CARE HOMES FOR OLDER PEOPLE
The Beeches West Harling Road East Harling Norwich NR16 2NP
Lead Inspector Judith Huggins Announced 24 May 2005 09:30 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 Version 1.10 Page 3 SERVICE INFORMATION
Name of service The Beeches Address West Harling Road East Harling Norwich Norfolk NR16 2NP 01953 727584 01953 717584 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) The Beeches (East Harling) Ltd Mrs Sheila Kingsmill-Brown Care Home 36 Category(ies) of Dementia - over 65 years of age (36), registration, with number Dementia (1) of places The Beeches Version 1.10 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home can acccommodate one named person, male, under the age of 65 years and with dementia, until such time as the person reaches 65 years of age or is no longer living at the home. Date of last inspection 04 November 2004 Brief Description of the Service: The Beeches is a large converted house in its own grounds, with an enclosed and private garden to the rear, providing accommodation and personal care to 36 people who are elderly and with mental frailties. There are four shared rooms, the remainder being single rooms. All rooms have en-suite toilets, washbasins and showers or baths. The majority of rooms are on the ground floor. Fees cover personal care, furnished accommodation, light, heat, all meals and drinks, and laundry. Health care services are obtained locally, with residents registering with a local medical practice. A dentist visits and arrangements are made for eyesight and hearing tests as need be. The Beeches Version 1.10 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection lasted 9 hours. A partial tour of the premises was made (not all bedrooms were seen and the outside of the building was not inspected). It is difficult to gain a wide collection of views about the home from residents. However, three residents were spoken to, the inspector spent two hours in the corner of the main lounge, watching how staff assisted residents, and how they communicated, and watched the lunchtime meal being served. Seven care staff, the cook, the manager and the proprietor were spoken to. Comment cards were received from one health professional and twenty relatives. Where appropriate their views have been incorporated into the report. What the service does well: What has improved since the last inspection?
One relative says in a “comment card” that the Beeches has improved “enormously” since last summer. Training has improved, and the manager has attended courses and conferences to increase her own knowledge and awareness of dementia care. The grounds to the front of the home have improved greatly. More parking space has been provided for visitors and staff, and there is safer access to the road. There is new fencing, and shrubs have been planted alongside this. The damaged perimeter wall has been repaired (although sadly a car had hit it in another place now needing repair). Restructuring of the staff team means that there is additional support to the manager and good progress has been made towards meeting requirements. The Beeches Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Beeches Version 1.10 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 Version 1.10 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) 3 There is better assessment of resident’s needs before they move into the home, but room for further improvement so that residents and their relatives can be assured their needs will be met. EVIDENCE: Information about one respite care person’s needs has been obtained from the social worker, before the person was admitted on 7th May. However, this does not cover all the information needed and set out in standards. Other relevant aspects of care (e.g. risk of falls, needs for daily living) were not assessed until after admission. There is no reference to religion on the assessment of daily needs. The care plan has been developed only in regard to the person keeping in contact with their partner and does not cover other aspects of daily living and the help the person needs. Not all the information is signed and dated, and assessments are not all kept under regular review. The Beeches Version 1.10 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 and 9 Individual plans have improved in the way they set out the care needs of residents, although there are still shortcomings which compromise the ability of staff to meet residents’ care needs properly. Residents’ health care needs are not fully met. Procedures for dealing with medicines have improved, but further work is needed to ensure that these fully protect residents. EVIDENCE: One person admitted initially for respite care, but remaining in the home since 7th May, does not have their and health care needs clearly set out. However, social needs for contact with a partner are set out clearly. Records show that staff have assisted with the first goal set out, but there is no evidence in records or from staff and the resident, that they have provided the support needed to achieve the second. A new “Care to Communicate” package has been introduced. This was on one of the files sampled, but only the first page has been completed (and is undated).
The Beeches Version 1.10 Page 10 There are monthly reviews of most care plans. However, underpinning assessments are not consistently reviewed and updated. For example, one person’s moving and handling care plan is dated December 2004 and has not been updated although notes show the person is becoming increasingly frail. None of the files seen contained a personal history or life story, essential to understanding the needs and behaviours of people with dementia, although one person has had considerable family involvement to develop a life story book. The care plan for one person shows that they can be short tempered and aggressive and directs staff to defuse situations likely to lead to aggression. There is no guidance set out about what these triggers might be although staff have had training in challenging behaviour. Representatives do not sign the care plan but all feel that they are kept informed and almost 90 say they are consulted about decisions. Almost 90 of relatives are satisfied with overall care. The remainder are not. Specific comment is made by one person about the lack of information about activity programmes and lack of opportunity for activities outside the home One health professional states that the home communicates clearly and works in partnership, but there is not always a senior member of staff to confer with and staff do not always demonstrate a clear understanding of care needs. The person is not satisfied with the overall care provided to residents at the home. One file records a hospital appointment with no entry for what this is for or what is being investigated in the daily notes, GP record or other charts. The person giving medication checked dosages properly and locked the trolley when it was left unattended. There were no omissions from records and refusal of medication is recorded. However, some medication shown as for regular administration on records is recorded regularly as “not required.” Medications for local administration (e.g. eye drops) are not regularly given. There is a helpful annotation on one chart to warn staff that two medications contain Paracetamol and therefore that both should not be given together. However, pharmacy information about medication being taken before food is not adhered to. The home’s policy about not handling medicines was not followed. The Beeches Version 1.10 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) 12, 13 and 15 The lifestyle in the home has improved, although shortcomings in gathering life histories and reflecting cultural and religious needs means it might not always meet expectations and preferences. Residents can maintain contact with family members and friends. Residents are offered a balanced diet with some difficulties, although flexibility in the time of the main meal is limited. EVIDENCE: Residents are known to rise at a variety of times, with breakfast being staggered. The main mealtime still results in residents sitting at the table for some time before being served their meals, although this did not cause the level of agitation seen previously. Two people are noted to spend time in their rooms regularly, and one was spoken to, confirming this is their preference. A relative expresses the view that more activities are needed. However, notes show that one person is allocated to activities at least four afternoons each week. These include walks out in the village. A reminiscence room has been developed, with more work planned, and two staff have completed training in reminiscence. Manicures are offered and nails polished. A newsletter shows
The Beeches Version 1.10 Page 12 some of the organised events that are to happen, but activities are not well publicised in all areas of the home. Combined records are kept meaning representatives cannot access them. During the afternoon of the inspection the television had the sound turned down and a feature film showing, while a CD was playing old comedy sketches and songs not relevant to the pictures showing on TV. Almost 95 of relatives feel welcome at any time, although two comment that they often do not see staff when they arrive. Almost 90 can visit in private, but shared rooms present difficulty for some. The visitor’s book shows people come to the home regularly. A newsletter devised by the manager helps to keep relatives in touch with what is going on in the home. The cook confirms she is aware that some people find it difficult to sit and eat a full meal, and makes a written record, which she reports to senior staff. She is aware of the importance of alternatives such as finger foods. Two residents say the food is very good. Staff sit next to residents when they need to help the person to eat. There are supplies of fresh vegetables and meat delivered regularly. The nutrition assessment for one person had not been updated since March 2004. This is despite reported difficulties with the person having proper meals. The Beeches Version 1.10 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 standard(s) 18 Residents are protected from abuse. EVIDENCE: The training matrix shows that the majority of staff have received training in abuse awareness. Those spoken to are aware of the importance of reporting concerns, however the manager states that she has had to speak to a couple of people about “teasing” but that this has stopped. Carers speak quietly and kindly to those they are helping, based on observation throughout the inspection. The manager is actively seeking to promote the rights of those who are denied access to their full personal allowances and has contacted the appropriate agencies. The Beeches Version 1.10 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 standard(s) 19, 20, 21, 25 and 26 Routine maintenance needs to improve if residents are to live in a wholly “well maintained environment.” Residents do not currently have access to safe outdoor spaces. Residents still do not have access to sufficient washing facilities in spite of assurances this had been attended to previously. Odour control in many areas, and laundry facilities have improved significantly from earlier inspections. However hygiene may be compromised from time to time. EVIDENCE: There are routine maintenance tasks needing attention, such as damage to curtain rails, knobs loose or missing from significant amounts of bedroom furniture, curtains hanging loose from the rails. Makeshift grills protect the top of radiators. However, other tasks, such as refurbishment and redecoration of some areas have been undertaken. Some new furniture has been provided.
The Beeches Version 1.10 Page 15 The gardens are not secured so confused residents can use them. One relative expresses the view that it would be nice if residents were to be encouraged to use the grounds in fine weather. Corridors have some pictures to help with orientation. Bedrooms are identified by names and numbers. Parts of the corridors have low intensity lighting and natural light only from extreme ends. The small quiet lounge has had its ceiling repaired and redecoration work completed. “Period items” are available that can be used in reminiscence work. The external door to the courtyard does not fit properly in the frame. There is one assisted bathroom. Three showers do not have hot water supplies and four are “stuck” according to the manager. Privacy bolts are fitted to WC’s but not to the assisted bathroom as required at the last inspection. Those areas of the home seen are clean. However, there are some difficulties with odour control in a few areas. The manager and inspector were unable to locate the source in one room, but in another, the curtain to the en-suite shower has been badly stained with urine. The laundry has been partially refurbished, with a sink unit yet to be fitted but in hand. There is one domestic washing machine, one industrial washer and tumble dryer. The industrial washing machine provides for a sluice cycle. There is written guidance for infection control according to the pre-inspection questionnaire, which states that the policy was implemented in 2003. Staff report occasional problems with the supply of protective gloves needed to protect themselves, and residents, from cross-infection. On the day of the inspection these, and aprons, were available. The Beeches Version 1.10 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 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 Residents needs are met by the numbers of staff, but sometimes compromised by the way these are deployed – which needs to be more flexible at peak times. EVIDENCE: The duty roster shows that there are sufficient staff on duty. However, six staff identify a problem with how staff are used. This is said to be due to difficulties with multiple and conflicting tasks being delegated and obtaining prompt assistance. The inspector was informed that some time is nominally designated as management time, and some to assisting carers with their work. Comment cards show that 16 of relatives do not feel that there are always sufficient staff on duty. On the week of the inspection, 9 care staff are shown as working in excess of 50 hours, with 7 of these working in excess of 60 hours. This presents difficulties maintaining staffing levels where there is sickness. Carers have a good understanding of their roles. The Beeches Version 1.10 Page 17 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) 38 The health and safety of service users and staff is not protected at all times. EVIDENCE: The fire records show appropriate maintenance and testing. There was an inspection by officers of Breckland District Council, under the Health and Safety at Work Act on 12th April 2005 which indicates two contraventions in lack of signing and dating of the Health and Safety Policy Statement, and in failure to notify accidents/incidents in accordance with relevant regulations. There are three recommendations. Two of these relate to the development of polices and testing of electrical appliances. At this inspection the manager’s comments about concerns regarding service users moving (or throwing) bedside lights are noted, and one, selected at random is significantly overdue for testing.
The Beeches Version 1.10 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. 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 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 2
COMPLAINTS AND PROTECTION 2 2 2 x x x 2 2 STAFFING Standard No Score 27 2 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 x x x x x x x x x x 2 The Beeches Version 1.10 Page 19 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 7 Regulation 14 Requirement The registered persons must ensure that a full assessment of need is obtained before admission, including for those admitted for respite care. The registered persons must ensure that residents individual personal, healthcare and social needs are clearly set out in a plan of care, promptly on admission, or before where planned. The registered persons must ensure that assessments are kept under review The registered persons must ensure that risk reduction strategies are clearly set out where people are assessed as potentially aggressive. The registered persons must ensure that accurate dosage instructions are stated on medication administration records so that residents receive their prescribed medications. The registetered persons must ensure that medication prescribed for administration before, with or after food is administered appropriately..
Version 1.10 Timescale for action 30/06/05 2. 7 15 30/06/05 3. 4. 7 7 14(2) 15(1), 13(4) 31/07/05 31/07/05 5. 9 13(2), 13(1)(b) 30/06/05 6. 9 13(2), 13(4)c 30/06/05 The Beeches Page 20 7. 9 13(2) 8. 15 14, 15 9. 19 23(2) 10. 19 13(4), 23(2)(a) and (o) 13(4), 23(2)(p) 23(2) 23(2)(j) 11. 12. 13. 19 19 19 14. 21 12(4)(a) 15. 38 23(2)c, 13(4), 23(5) The registered persons must ensure that good hygiene practices are followed in administering medication to avoid risk to both staff and residents. The registered persons must ensure that nutrition assessments are reviewed used to update care plans that reflect changing and actual needs. The registered persons must ensure that routine maintenance issues are monitored and attended to promptly. The registered persons must ensure that the grounds are secured and safe for residents to access. The registered persons must review and increase lighting levels in corridors. The registered persons must replace the external door to the reminiscence room/quiet lounge. The registered persons must ensure supplies of hot water at or close to 43 degrees Centigrade, to en-suite showers. THIS IS A REPEAT REQUIREMENT. The registered persons must fit a privacy bolt to the communal bathroom, that can be opened from the outside in an emergency. TIMESCALE OF FEBRUARY 2005 NOT MET. The registered persons must ensure that monitoring systems are developed with remedial action for meeting health and safety issues. 30/06/05 31/07/05 31/07/05 31/07/05 31/07/05 31/08/05 30/09/05 30/06/05 31/07/05 The Beeches Version 1.10 Page 21 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 7 7 7 9 Good Practice Recommendations The registered persons should progress the assessment information for communication to better reflect the needs of those with dementia. The registered persons should ensure that all documentation is dated and signed so that the need for review can be identified, and accountability is retained. The registered persons should ensure that life histories are completed as part of the assessment and care planning process, as these are intergral to good dementia care. The registered persons should discuss with the pharmacist the inclusion of an additional code on the MAR charts to record when medication is refused and destroyed after it has been taken from cassettes, to improve the audit trail. The registered persons should ensure records of participation in activities are held on individual files to show how individual social and recreational needs are being met in accordance with the care plan, and to facilitate monitoring that all residents are given such opportunities. The registered persons should ensure that the sounds and visual cues in the environment are not conflicting and that they promote rather than compromise orientation of residents. The registered persons should ensure that the means for confused residents to identify their own private rooms are appropriate and assist with orientation. 5. 12 6. 12 7. 8. 19 The Beeches Version 1.10 Page 22 Commission for Social Care Inspection 3rd Floor - Cavell House St Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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