Inspection on 04/10/05 for The Beeches

This inspection was carried out on 4th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 11/11/08

The Beeches 07/08/07

The Beeches 24/08/06

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 Unannounced Inspection 4th October 2005 13:20p 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.V255560.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. The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 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.V255560.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th June 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. The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 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 Care Home, on the 4th October 2005, commencing at 13:20 and finished at 17:10,this was the homes second Inspection since April 2005. Any standards not covered in this inspection were covered in the unannounced inspection that was conducted early in the year. It may be the case that some standards will be covered twice in the inspection year 2005/2006, which is considered good practice, and consistent with a professional approach to regulation. During the Inspection we looked at chosen number of documents, sampling of records, and direct and indirect observation of staff interaction with residents, this Inspection also included individual and group discussions with residents, and feedback from relatives and visitors on the day. Any issues or concerns that were raised were discussed with the Manager during and at the end of the Inspection. What the service does well: What has improved since the last inspection? The company has addressed most of the requirements made at the last Inspection; recruited new members of staff in order to fill the vacancies at the home and four more staff have NVQ level 2 qualifications. The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 Page 6 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.V255560.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 The Beeches DS0000007985.V255560.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): 36 No residents move into the home without having their full needs assessed, to ensure all their needs with be met by the home. EVIDENCE: Intermediate care is not provided at this home, although they do offer respite care if they have a bed available. The inspector questioned how well the home is meeting the needs of this client group; by speaking to care staff and manager also examining care plans. Evidence was seen in care plans that residents are fully assessed prior to admission to the home, including any assessment that has been completed by other professionals; this is to ensure the home can meet resident’s needs. Residents are also re-assessed after their initial six week review to ensure the home are meeting the residents care needs, or after a hospital admission to ensure care needs have not changed. The Beeches DS0000007985.V255560.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): 789 Resident’s health care needs are fully met, with documentary evidence available, and those residents spoken to state that staff treat them with respect and were happy with care provided. EVIDENCE: Evidence was seen that residents have access to all health care services; two care plans were chosen at random and checked, these were cross-referenced with medication and accident records. Each resident had a comprehensive plan of care to ensure their needs are fully met, various assessments are completed dependent on individual need, and evidence was seen that other professional are involved in residents care for example district nurses. 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. Medicines in the custody of the home were checked, random MAR sheets were examined and found satisfactory with; Mar sheets that are hand written had The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 Page 10 two signatures and when medication was omitted, Mar sheets stated the reason why. Residents that were spoken to stated that staff treat them with respect and were happy with care provided; all were dressed appropriately with any aids they required. Staff was observed conversing with service users 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. The Beeches DS0000007985.V255560.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 14 Atmosphere within the home appeared good and lots of verbal communication between staff, residents and visiting relatives, and all the standards in this area are met. EVIDENCE: The home do have an activities person in post who works Monday to Friday, and during the Inspection a number of residents were spoken too, all made positive comments about their daily life within the home,” staff and manager very approachable” “I feel very safe and secure here”. Some residents gave examples of what activities take place within the home, bingo sessions, arts and crafts, exercise to music session and entertainers come into the home. A number of residents are capable of visiting the local shop on their own and this was confirmed when speaking to residents, who informed the Inspector that they visit local shops on their own and carers take other residents whenever possible. Routines in the home are kept to a minimum and during periods of observation it was clear residents pleased themselves in their movements around the home. The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 Page 12 Residents can have visitors at any reasonable time, and this was confirmed when speaking to visitors. The home encourage residents to exercise choice and control over all daily living needs whenever possible, this was confirmed by residents who could voice their opinion stating they manage their own finances, and make choices when they need too. Both residents and families are encouraged to be involved in care planning and reviews. The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 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): 18 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 policies and procedures for adult protection, and staff have completed a course at Doncaster College re-Abuse and its Prevention in January 2005, staff that were spoken to were aware of policy and procedures and could stated what action to take if they suspected abuse, also aware of the whistle blowing policy. All new staff has been CRB and POVA checked before they commenced employment. The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 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): These key standards were assessed on the last Inspection, and were met. EVIDENCE: The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 Page 15 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 30 Appropriate staffing and skill mix, to meet residents care needs, and on going development of staff was evident by some staff achieving NVQ qualifications. EVIDENCE: Staffing numbers was discussed with the acting manager, who informed the Inspector that the home has recently recruited two more care staff. Examination of duty rota shows sufficient numbers of care staff were on duty, including, activities person, domestic, kitchen and laundry staff. Staff have adequate skills to meet residents needs, and out of the nineteen care staff, six of these have completed N.V.Q level 2 training, and other members staff have enrolled on N.V.Q.training courses. Recruitment was discussed and any new staff since the last Inspection their files were examined, and records show that all recruitment policy and procedures had been followed, with the relevant references being sought, advised the manager that good practice was to also seek a verbal reference, CRB and POVA checks completed. 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.V255560.R01.S.doc Version 5.0 Page 16 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. The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 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 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 37 38 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, although incident reports must be sent to the Commission for Social Care Inspection. EVIDENCE: Since the last Inspection the homes manager has moved to another home within the company, and the deputy manager as been put forward as the new manager, and proceeding through the Commission for Social Care Inspection application process. Quality monitoring systems was discussed and records of any current audits were examined. Care needs of residents are reviewed every six months, and evidence was seen that families and social workers are involved. The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 Page 18 Although resident can access any money they need, this is now pooled and kept in one account balances of individual accounts could not be audited by the Inspector as the company have changed how finances are handled within the home. All services users money must be kept in individual wallets, as stated in standard 35.3 for the company to meet this standard. Records required for regulation were found to be up to date and accurate with the exception of; not completing incident reports and sending them to the Commission for Social Care Inspection. Safe working practice was discussed with the staff on duty at the time and the acting manager; observation of practice and the examination of records were also undertaken. Fire records show all safety procedures are followed and that staff has the appropriate training. The homes maintenance man ensures that any repairs are addressed when required, staff documents any issues or repairs in a book, which is checked by the maintenance man on a daily basis. The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 Page 19 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X 2 3 The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? YES 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 2 Standard OP31 OP37 Regulation 9(1)(2) 17(1) Requirement The acting manager must complete their application as soon as possible. Records required by Regulation with regard to Regulation 37 notifications, these must be sent to the Commission for Social Care Inspection. Services users money must be kept in individual wallets, as stated in standard 35.3 Timescale for action 30/11/05 04/10/05 3 OP35 20(1)(a) 01/12/05 The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 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 Refer to Standard OP28 OP29 OP31 Good Practice Recommendations A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 31st December 2005. Good practice of recruitment, to also seek verbal references. The registered manager achieves NVQ 4 in management by an agreed date. The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI The Beeches DS0000007985.V255560.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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