Inspection on 29/09/05 for The Beeches

This inspection was carried out on 29th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Beeches 18/05/06

The Beeches 19/04/05

The Beeches 09/11/04

The Beeches 06/05/04

Similar services:

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

Insight - Eastchurch

Southfields

Magenta

Seabourne House

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

CARE HOMES FOR OLDER PEOPLE Beeches (The) The Beeches Forty Foot Road Leatherhead Surrey KT22 8RN Lead Inspector Janet Daulton Announced Inspection 29th September 2005 10:00 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 Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 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. Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beeches (The) Address The Beeches Forty Foot Road Leatherhead Surrey KT22 8RN 01372 227540 01372 374564 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) Anchor Trust Mrs Linda Ryan Care Home 52 Category(ies) of Dementia - over 65 years of age (24), Learning registration, with number disability over 65 years of age (12), Old age, not of places falling within any other category (16), Physical disability over 65 years of age (6) Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Of the 16 (sixteen) service users in the category OP up to 6 (six) may also be in the category PD(E) The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE That the Manager completes level 4 NVQ in Management by June 2005 That the Manager attends a vulnerable adults training organised by Social Services specifically for senior staff within four months of registration. 9th November 2004 Date of last inspection Brief Description of the Service: The Beeches is a purpose built care home, owned by Anchor Homes, and provides care for up to 48 older people. The home is situated a short distance from Leatherhead town centre. The accommodation consists of five separate units, four of which have a separate kitchen area, and all units have separate lounge and dining facilities. All bedrooms are for single occupancy, with ensuite facilities. A courtyard area is situated in the centre of the building, with wheelchair access. There is ample car parking to the front of the home. Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 4 hours and was the second inspection carried out by the Commission for Social Care Inspection for the year 2005-2006. The inspection was carried out by Mrs. J Daulton, Lead inspector for the service. The Manager Ms. Linda Ryan was present for all of the inspection. A tour of the premises took place. Five care plans, the complaints log, and a sample of safety certificates were inspected. The inspector spoke to many service users during the day. The inspector also spoke with some of the staff on duty at the time of the inspection. The inspector had received written feedback from ten service users, five relatives/visitors, I GP, 2 Health Care professionals, and 3 Social Services Care Managers. This was a positive inspection, and the feedback from service users, health professionals and relatives was generally very complimentary. The inspector would like to thank the staff and service users for their time, assistance, and hospitality during the inspection. What the service does well: The home continues to provide a homely and attractive environment for the service users. The staff were seen to be caring for the service users in a friendly and respectful way. All service users contacted stated that they felt safe and well cared for in the home. Service users were encouraged to maintain control over their daily life as much as possible. Meals were varied, well balanced and nicely presented, offering a choice and variety. The service users care plans were detailed. They gave clear instructions to the staff about the service users needs and the care that had to be given to meet those needs. The Manager provides good leadership and a supportive environment for service users and staff. Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 6 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. Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 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 Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 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): 1,5,6 There was a range of information available to prospective service users and their relatives, which gave clear details about the home and the services provided. The home was able to provide suitable care for those service users with a specific diagnosis of dementia. EVIDENCE: The Statement of Purpose and Service User Guide provided clear information about the home. The inspection report was displayed in the entrance area. Prospective service users were encouraged to stay for a day or have lunch at the home, before making a decision about moving in. One visitor was looking around the home on behalf of her mother on the day of the inspection. The staff have received training in caring for service users with specific conditions like dementia, and the Registered Manager is starting a Diploma Course in Dementia care. The home does not provide intermediate care. Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 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, 10 The service users health, personal and social needs were set out in an individual plan with all the needs clearly identified and there was documentary evidence of the identified needs being met. EVIDENCE: Service users spoken with on the day of the inspection were very complimentary about the care that they received at the home. Comments included “staff are very gentle and kind”, and “I enjoy living here”. The written feedback from service users and visitors was also complimentary, The five care plans, called Individual Lifestyle agreements, randomly selected and inspected were very detailed and clearly set out the actions which needed to be taken by the care staff to make sure that all aspects of the health, personal and social care needs were met. There was good emphasis on social care and the service users previous experiences. All the care plans sampled were signed by the service users to indicate that they were consulted when drawing up the care plans, and they were reviewed regularly. The personal care charts were not always being completed satisfactorily, to give a comprehensive record of what personal care had been carried out. Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 10 The previous requirement to have a policy for service users self-medicating had been met. The medication procedures were not assessed at this inspection. The Manager has taken action in an attempt to reduce the number of falls throughout the home. Several rooms, where the service user is at high risk of falling, have been fitted with alarm devices. Staff were observed treating the service users in a friendly, and professional way, with due regard for the service users privacy and dignity. Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 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, 13,15 The social and recreational activities were varied and appropriate. Service users were able to maintain contact with families and friends. The catering arrangements and facilities were satisfactory. EVIDENCE: On the day of the inspection several service users from the separate units were playing skittles. An activities programme was displayed on each unit. Several service users stated that they enjoyed joining in the activities. Provision was made for service users to attend local churches, Feedback from the service users about the quality and variety of the food was positive, and a choice was offered at each meal. One service user chose to have his breakfast later in the morning and this was arranged by the home. The presentation of the meal served on the day of the inspection was satisfactory. Staff wore protective aprons when serving the food. Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The home had a simple, clear and accessible complaints procedure, which included timescales for the process. The homes policy for dealing with allegations of abuse was in line with Surreys Multi - agency procedures. EVIDENCE: The home had a complaints procedure, which was displayed, in the home. A complaints file was kept. The home has had 7 complaints during the last 12 months. These were seen to be dealt with appropriately. The service users stated that they would complain to the manager of the home without fear of recriminations. Staff had received vulnerable adults training and when questioned by the Inspector were knowledgeable about what constituted abuse of service users, and the action that they must take. Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The location and layout of the home was suitable for its stated purpose. It was accessible, safe, and well maintained with a pleasant and homely atmosphere. EVIDENCE: During a tour of the home the premises were seen to be well maintained with service users able to access all areas of the home and gardens. On the day of the inspection the home was found to be warm and bright with a homely atmosphere and a satisfactory standard of housekeeping and cleanliness. The garden areas were pleasant. There was a programme of routine maintenance in the home, and a full assessment of the environment had been carried out in August 2005. The home had infection control policies, and staff were seen to carry out good basic infection control measures when caring for the service users. There were sufficient laundry facilities in the home. Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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, The numbers and skill mix of the staff met the service users needs. EVIDENCE: The staff rota inspected demonstrated that the staffing numbers and skill mix were appropriate to meet the assessed needs of the service users living in the home. It was pleasing to note that the Manager had recently increased the staffing level at night. Domestic and laundry staff were employed. All interactions observed between staff and service users during the inspection were seen to be caring and respectful. The Manager informed the inspector that the home had almost reached the level of 50 of the care staff being trained to level 2 NVQ. Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 32,33,35,38 The home is well managed, and staff receive the support necessary from the manager. There were policies in place in the home to ensure that, as far as is reasonably possible, service users were protected. EVIDENCE: The staff who were spoken with on the day of the inspection felt very supported by the Manager, who has an open door policy. There was a commitment to training and personal development of each staff member. A service user quality survey had been completed in August 2005. This had produced very positive feedback, and covered many aspects of the home, including food and activities. Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 16 All service users have personal accounts, and there was no pooling of service users monies. Records and receipts were kept for any purchases or expenses, and the home had secure facilities for safe- keeping of any money or personal possessions. Health and safety records were sampled, including moving and handling training, fire drill and fire safety checks. These were all in order. The manager was awaiting the PAT testing certificate, and a requirement was made that a copy of this is forwarded to the CSCI. The home has appointed first aiders, and a record was kept of any incidents or accidents. Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 17 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 3 x x 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 3 x 3 x x 2 Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? No 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 12(1)(a) Requirement Timescale for action 30/11/05 2 38 13(4) The personal care charts must be regularly completed to provide an accurate record of the personal care carried out. The Registered person must 30/11/05 forward to the CSCI a copy of the PAT testing certificate 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 Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beeches (The) DS0000013565.V255315.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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