Inspection on 29/10/07 for The Beeches (Rowley Regis)

This inspection was carried out on 29th October 2007.

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 (Rowley Regis) 06/12/06

The Beeches (Rowley Regis) 14/06/06

The Beeches (Rowley Regis) 24/01/06

The Beeches (Rowley Regis) 22/06/05

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

CARE HOMES FOR OLDER PEOPLE The Beeches ( Rowley Regis) 17 Waterfall Lane Rowley Regis West Midlands B65 0BL Lead Inspector Mr Jon Potts Key Unannounced Inspection 29th October 2007 09:50 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 ( Rowley Regis) DS0000066557.V345367.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 ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches ( Rowley Regis) Address 17 Waterfall Lane Rowley Regis West Midlands B65 0BL 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) 0121 744 1659 janet.wyatt2@btopenworld.com thebeeches.care@btconnect.com Janet Wyatt Vacant post Care Home 17 Category(ies) of Dementia (17) registration, with number of places The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2006 Brief Description of the Service: The Beeches is a large traditional Edwardian detached house located near the centre of Blackheath and the range of facilities this offers. The Beeches is registered to provide personal care to older people with dementia. The Beeches has been extended and adapted for its present use. There is car parking available at the front of the home with a pleasant, mature garden to the rear. The home is sited off a steep hill and the drive to the home is also inclined. The building is in a commanding position, with some good views of the local area and Clent hills from some bedrooms. The home offers 11 single and 3 en-suite double bedrooms, two communal lounges a dining room, one bathroom, one shower room and five communal toilets. A shaft lift enables easy access between floors. The home is managed on a day-to-day basis by an acting manager who has regular support and contact from the homes provider. The acting manager supervises a team of seniors, carers and ancillary staff. Weekly fees for The Beeches whilst clear in contracts are not available in the homes statement of purpose. The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over two days and involved what was primarily an assessment of the homes performance against key national minimum standards. Evidence was drawn from a number of sources but including the tracking of resident’s care, which involved looking at care records, talking to residents and relatives about these and life in the home, observation by us during the course of the visit as well as considering the views/knowledge of staff. Other evidence was drawn from reading other documentation including that related to health and safety and staffing. There was also information supplied pre inspection by the homes manager (within an AQAA – annual quality assurance assessment) and from CSCI questionnaires received from residents and relatives. The residents, staff and management are to be thanked with their ready assistance with the inspection process. What the service does well: Based on the comments received from residents and relatives there is a high level of satisfaction with the service provided by the home in particular in respect of the care provision and how staff promote resident’s privacy and dignity. Discussion with staff showed that they thought in a ‘residents first’ way and were committed to the home. The home is provides a friendly environment and visitors are welcomed and hospitality is offered as a norm, this building on the way the home handles admissions where time is put aside to ensure residents are introduced sensitively. Comment was made by relatives as to the management and staff’s openness to listen to what people had to say and there is a willingness to try answer any queries or address any concerns. This underlines the confidence in the service that was apparent based on what people told us and what was observed during the course of the visit with, warm and positive interaction between staff and residents. The environment also provides a homely and as far as possible non – institutional home with relatives stressing that one of the service’s strengths the fact it was a smaller, more intimate unit. The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Whilst there has been much improvement there is still a need to continue this with the following areas needing attention as a priority: • Improving the homes documentation in respect of such as activities, resident’s express choices in regard to lifestyle, care planning (this to show evidence of involvement and to consistently cover the full range of residents needs as identified in assessments), staff files and generic/environmental risk assessment. • To continue with staff training prioritising dementia care training, infection control and risk assessment (the latter for key staff). • To ensure staff receive one to one supervision on a regular basis. • To review the homes medication policy so that it is up to date. • To ensure that footrests on wheelchairs do not prevent a hazard to staff or residents. • To provide a handwash sink in the laundry area for staff hygiene purposes. • To continue in trying to identifying a suitable dentist for domiciliary visits to the home. • To fully consider the implications of the mental capacity act for the homes practices. • To ensure that the fees for the service are clear in the homes statement of purpose. Overarching the above the planned improvement of the homes quality monitoring systems which will assist in the consolidation of many of the homes The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 7 strengths whist helping to identify potential weaknesses and strategies to address these. 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 summary of this inspection report can be made available in other formats on request. The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 & 4 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is sufficient information available to prospective residents and their representatives to allow them to make an informed decision about potential residency at the Beeches. The management are robust in ensuring that they are able to meet a residents needs prior to admission wherever possible. EVIDENCE: The home provides a Statement of Purpose that is specific to the individual home, and the resident group they care for. It clearly sets out the objectives and philosophy of the service. Copies of CSCI inspection reports were seen to be readily available in the homes foyer. New residents are provided with a Statement of Terms and Conditions/Contract, which sets out what is not included in the fee, the role The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 10 and responsibility of the provider, and the rights and obligations of the individual. This is clear, jargon free, easy to understand and gives a very clear understanding of what residents can expect. There was evidence that the contract has been reviewed and revised since the last inspection and there was clear evidence that contracts are reviewed if there are contractual changes (for example change of bedroom). Comments from relatives in respect of the homes admission processes, as well as sight of the records kept by the home in respect of individual residents and the homes policies support the judgement made. There was clear evidence that there was sufficient information to assist prospective residents and their representatives in making a decision as to moving into the home. The home always carries out pre admission assessments, this usually involving the provider, who is known to make herself available on the day of resident’s admission to the home to introduce the resident to the staff and other residents and answer any queries that may arise. Relatives made comment to the admission process being handled sensitively and professionally. In addition to the assessment carried out by the home copies of care management assessments are obtained (where appropriate) or where these have not been available assessment information has been gained from the care home the individual was admitted from. The homes admission process is supported by the homes pre admission procedures, these summarised in the homes statement of purpose. The statement of purpose underlines the service’s emphasis on ensuring it can meet residents needs prior to admission. Following admission a review is carried out after approximately one months time to assess the residents trail period at the home, this applicable to self funders as well as those supported by social services. The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs, although care plans could better describe these in some instances. The homes practices in respect of handling of medication have improved but need to be supported by a more robust policy and procedure. Staff put the principles of respect, dignity and privacy into practice when providing care to residents. EVIDENCE: Al residents were seen to have care plans in place these covering a variety of issues relating to personal, social and health care needs although the content within those seen was variable with some far more detailed than others. There was evidence in some of the residents individual requirements having been sought through assessment and in some instances carried through to the care plans although this practice was not consistent, this meaning that there is scope for improvement and a need for an internal quality benchmark for use in auditing care plans. Care plans need to be more cohesive so that they can be The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 12 used as stand alone documents that summarise the full range of information needed by a carer or resident, this presented in an easy to understand format. There was no evidence of any residents or relatives having agreed to the plans through signature, or any record of their involvement in the planning of the same. In discussion the acting manager was aware that the plans needed review and stated this work was planned. There was however evidence that the home has significantly improved risk assessments in respect of nutrition, falls and tissue viability. These (and the care plans) are reviewed monthly and tracking of these evidenced that they are followed through into practice, this based on observation, comments from residents/relatives and other documentation. It was noted that there has been some inaccuracy in residents weights, this leading to the home having purchased sit on scales, which give a far more accurate reading. Resident’s weights are compared against a recognised guidance tool (MUST). Documentation, supported by comments from residents and relatives, evidenced that residents have access to health care services both within the home and in the local community. They have choice of their own GP (within catchment areas) and attend local opticians and other community services. The only access that is currently problematic is that to dental services (this an issue the manager was aware of) although where needed the home had pursued dental treatment through a hospital due to difficultly obtaining treatment locally. The home was seen to have a medication policy although this would benefit from review and expansion, with a copy then made available in the home MARs folder to assist staff to have easy access. The manager was advised to refer to the new pharmaceutical guidelines for care homes in doing so. There was clear evidence that issues identified at the time of the last inspection in respect of the safe handling of medication have received attention, this assisted with the home have changed contracted pharmacists. Records of medication regimes were clear and there was no reference to ‘as directed’ medication except for warfarin, although directions for the later were clear in letters from the resident’s G.P. There was no evidence of medications not having been signed out with the exception of one occasion in respect of creams, and observation of the medication been given showed that staff took time and care when doing so. It was pleasing to see that the home did not keep excess stocks of medication and all medications seen were stored safely (this including creams in bedrooms where there are lockable cupboards specifically for this purpose). Discussion with some of the staff evidenced that they think in a person centred way when considering an individual’s personal care needs, this further evidenced by comments from relatives. Staff are aware of the need to, and in practice were seen to treat individuals with respect and to consider dignity when delivering personal care. The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are able to make choices about their life style, and are supported to maintain their life skills. Social, educational, cultural and recreational activities meet individual’s expectations although documentation that reflects how the home does this needs to be more robust. EVIDENCE: Based on comments from residents and relatives people who live at the home have access to and involvement in meaningful daytime activities of their own choice and according to their individual interests and abilities. Examples cited included music to movement, trips out, reflexology, parties, involvement in some food preparation and holidays (the latter at additional cost). Relatives stated that they felt residents were able to live the life they chose and routines were seen to be flexible with such as extended meal times this allowing residents that did not rise early to have breakfast at a leisurely pace. One resident made reference to the fact that there was not such a rush to get up in the mornings (as had been the case under previous management) and that they were able to have a bath when they wanted and also have involvement in The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 14 chosen individual activities. It was however noted that documentation of the activities the residents were involved in was limited with a general activity record not completed since May 2007 and little clear recording of day-to-day individual activity and stimulation for residents. The recording of resident’s chosen day-to-day routines could also be improved through enhanced care planning. Discussion with a number of resident’s relatives evidenced that the home encouraged and supported the maintenance of important personal and family relationships. The practice of staff promotes good relationships between the home and resident’s relatives and friend’s through ensuring they are welcomed into the home and offered hospitality. The staff were seen to be conscious of security and safety of residents and access to the home was through a member of staff at all times. The home was also stated to be good at keeping others up to date with any significant developments. Residents were seen to be able to bring in their personal possessions into the home within health and safety restrictions and the homes policies reflect that residents would be encouraged to retain independence within the remit of their capabilities. There was discussion with the acting manager to the extent to which residents maybe able to have full and active involvement in informed decision making without the support of representatives and there is a need to ensure that assessments are carried out in respect of resident’s capacity to do so (in accordance with the Mental Capacity Act 2005) this so that their right to any individual decision making is fully protected. The manager and staff have received some training in this area. The homes menu is varied with a number of choices, these based on consultation with residents through meetings. Staff ask the residents as to their choices on a daily basis although it was stated by staff that additional portions of each choice are prepared to allow for residents changing their minds at meal times. The acting manager was advised to consider the use of pictorial menus to assist residents to select meal choices. The staff were clearly aware of the need to be vigilant in respect of residents with poor appetites and records showed that there were robust nutritional assessments that make use of recognised tools to reflect residents weights against set criteria; this highlighting any cause for concern. One method used by the home to assist with nutritional intake is to make smoothies, with residents assistance, this a way of ensuring intake of healthy foods. In addition where residents have difficulty digesting foods staff purée these, and comment from one resident who had food so prepared indicated that they were pleased with this, in respect of presentation and taste. Care staff are sensitive to the needs of those residents who find it difficult to eat and were seen to give appropriate assistance with feeding. In discussion they were aware of the importance of feeding at the pace of the service user, making them feel comfortable and unhurried. The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure. The service is aware of how to protect people from abuse with staff knowledge improving through the provision of training. EVIDENCE: Based on comments from residents and their relatives the home has an open culture that allows residents to express their views and concerns in a safe and understanding environment. Residents and others involved with the service say that they are satisfied with the service provided and well supported by staff and management. All those spoken to were aware of the homes complaints procedure and comment from those who had raised minor concerns in the past indicated that staff listen to them and try and resolve issues. The service has a complaints procedure that is easy to understand, this on display in the reception area of the home (as indicated in the homes statement of purpose). Residents have also been presented with a copy of the format in large print and the complaints procedure is issued with copies of individual terms and conditions. The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 16 The home keeps a record of complaints, this not including all the detail of the investigations and actions taken, although records seen at the time of the inspection are known to be supplemented by other records that are more comprehensive, although these were not available at the time. The homes Policies and Procedures for Safeguarding Adults, these revised since the last inspection, are available and whilst brief are supplemented by the social services safeguarding procedures as well as the department of health document ‘No Secrets’ and the protection of vulnerable adults list procedures (relating to referral of staff when there have been issues with the protection of residents). The combination of all these documents together gives clear and specific guidance to those using them. Discussion with staff evidenced that they were aware of the indicators in respect of potential abuse and what action to take should they have concerns. When not sure of the external body to refer to should this be necessary, they were aware of the availability of this information in procedures. The provider has recognised (in the annual quality assurance assessment) that further stakeholder feedback could be encouraged through such as questionaires. The inclusion of local social service departments within this could assit the home to assess its performnace and communication in respect of such as any potential safeguarding concerns and assist with a better working relationship with such external agencies. Training of staff in the area of protection was arranged earlier this year and all care staff have attended, this evidenced by certificates seen. Staff have not received training in dealing with physical and verbal aggression or restraint to date, this to be seen as an integral part of the wider need for on going training for caring for individuals with dementia. The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 & 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a generally safe, well-maintained and comfortable environment, which allows independence. Further development of the homes approach to risk assessment will further improve the safety of the environment. EVIDENCE: The Beeches provides a comfortable and interesting environment with the presence of period features enhancing the environment’s presentation. It is clear that there has been on going work to improve the environment with continued redecoration and refurbishment, this assisted by the employment of a handyman who takes care of routine maintenance issues. Building work completed since the last inspection has included redecoration of the hallway, downstairs shower room and some bedrooms. Radiators within The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 18 the home are now all suitably guarded and efforts have been made to rationalise the storage of supplies such as incontinence pads so that whilst easier to access they are safely stored. There are clear plans to continue refurbishment with the upstairs bathroom and toilets soon to be revamped. A member of staff has also been appointed to carry out safety checks on the home once a week and discussion with this staff member evidenced that this is helping to highlight any potential concerns. Checks carried out by this member of staff and the handymen are documented. One concern identified by staff is the hazards presented by footrests on wheelchairs, which by swinging freely have on occasions hit staff or residents. A solution to this needs to be found without the current practice of staff removing footrests, this despite the one staff member constantly ensuring they are refitted. The health and safety advisor stated that they were looking to complete a risk assessment of the environment to build on that completed by the assessment carried out by a consultancy last year. The provision of training for this member of staff to better prepare them for this task would be advisable, this so that they fully understand the legal context and reasons for completion of risk assessments. A recent Fire Prevention Officers visit did raise some issues in respect of the maintenance of fire precautions although there was evidence that the home is progressing these works, although it was highlighted to the acting manager that care should be taken not to use door wedges to hold open fire doors as this can result in compromising their effectiveness. This was only an issue with a small number of doors as a number have hold open devices fitted. The home has two lounges, one a smaller more intimate room, the other a larger one this allowing residents a degree of choice. Bedrooms are only shared by agreement with the people using the service, and they are always given the choice to move into a single room when one becomes vacant. Screens are provided for privacy and the rooms reflect the personal belongings of both people. The home was able to evidence that it is open and honest with people using the service when discussing the use of shared rooms and the prospect of having their own room. All the homes bedrooms have an ensuite facility available which assists with the promotion of privacy and dignity, although the home also needs to ensure that all residents are offered the opportunity to have access to bedroom door keys or where this is seen as a risk, the appropriate assessment is completed to validate this. The equipment and aids available at the home were seen to be appropriate for the needs of the residents accommodated, with a shaft lift, hoists on every floor, floor level shower, assisted bath, movement sensors (to assist with falls prevention), falls mats and a recently purchased set of sit on weighing scales. The use of bed rails has also been discontinued with specialise beds now in use. It was noted that whilst most windows have restrictors there are some The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 19 sash windows (in a room that was been redecorated at the time of the inspection) that may need restriction dependent on the outcomes of a risk assessment the home needs to carry out. The home has two lounges one a smaller more intimate room, the other a larger one this allows residents a degree of choice. Bedrooms are only shared by agreement with the people using the service, and they are always given the choice to move into a single room when one becomes vacant. Screens are provided for privacy and the rooms reflect the personal belongings of both people. The home was able to evidence that it is open and honest with people using the service when discussing the use of shared rooms and the prospect of having their own room. The home is well lit, clean and tidy and smells fresh. The management now has health and safety policies and procedures developed by a consultant and there is reference within these to some areas of infection control. Discussion with staff indicated a good awareness of ways in which to reduce cross infection and personal protective equipments (gloves and aprons) was seen to be readily available and used by staff. Three staff to date have completed their infection control training. As raised at the last inspection report there is no hand wash sink in the laundry, this so that staff are able to wash their hands immediately after handling soiled laundry. The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Staff in the home present as skilled and are available in sufficient numbers to support the people who use the service. Further training of staff in dementia care so as to improve their knowledge of this specialist area and more care in documentation would further enhance the service the home provides as well as further protecting residents. EVIDENCE: People who use the services offered by the home expressed confidence in the staff team this including the ancillary staff. Residents and relatives said that there was always or usually enough staff available to provide for their needs this consistent with observations made by us during the course of the inspection. There has been revision to the homes staffing arrangements since the time of the last inspection of the home and the staffing levels at the point of this inspection were judged sufficient to meet the number and dependency of the residents accommodated at the time. In addition the home now has two housekeepers to undertake cleaning of the building freeing up carers time for direct care. The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 21 The service has an adequate recruitment procedure that defines the process to be followed. As the home has not recruited any new staff recently it was not possible to fully assess the homes compliance with its procedures and when four existing staff files were checked there were found to be gaps as follows: • • • • Only 2 of the 4 had a full employment history or explanation of gaps. Three were missing a statement as to the employee’s mental/physical health One had no references (this member of staff employed by the home for a number of years) 2 had no photos in place On a more positive note all other recruitment checks were found to be present including POVA (protection of vulnerable adults list) and enhanced disclosures. The view of residents and relatives was that the staff presented as knowledgeable and well trained and the ratio of care staff with a vocational qualification is now in excess of 50 , although there are areas where the management need to prioritise training this to include the continuation of accredited dementia care (as commenced by four staff). Once again as no recent staff have been recruited it was not possible to assess how robust arrangements for induction are at the present time, this hampered by the lack of procedures relating to the same. The acting manager was however fully aware of the process that should be followed in respect of use of nationally recognised common induction standards, (blank copies of the same seen to be available). There was evidence that staff meetings have been taking place on a regular basis of late and some one to one supervision with staff has taken place, although not at the expected frequency. The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on comments from stakeholders is open and accessible although there is a need to strengthen some of the homes management tools to ensure that residents best interests and safety are maintained. EVIDENCE: The home does not currently have a registered manager and whilst the acting manager has the necessary experience to run the Home (having recently been the manager of a home of similar size and purpose) it is imperative that an application for her registration is submitted to the CSCI Central Registration Unit to confirm these management arrangements. The Acting Manager is The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 23 aware of the need to keep up to date with practice and continuously develop management skills and in discussion stated that she was well supported by the provider. There has been clear development of systems for monitoring of the services performance including regular residents and staff meetings with the use of annual questionnaires to residents and relatives to gain their views. These have been used to inform the homes annual self-assessment prior to its submission to the CSCI although the development of systems for self-analysis would benefit the home further. The acting manager spoke of use of an ‘off the shelf’ system that would be acceptable and hopefully assist the home identify issues such as those highlighted within this report prior to inspection by external agencies. Comments has been made earlier in the report to specific issues in respect of record keeping and whilst some records seen were well maintained others showed gaps in recording such as with meal records where supper entries were sometimes blank, this indicative that more care needs to be taken by staff. Records related to residents monies in safekeeping and valuables were however found to be well recorded and accurate. The manager is aware of the need to promote safeguarding and there has been use made of an external consultancy to develop a robust health and safety policy that meets health and safety requirements and legislation. There is still a need to develop risk assessments in respect of safe working practices on a broader scale, this an issue that has been identified by the homes health and safety advisor who is looking to complete a generic risk assessment of the premises and working practices to build on the general assessment the homes has had carried out by a consultant last year. Advice can be obtained from environmental services as to areas that are seen as priorities, this including issues such as the need for regular testing of the food temperature probe. Discussion with staff evidenced their awareness of their responsibilities in respect of safe working practices although one area of concern as previously mentioned was the issues in respect of the wheelchair footrests. Checks show records are generally up to date although some gaps are found in recording. The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 24 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 3 2 3 2 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 2 2 The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 25 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. Standard OP7 Regulation 15(1) 15 (2) Requirement The registered provider must be able to evidence at all times that residents’ are consulted with when their care plans are prepared and reviewed. The registered provider must ensure that the resident/and or representative agrees with their care plan and signs to indicate this agreement. Timescales of 01/02/05,13/06/05, 07/07/06 and 10/1/07 not met. The registered person must ensure; That care plans clearly describe each need or goal. That dementia care plans are expanded upon to include each need examples being; recreation, behaviour, supervision etc. Timescales of 20/12/06 not fully met. This is necessary to ensure that The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 26 Timescale for action 30/03/08 2. OP7 15(1) 30/03/08 3. OP9 13(2) residents (or representatives) and staff are clear as to what care is to be provided and how. The registered person must revise the homes medication policy to ensure; That staff are clear that all homely remedies must be ratified by the individual service users doctor- this to include oils used for alternative medicine. That a section is added concerning medication errors and the need to inform the CSCI in accordance with Regulation 37. Timescales of 4/01/07 not met. 31/12/07 4. OP12 16(2)(n) This is necessary to ensure medication is administered safely and when there are errors the appropriate steps are clear to staff The registered provider must 31/12/07 ensure that all activity participation is recorded as per day and date. Timescale of 24/02/06 and 20/12/06 not met. This is necessary to evidence that activity is provided in accordance with the residents agreed care plan and as such can be easily audited. The registered provider must ensure that where risks have been identified for example weight loss, poor appetite etc that a full record of food consumed is made to include at least 4 meals per day. Timescales of 15/12/06 are part met – records available but not DS0000066557.V345367.R01.S.doc 5 OP15 17(2) Sch 4 (13) 31/12/07 The Beeches ( Rowley Regis) Version 5.2 Page 27 always fully completed. This is necessary to evidence that foods are provided in accordance with the resident’s needs/choices and as such can be easily audited. The registered provider must ensure that; Risk assessments for the laundry are produced. Evidence is available to demonstrate that all of these have been read by staff and when. That these policies/ processes are being consistently and diligently adhered to. A second sink for hand washing purposes is installed in the laundry. Timescales of 08/07/05, 01/03/06, 01/08/06 and 30/01/07 not fully met. This is necessary to ensure risk to residents from cross infection are minimised. The registered person must 31/12/07 ensure; That a full employment history complete with dates is obtained from any prospective staff member. That wherever possible a reference from the previous last employer is obtained for any new staff member (for new employees) Timescales of 25/12/06 not fully met. In addition the registered provider must ensure that each The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 28 6. OP26 13(3) 29/02/08 7. OP29 13(6) 19(2) member of staff completes a statement in respect of their physical and mental health. This is necessary to ensure that staff are safe and fit to complete their duties consummate with their job description. The registered provider must provide evidence to the CSCI of training dates confirmed for staff in respect of (accredited) dementia training (for all staff) Timescale of 15/02/06, 25/08/06 and 30/01/07 part met. This is to ensure staff are appropriately trained to work with older people with dementia. The registered provider must implement / continue developing the homes system for improving the quality of care in the home, this to include; Production of an annual development plan. Self audit tool against all National Minimum Standards For older people. Implement a system for monthly Regulation 26 visits for The Beeches. Timescale of 1/2/07 not met. This is to ensure that the provider has a robust system for self-assessment and maintaining good outcomes for residents. 8. OP30 18(1)(a) 31/01/08 9. OP33 24 31/03/08 The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 29 10. OP38 18(1)(a) The registered provider must ensure the following; That all staff have had; Infection control training Timescales of 20/08/06, 01/03/06, 01/09/06 and 1/2/07 not met 30/05/08 11. OP38 13(4) a 12. OP38 13(4) a This is necessary to ensure risk to residents from cross infection are minimised. The registered provider must 31/12/07 ensure that all areas in relating to potential hazards to residents are fully risk assessed this to include: - The potential for falls from sash windows. The registered provider must 31/12/07 ensure steps are taken to reduce the risk to residents and staff from free moving wheelchair footrests (without removing footrests from wheelchairs). 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. Refer to Standard OP1 Good Practice Recommendations The registered provider should ensure that the charges for the homes are clearly documented in the homes statement of purpose to assist the provision of information to potential residents. The registered provider should source a suitable dentist for use in carrying out domiciliary visit to the home. 2. OP8 The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 30 3. OP14 4. 5. OP15 OP18 6. OP24 7. OP36 8. OP31 9. OP38 The registered provider should ensure that assessments are carried out in respect of resident’s capacity to make decisions in accordance with the Mental Capacity Act 2005, this so that their right to any individual decision making is fully protected. The registered provider must ensure that all menus are produced in a format appropriate to all residents, this to assist them to make choices. The registered provider should ensure that all staff have training in the management of potential aggression and understanding restraint to increased their understanding of these areas of practice. The registered provider should ensure all residents are given the choice of a key to their bedroom, or when this is not seen as safe, a risk assessment is completed validating the reasoning for this decision. The registered provider should ensure that all care staff are supervised at least once every two months (six times per year) so that they have sufficient one to one time to reflect on personal work and practice issues. The registered provider should ensure that the acting manager submits an application for registration to the central registration team so as to valid her position as manager of the home. The registered provider should provide staff delegated health and safety responsibilities with appropriate risk assessment training to allow them a better understanding of the tasks devolved to them. The Beeches ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 ( Rowley Regis) DS0000066557.V345367.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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