspector would like to thank all the staff and residents for their cooperation in the Inspection process, and any issues or concerns that were raised were discussed with the manager at the end of the Inspection. The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 Quality in this outcome area is Good. This judgement has been made using the available evidence including a visit to the service. Most resident’s needs are met, with pre assessments being completed before residents move into the home. Residents are issued with contracts/statement of terms and conditions to ensure they are fully aware of the services and facility provided. EVIDENCE: Case tracking of care plans show that residents are assessed prior to moving into the home, files also contained assessments from other professionals who are involved with the residents care including an assessment from the social worker who made the referral. Random files seen show that service users receive a contract/statement of terms and conditions with the home, although still are in Highfield and need changing to Southern Cross, the same as new residents. The range of fees is documented on page 5 of this report, also the extras that are charged. The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 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 the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is Good. This judgement has been made using the available evidence including a visit to the service. Each resident as access to health care services and receives health and personal care based on their individual assessed needs, and is referred to any specialist services when required. EVIDENCE: Two care plans were case tracked each contained a full needs assessment, prior to the resident moving into the home, various other assessment were completed dependent on individual needs assessed. Risk assessment completed when initial assessment highlighted an issue, and daily documentation and monthly evaluations including review of care plan when required was also evident in the care plans seen. The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 10 All accident records were completed when either service users had a fall or an incidents as occurs, the homes accident book was checked and found the home had the relevant policy and procedures in place, when examined it was found that staff completed all the relevant documentation required, and monthly analysis reports completed by the manager who also completes an Reg37 incident form and sends it to the local Commission for Social Care Inspection office. Care plans case tracked show that residents have access to health care services, and those residents spoken to say they had access to GP, dentist and chiropody. Staff was observed conversing with residents and attending to care needs, they explained to the resident any tasks they were going to complete, and It was evident from observation and speaking to staff, that personal care is always given in privacy and any nursing tasks required by district nurse is usually performed in resident’s own bedrooms. All residents were appropriately dressed with any aids they required for example glasses, hearing aids and walking sticks. Medication procedure was observed and found satisfactory for example; the carer ensured that the resident took their medication before signing the MAR sheet. The home use MDS system and stocks of medicines checked were satisfactory. Controlled drugs were checked and records show that all documentation is correct; the manager also completes audits on a monthly basis, and a visiting pharmacist as also audited the medicines since the last Inspection. The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is Good. This judgement has been made using the available evidence including observation at mealtime. Flexible choice in how the residents spend their day and opportunities for residents to participate in various activities if they wish. Residents receive a wholesome and appealing balanced diet with a selection of choices for meals. EVIDENCE: Activities within the home are varied, and residents spoken to on the day gave these as examples, Bingo, quizzes, sing- a -longs and light exercise. Throughout the morning some of the residents were taking part in a quiz, others were occupying themselves by reading the newspaper or knitting. The home does have an activities organiser in post that works Monday to Friday; one of the more able residents does devise some of the activities within the home and when the activities person is not available she will do Bingo or some craft work, she informed the Inspector they are working on calendars for next year. The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 12 Residents stated they could have visitors at any time and those relatives spoken to say they were made welcome, and staff always offer to make them a tray of tea for them to have on our own with their relative. Residents have links with the community and visit local shops, churches and the library, as many of the residents go out independently to local shops. A number of residents spoken to stated they had a choice and control over a number of daily living needs and gave examples; “I can get up when I want and go to bed when I want” “take part in activities” “choice at meal time” also those residents that are capable can look after their own finances. Menus are varied and nutritionally balanced (and each residents is nutritional assessed and weighed) menus were displayed on a board in the dining area. Tables were nicely set with table clothes, napkins, cutlery and condiments, lunch was observed it was unhurried and relaxed with staff in attendance if needed. Comments received from residents after the meal stated they were happy with the food at the home, and the quality and quantity of food was excellent. The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is Good. This judgement has been made using the available evidence, speaking to staff and a visit to the service. Residents and relatives are provided with information to enable them to raise concerns or complaints about the home and their care, and vulnerable adults procedure ensures that service users are protected from abuse. EVIDENCE: The home has a complaints procedure, which is clear procedure to follow and makes reference to the Commission for Social Care Inspection. Complaints records were checked as the manager had stated they had received three complaints since the last Inspection, records show that these were investigated and dealt with promptly and effectively. A complaint procedure is accessible for visitors as this is placed on the main corridor notice board and in the homes statement of purpose. The home has policies and procedures for adult protection, all new staff has been CRB and POVA checked before they commenced employment, and some staff stated they had completed a course at Doncaster College re-Abuse and its Prevention in 2005. Staff were also aware of the homes policy and procedures and could stated what action to take if they suspected abuse, and aware of the whistle blowing policy. The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26 Quality in this outcome area is Good. This judgement has been made by a visit to the service and tour of the premises. Well-maintained and renewal of equipment ensures that residents live in a safe and comfortable environment, with private space that allows them to have their own possessions around them. EVIDENCE: Tour of the premises took place; reception area contained a notice board with photos of the members of staff and forth coming activity events. Other information available on the notice board for resident, relatives and visitors, statement of purpose, service users guide and complaint procedure. Discussed with the manager that the most recent Inspection report must be available for people to read, although they can ask to see this to, it would be more accessible on the notice board for people to read at their leisure. Registration and Insurance certificate were also on display in the reception area. The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 15 Communal areas were found to be clean and tidy with suitable range of furniture available. Tour of random bedrooms upstairs and downstairs was seen and found satisfactory, some bedrooms have had new furniture, and all looked homely and had been personalised by each individual resident. Bedrails checked in two of the bedrooms, highlighted one issue, which was discussed with the manager who will look into this and address as appropriate. Other areas checked within the home were, laundry facilities, which are upstairs, these were checked and found clean and tidy with appropriate washing and drying facilities. The home has sufficient bathroom and toilet facilities, all of which were clean and tidy. Outdoor garden area is kept in good order with furniture for resident and visitors to sit and enjoy the garden. The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is Good. This judgement has been made using the available evidence, talking to staff and includes a visit to the service. Appropriate staffing and skill mix, to meet residents care needs, and on going development of staff was evident by more than 50 of the staff achieving NVQ qualifications. EVIDENCE: Staffing numbers was discussed with the manager, and examination of duty rota shows sufficient numbers of care staff were on duty, including, activities person, domestic, kitchen and laundry staff. Staff has adequate skills to meet residents needs, and out of the fifteen care staff, ten of these have completed N.V.Q level 2 training. Recruitment was discussed and new staff since the last Inspection were examined, and records show that all recruitment policy and procedures had been followed, with the relevant references being sought, CRB and POVA checks completed, and all personal files seen contained proof of identity of each person employed. Training was discussed and records examined, new staff at the home receives at least two days induction to the home, and an induction booklet. Which is for The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 17 them to work through, this covers all the principles of care and safe working practice. Discussion in the past with the company whether or not the homes training and development meet the TOPSS standard and other evidence was sought via a discussion the company’s trainer, who verified this, in writing, confirming that there care induction booklet meets the TOPSS induction standard. Some issues had been raised regarding some staff requiring updates in various areas, health and safety, infection control and COSHH all of which the manager is trying to address and arrange this as soon as possible. The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is Adequate. This judgement has been made using the available evidence, talking to staff and includes a visit to the service. Residents live in a home that is managed to ensure their safety and welfare are promoted and protected, and records required by regulation and for their protection are maintained, the manager was addressing any issues raised on this Inspection. EVIDENCE: The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 19 Since the last Inspection the homes as a new manager, who is going to put her application for Registration with the Commission for Social Care Inspection as soon as possible. The manager as also started her RMA in May 2006 and confirmed she had an induction to the home when she first started; she was able to show me her home development programme. Since her appointment the manager as had meetings with residents, relatives and staff and as an open door policy for all Although resident can access any money they need, this is now pooled and kept in one account balances of individual accounts were available on the PC, which shows individual records of resident’s monies, but this could not be audited, as it was all together. Secure facilities are provided and the safe contained various items belonging to the residents, and a list was available of the contents. Health and safety was discussed with some of the staff, who state they had completed fire training, although records show that some staff still require updates, but evidence was available with pre-planned dates evident. All other fire records were satisfactory. Maintenance records show when the lift and hoists were last serviced all of which was up to date, and records to show water temperatures are checked on a regular basis. Staff confirmed they have received moving and handling updates, but some issues raised regarding updates in a number of training areas, Health and safety, Infection control and COSHH training, however the manager as drawn up an action plan to address the updated training needs of the staff. Issue raised regarding bed rails this was discussed with both the manager and the maintenance man, they have information regarding the fitting of these and can access expert support to ensure they are using the right bedrail for the right bed the manager stated she will ring them to ask for advise, and ensure that this is addressed. The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last YES 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 OP30 Regulation 18(1)(a) Requirement Training for staff; The Registered provider must ensure that all staff receive updates in, 1) Health and Safety 2) Infection Control 3) COSHH The acting manager must complete their application as soon as possible to the CSCI Health and Safety, The Registered provider must ensure that all bedrails are fitted correctly and suitable for the bed being used. A first aider must be on duty at all times. Timescale for action 31/10/06 2 OP31 8(1) 01/10/06 3 OP38 12(1)(a) 30/09/06 4 OP38 13(4) 31/10/06 The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Beeches DS0000007985.V302148.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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. 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