Inspection on 06/12/06 for The Beeches (Rowley Regis)

This inspection was carried out on 6th December 2006.

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) 29/10/07

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 OBL Lead Inspector Mrs Cathy Moore Unannounced Inspection 6th December 2006 07.20 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Beeches ( Rowley Regis) DS0000066557.V321373.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.V321373.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 OBL 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 Janet Wyatt Care Home 17 Category(ies) of Dementia (17) registration, with number of places The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14/06/06 Brief Description of the Service: The Beeches is located near the centre of Blackheath and is in close proximity to a number of shops and other amenities. The Beeches is registered with the Commission for Social Care Inspection to provide personal care to 17 residents who fall within the categories of Old Age/ Dementia Elderly. The Beeches is a traditional Edwardian detached property , which has been adapted and extended for its present purpose. The grounds have mature gardens and car parking available to the front. 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 , two bathrooms , one shower room and five communal toilets. A shaft lift enables easy access between floors. Weekly fees for The Beeches range from £328- £410. The Beeches ( Rowley Regis) DS0000066557.V321373.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 on one day by two inspectors’ between 07.20 and 16.45 hours. The inspection assessed all key National Minimum Standards for Older People and focussed on previous requirements made. Part of the inspection was carried out in the lounges and the dining area where daily routines could be observed as well as involvement between staff and service users’. The premises were part assessed to include a number of bedrooms, toilets, the lounges, dining room, laundry, kitchen and garden. Medication systems, health and safety and infection control processes were all assessed. Staff files were examined to judge recruitment processes and training. Three service users were cased tracked this process involves looking at their care in detail and speaking to them and where possible their relatives. Four staff were spoken to along with the acting manager. The owner was involved in the inspection process. As part of this unannounced inspection the quality of information given to people about the care home was looked at. People who use services were also spoken to, to see if they could understand this information and how it helped them make choices. The information included the service users’ guide ( sometimes called a brochure or prospectus), statement of terms and conditions ( also known as the contract of care) and the complaints procedure. These findings will be used as a part of a wider study that CSCI are carrying out about the information that people get about care homes for older people. This report will be published in May 2007. Further information on this can be found on our website www.csci.org.uk. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The premises have improved considerably since the new owner has taken over. Lounge areas and the dining room have all been redecorated and new flooring, furniture and light fittings provided. An attractive laminate style flooring has been fitted in the small lounge and new carpet in one ground floor corridor. The ground floor bathroom has been refurbished to provide a walk in shower. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 7 The main hall, stairs and landing have been redecorated. Window dressings have been ordered for some windows. A number of bedrooms have been redecorated. A number of new beds have been purchased. New boilers have been installed. Ventilation extractors have been provided in toilets. The garden is being maintained all year. It was surprising this time of year to see that the lawn had recently been cut and looked very tidy. Railings have been provided in the garden to enhance safety in respect of the step areas. A handyperson has been employed part time to enable the premises to be maintained continually. An acting manager has been appointed to assist the homes progress in terms of care plans, record keeping and staff development. All but one staff member has received medication training. Six residents went on holiday to Ross On Wye accompanied by staff. Each resident has been issued individual large print information about complaints processes and a questionnaire has been issued on this subject. What they could do better: This home has improved considerably since the new owner has taken over this confirmed by observations of the premises, records and services provided and feedback from service users, relatives and staff. The home still has a lot of work to do to improve further to ensure it is meeting all of the National Minimum Standards for Older People and Care Home Regulations 2001. High risk areas where improvements are needed are medications and the guarding of hot pipe work and radiators. These have a potential to place service users at risk. Activity provision is an area which also needs further improvement to ensure that all service users who want to are stimulated and have interests. Complaints and protection need further improvement to ensure that staff are fully aware of processes to allow service users to voice concerns and be protected. Care planning and risk assessment feedback into care plans is lacking at the present time which may prevent the full range of care being provided to individuals. Staffing needs to be addressed and reassessed to ensure that there are adequate staff at all times. Similarly, action needs to be taken to ensure that staff are trained in all mandatory areas and also to meet specific needs such as dementia. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 8 The home needs a permanent registered manager as there has not been one in place for 12 months. The home has 52 requirements which need to be addressed a number of these outstanding from previous inspections. However, the Commission recognises and acknowledges the improvements that have been made since the new owner has taken over and the overall general reduction in risk to service users. The history and improvements and overall outcomes for service users’ have been carefully considered in determining the risk rating for this home. The new owner is being given the opportunity to meet requirements made within the timescales made to retain the current risk rating. If they are not met then the risk rating may have to be reconsidered. 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.V321373.R01.S.doc Version 5.2 Page 9 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.V321373.R01.S.doc Version 5.2 Page 10 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): 1,2,3,4 Quality in this outcome area is adequate. More evidence must be made available to confirm that all prospective service users are given sufficient information about the home to enable them to make a decision about its suitability. More development is needed in respect of terms and conditions or contracts. No service user moves into the home without having their needs assessed, however, there was no evidence to demonstrate that the home is confirming that they can meet these needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was positive that information about the home including latest inspection reports were on display within the home. The homes’ service user guide and The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 11 statement of purpose were revised when the new owner took over the home. Unfortunately relatives and residents spoken to did not recall seeing a copy of the homes’ service user guide. However, this may have been due to the fact that all spoken to had not been involved with the selecting of the home. One resident said; “ My son did all that for me-he may have one”. Two relatives spoken to confirmed that another relatives had dealt with the admission process. The home does have in operation a check list for new admissions this should be added to, to allow relatives to sign to confirm that they have been given a copy of the service user guide, statement of purpose and complaints procedure. The quality of terms and conditions documents viewed was mixed. Two were very up-to-date, one accompanied by a break down of fees from the funding authority the other was not this precise. The third one was very old and did not contain the correct fee for this financial year. Again all persons asked about fees and changes of fees were not able to answer as either their family dealt with this or another family member. One relative did confirm; “ I am sent an invoice every month showing the fee rate”. It is positive that evidence was available to confirm that an assessment of need had been carried out for each service user. Two service users confirmed that their family had dealt with the admission process and had looked around the home on their behalf. One relative confirmed that her mother had visited the home prior to her admission. No evidence was available on file to confirm that a letter had been issued by the home stating that individual needs could be met as it should do. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 12 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 poor. Care plans need further development and improvement to ensure that all needs and risks are captured within. Personal care evidencing needs further development. Medication systems need improvement to prevent risks to service users. Service users feel that they are treated with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although care plans have developed somewhat, further improvement is needed. One shortfall is the failure to include all needs and risks in the care plans. For example; at least two service users have lost weight yet there is no care plan available to instruct staff how to deal with this. One of the service users whose care plans were viewed has dementia but apart from challenging behaviour no other needs concerning her dementia were mentioned. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 13 Concerns have been raised in previous inspection reports about the lack of evidence to prove that service users are being consulted with about their care plans or if they even know that they have a care plan to date this still has not been rectified. Concerns have been raised in previous inspection reports about the lack of evidencing adequate personal care delivery. Whilst it must be said that service users observed during the inspection all looked well cared for in terms of personal care ( one service user said; “ They look after us very well), records to evidence this are not being maintained consistently enough. A comment was made to the inspector that bathing is maybe not carried out frequently enough. Records were available to confirm that service users are having access to healthcare services when needed or on a regular basis. The district nurse visited one service user during the inspection. One service user during the inspection did say that she would like a set of top dentures. Another was observed to have a very sticky eye. The owner said that she would deal with these things. It was very interesting to meet the outside provider who delivers a range of alternative medicine therapies examples being; aromatherapy and reflexology. This service is a great asset to the people who live in the home. The only issue raised was the lack of treatment plans being used at the present time and the approval from individual service users doctors in terms of oil usage. The therapist however, did know all about treatment plans and said; “I will sort that out”. It was noted that two service users have lost weight yet there was no evidence to demonstrate that this is being dealt with as there should be. Staff spoken to did know when they should call a doctor or ambulance. One said; “ If someone looked unwell or pale. I would call for a fall, stroke or fit”. Another said; “ If a resident looked unwell, was not eating or seemed confused”. It was noted during the inspection that one doctor in particular refuses to come to the home when called. To combat this the owner has on one occasion written to the doctor to state her concerns. It was advised that further instances should be reported to the relevant Primary Care Trust. Medication systems have improved in that staff have received medication training and a number of previous medication requirements have now been addressed to a satisfactory standard. However, new shortfalls were noted which have potential to place service users at risk. Two service users medication Rampril had not been available for 3 days. This may have been a pharmacy issue but still they did not have this medication. The owner did confirm however, that these service users prescriptions have now been changed in terms of frequency of prescribing to prevent this happening again. A number of medication records seen were hand written by staff yet there was no evidence that these had been checked by two staff to ensure that the transfer of information was correct to prevent error. Where a variable dose had been prescribed for example; one or two staff are not recording how many have actually been give. There was a number of signature gaps on medication records. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 14 No one at the time of the inspection was self medicating. No controlled drugs were being prescribed and no oxygen was in use. Staff observed during the inspection were polite and friendly to the service users. They gave them choices about food and what they wanted to do. It was pleasing that the preferred form of address for each service user had been determined and recorded. One relative said; “ Oh yes, the staff are always very polite”. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 15 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 adequate. Further improvement is needed to ensure that the lifestyle experienced by service users matches their full expectations. Service users are encouraged to maintain contact with family and friends. Service users are helped to exercise choice over their lives. Although wholesome appealing meals are offered further developments are needed in terms of food intake and special monitoring. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It must be highlighted that activity provision in the home has improved. Staff encourage service users to play board games and interact in various activities offered . A number of service users went on a weeks holiday in the summer accompanied by staff. They went to a specially adapted hotel in Ross On Wye. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 16 During the inspection an external entertainer played music. This was partly for one service users birthday. It is clear that all birthdays are well celebrated with party food and a cake. During the summer the planned ‘staff members wedding’ was replayed in the garden area. The press covered this story and recently the 100th birthday of one of the service users. Obviously the management and staff should be congratulated on their efforts to improve activities within the home. More is needed though to ensure that the service users with dementia get appropriate stimulation. One person commented; “ There needs to be a bit more activity provision” Another said; “ Residents should be encouraged to exercise more”. One person said; “ I would like it if someone from the church came in”. The owner did confirm that this is being arranged at the present time. It was apparent from speaking to service users and relatives that visitors are welcomed by the home. One relative said; “ Yes we are made to feel welcome”. Another said ; “ Me or my sister visit every day”. Many service users spoke about their visits from sons, daughters and grandchildren. External advocacy information was available within the home for service users and relatives to access if they wish. One service user said when asked; “ They sort out the voting if we want to. I don’t think anyone wants to though, I don’t. Bedrooms viewed held a range of personal belongings from pictures and ornaments to radios, televisions and singing/walking snowmen for the festive season! The dining room has been refurbished since the new owner purchased the home. It has been redecorated and provided with nice new tables and chairs. The room is cosy. It has big windows that give a good view of the garden. The breakfast and lunch time were partly observed. There are two sittings with the intention of staff being able to give their full attention to service users who need assistance. The tables were nicely laid with delicate artificial flower decorations, table cloths, mats and condiments. Small milk jugs and sugar bowls are provided to enable service users to help themselves. Breakfast is flexible regarding times. There was a range of options to choose from porridge, other cereals, toast with or without marmalade or sausage sandwiches. The lunch looked and smelt very nice. It consisted of chicken, potatoes, mixed vegetables and dark green cabbage followed by cherry crumble and custard or ice-cream. A number of service users were very complimentary about the food saying it was ;”Good” and “very nice”. It was very positive to see that service users were being given drinks as soon as they got up which they enjoyed. One service user said, “ that’s lovely, a cup of tea”. Food stocks in the home were good and there was plenty of fresh fruit and vegetables. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 17 The cook on duty had a good knowledge of the dietary needs of the service users living at the home as well as their individual food likes and dislikes. Some improvements are needed however. Examples being; the second sitting whilst the intention is very positive did not start until 10.30. If service users had not eaten since tea time the day before it is a long time without food. Whilst the majority of service users looked to be of a adequate weight a couple have lost weight. It is important that their food intake is recorded precisely. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 18 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 adequate. Complaints processes overall need some development to ensure that staff, relatives and service users all know how to make or deal with a complaint . Protection processes also need improvement to ensure that they fully protect service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home or the Commission has received no complaints. The home has a complaints procedure that is available within the home and detailed in the homes terms and conditions document. Staff spoken to knew that if a complaint was made that they should speak to the owner. However, they did not know the full processes of how to deal with a complaint themselves. Service users asked were not aware of the complaints procedure as such. No one could recall seeing a copy. One said; “ If I had a complaint I would speak to my son or the staff”. Another said; “ My son probably knows about this”. Visitors spoken to all said that their relatives dealt with everything and it was they who would have been given a copy of the complaints procedure. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 19 It is positive that the owner has recently issued to families information about the complaints procedure which has been produced in large print. A questionnaire has been included in this information to gauge knowledge in general about complaints processes with a view to improvement if needed. One allegation was made about the home since the last inspection concerning a delay in seeking medical attention for someone who was ill. Sandwell Council investigated this but found no conclusive evidence. However, recommendations were made about educating staff in stroke awareness. To address this the owner obtained a leaflet called “ Fast Response” which gives signs and symptoms of stroke. It is felt that staff need a bit more in terms of stroke awareness such as; training from an expert in this field. Staff to date have not received abuse awareness training although this has been arranged for December 2006. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 20 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): 19,24,25,26. Quality in this outcome area is adequate. Service users live in a home where the environment has improved significantly of late. Communal areas and bedrooms are comfortable and generally well maintained. Safety must be enhanced where heating and water temperatures are concerned. Infection control processes require some further improvements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new owner should be congratulated on the improvements made to the premises and general environment. Over the last year much work has been completed which service users, relatives and staff have welcomed. One relative commented; “ Things have The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 21 improved”. A service user said; “ look how nice the rooms are now”. Staff said; “ It is unbelievable what the owner has achieved in such a short time”, “ The home is really nice now”. Both lounges have been redecorated. The main lounge has had a new carpet the small lounge a laminate style flooring which looks bright and clean and new carpet has been provided in the ground floor corridor. New furniture and lighting has been provided in lounge areas. Since the last inspection the main hallway and stair area has been redecorated which looks really attractive. This work must have taken some time as the area is big and the ceilings very high. Window dressings have either been replaced or are on order. The garden has been fitted with attractive wrought iron railings to prevent access to the steps, which could be a hazard. The garden even in this mid wintertime was well tended. The lawn had been a cut and tress/ shrubs pruned. Many of the service users commented about the garden saying how nice it was. One said; “ I Like to sit and look out at the garden. It is lovely”. A number of bedrooms have been redecorated and have new flooring. New beds and bed linen have been provided in a number of rooms. It is positive that where able service users have chosen their own colour schemes in their bedrooms. Service users asked confirmed that they like their bedrooms. One said, “ Yes I really like my bedroom”. One relative said; “Mums bedroom is nice and it is a good size”. It is positive that bedroom audits have been undertaken in terms of what is provided and satisfaction with these. The concern is that not all bedrooms have a lockable facility, as they should. It is positive that new lighting has been provided in a number of rooms. The home has had new boilers since the last inspection as the previous were not satisfactory. Water temperatures in a number of areas were not as they should be one hand wash basin outlet was too hot others too cold. On-going concern is the lack of radiator guards. Whilst some are guarded others are not in areas such as bedrooms and toilets which presents a risk of burning. The owner however, was able to demonstrate that this is in hand. She has identified a company to make the radiator guards and all radiators have been measured this week to order the guards. She estimates that all radiators should be guarded within three weeks. In the interim the Commission have required that evidence of risk assessments be forwarded to them as a hazard preventative measure. Similarly, whilst a number of exposed hot pipes have been covered there are still some that have not such as the wall pipes in the new shower room. The laundry is small in size. It has however, been provided with new equipment since the owner has purchased the home. A machine that has a sluice cycle is now available. A number of shortfalls were identified concerning infection control as follows; not all staff have received infection control training, cleaning hours are not provided every day and there are a lack of infection control procedures in the laundry. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 22 The home did look clean during the inspection and no offensive odours were detected. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 23 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. Assessment is needed to confirm that staffing numbers are adequate concerning the number and needs of the service users. Over 50 of the staff team have NVQ meaning that the service users are in safe hands. Some ‘Fine tuning’ or improvement is needed to ensure that recruitment practices fully protect service users and that staff are fully trained to do their jobs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staffing levels were questioned during the inspection. The home caters for a wide range of service users from people who require personal care to people who have a diagnosis of dementia. Ergonomically, the home is large with three floors and has numerous rooms. Additionally, care staff have to undertake some cleaning, laundry and tea time catering duties. With this in mind it is felt that staffing levels may not be sufficient. Cleaning hours do need to be extended, these could then include any laundry duties during the day time. The owner did say that most washing is done during the night but there may be some that needs to be done in the daytime. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 24 If the home had an evening cook then again, this would prevent care staff hours being depleted. A commented was made that; “During evenings times it can be difficult”. To address the staffing situation the owner has been asked to undertake an assessment of the staffing levels using a recognised tool and provide a proposal to the CSCI. On the morning of the inspection two care staff and one senior were on duty. Between 9.00 and 14.00 an additional carer was provided. At 09.00 the acting manager was also on site along with the owner. There were 15 residents accommodated at this time. Morning catering hours does seem limited as well as the cook finishes at 13.30 hours and that is it for the day. Service user at the second sitting were still eating at 13.00 hours which does not leave much time for record keeping and cleaning. Staff observed during the inspection was seen to be confident and professional yet kind and caring. One staff member gave an update to service users about another service user who was in hospital. She said; “ .. daughter has phoned.. has had a comfortable night and is ok”. All service users listened to this and commented. They were pleased to hear this news. Service users and relatives were complimentary about the staff generally. One said; “ The staff are nice and kind. They look after us”. Another said. “ The staff are mostly alright”. It is positive that over 50 of the care staff team have achieved NVQ level 2. One senior said; “I have started my NVQ level 3”. Recruitment processes overall were seen to be satisfactory. Completed applications were available and most of the required checks which is positive. One shortfall identified was that a reference from one care staffs last employer had not been obtained although 2 references were on file. For another staff member a full employment history had not been provided. It is positive that an overall training plan has been produced since the last inspection. The home now needs to be able to evidence that formal induction processes are in place. Specialist training needs to be secured examples being; dementia and stroke awareness training to ensure that all staff have the skills and knowledge to do their jobs. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 25 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): 31,33,35,36,37,38. Quality in this outcome area is adequate . The home at the present time does not have a registered manager. Whilst it is acknowledged that quality assurance processes have improved further developments are needed. Some ‘fine tuning’ is needed concerning the management of service users money held in safe keeping. Further improvements needed concerning staff supervision and training to enhance direction and safety in the home. This judgement has been made using available evidence including a visit to this service. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 26 EVIDENCE: The home has not had a registered manager for nearly 12 months. The owner is making some future plans and if these work out she will put herself forward as owner/manager of The Beeches. In the interim an acting manager is in place. The Commission however, require confirmation of the acting managers experience and qualifications and an assurance that what ever happens concerning the proposed plans that a managers application for registration will be made in February 2007 at the latest. The owner does have daily involvement with the running of the home at the present time. Quality assurance systems and processes have improved. There was evidence available of service user and other questionnaires to gauge satisfaction or otherwise, the results of which will be published when the analysis of these has been completed. The acting manager is in the process of arranging service user and relative forums where all concerned can give their views about the running of the home and a newsletter is being produced to be issued December 2006. Further developments in this area include formal unannounced visits to the home by the registered owner and the production of a development plan. Generally, overall management of service users money held in safe keeping was acceptable. However, a shortfall was identified in the maintaining and systems for receipts for expenditure. It was also noted that the chiropodist is not issuing individual receipts to service users as he should. It is extremely positive that a staff supervision process has started. Staff have recently received an appraisal this confirmed by staff spoken to. A supervision matrix was available to address the shortfall of inadequate supervision in the past. A number of records have been identified throughout this report as being in need of improvement examples being; care plans and food intake records. It was also noted that handover sheets are used. Whilst these may be important in terms of communication between staff they hold personal information about a number of service users on each page which is non compliant with the Data Protection Act. The system needs to be revised. It is positive that the owner has worked considerably to improve procedures and polices within the home this work now needs to be completed and staff to sign all polices and procedures in operation. The owner has produced a training matrix which is positive to determine the training needs of staff concerning mandatory training. A number of gaps have been identified where training is needed examples being; infection control, fire drills and fire training. Generally, certificates were available to prove that the serving of fire fighting and lifting equipment is being carried out as it should which is positive. It was identified that a small number of service users require bedrails however, there was no evidence to show that regular checks are being made of these bedrails to ensure their ongoing safety. Similarly there was no evidence to The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 27 prove that wheelchairs are being checked for safety and that an asbestos survey of the building has been carried out. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 28 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 2 2 3 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 3 x x x x 3 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 2 2 2 2 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 29 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 OP2 Regulation 5(1)(bb) (bc) Requirement The registered provider must ensure that; All service users are issued with a revised terms and conditions /contract stating the correct fee for any given financial year. It is clearly detailed in terms and Conditions/contracts what is not included in the fee. 2 OP4 14(1)(d) The registered provider must confirm in writing to prospective residents’ that having regard to the assessment the care home is suitable for the purpose of meeting their needs. Timescales of 22/06/05,24/01/06, 24/01/06 and 07/07/07 not fully met. This must be evidenced at all times with each new admission from now on. 20/12/06 Timescale for action 10/01/07 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 30 3 OP7 15(1)15 (2) 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 and 07/07/06 not met. 10/01/07 4 OP7 15(1) The registered person must ensure; That care plans clearly describe each need or goal. That care plans include all risks identified examples being; poor diet, loss of weight, tissue risk etc. That dementia care plans are expanded upon to include each need examples being; recreation, behaviour, supervision etc. 20/12/06 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 31 5 OP8 12(1)(a) The registered provider must be able to demonstrate on a daily basis that each residents’ full spectrum of personal care needs have been met. Documents to evidence , baths, washes, hair, nail, foot and mouth care , incontinence care, continence promotion ( and other areas of care deemed appropriate ) Timescales of 10/07/05, 24/02/06 and 07/07/06 not fully met. The registered provider must ensure that baths are offered as far as possible at least on a weekly basis- or to the required frequency of individual residents. Timescale of 07/07/06 Special attention in dealing with the bathing needs of people with dementia must be made to ensure that they are bathed frequently enough. The registered provider must ensure that medication is signed out at the point of administration. Timescales of 04/01/05, 22/06/05,24/01/06 and 07/07/06 not fully met. 20/12/06 6 OP8 12(1)(a) 12(2) 20/12/06 7 OP9 13(2) 14/12/06 Concerns about this were discussed with the registered person during the inspection. The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 32 8 OP9 13(2) The registered provider must ensure that ‘handwritten’ medication administration records include the name any known allergies. Information detailed on handwritten medication administration records must be confirmed and witnessed by two staff whose names must be evidenced. Timescales of 10/07/05, 10/02/06 and 07/07/06 not fully met. The allergy section at the top of all medication records must be completed to detail allergy or none known. 15/12/06 9 OP9 13(2) The registered provider must ensure that medications are not prescribed as - ‘ as directed’. Doctors must be asked to prescribe specific times. All medication administration records must be amended accordingly to comply . Timescales of 22/07/05, 10/02/06 and 07/07/06 not fully met. Supplement drinks. 15/12/06 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 33 10 OP9 13(2) The registered provider must ensure that the balance of all medications is brought forward and recorded to ensure accurate monitoring/auditing of medications. Timescale of 10/02/06 and 10/07/06 not fully met. 01/01/07 11 OP9 13(2) The registered provider must ensure that a regular in-house audit of medication is undertaken to identify any shortfalls/ non- conformances to medication procedures and activate corrective actions. Timescales of 15/02/06 and 15/07/06 not fully met. Evidence must be available to demonstrate that these audits have been undertaken. The registered provider must ensure that where a variable dose is prescribed i.e ‘one or two’ then the amount given each time are to be recorded. The registered person must ensure that where medication records are handwritten that 2 staff sign to verify that the information being transferred is correct. The registered person must ensure that prescribed medication is available for service users at all times. Concerns about this were discussed with the registered person during the inspection. 04/01/07 12 OP9 13(2) 15/12/06 13 OP9 13(2) 15/12/06 14 OP9 13(2) 15/12/06 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 34 15 OP9 13(2) 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. 04/01/07 16 OP9 13(2) The registered person must 20/12/06 ensure; That all topical preparations are safely stored ( if in bedrooms in lockable facility) and are not used for anyone other than the person named on the medication label. That all topical preparations applied are signed for. That all topical preparations used are in date. The registered person must employ a suitable activities provider or delegate this task to a suitably trained staff member. The number of hours per week to be negotiated with the CSCI and entered on the weekly rota. Timescales of 24/02/06 and 15/07/06 not fully met. 01/02/07 17 OP12 12(1)(b)1 8(1)(a) The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 35 18 OP12 16(2)(n) The registered provider must ensure that all activity participation is recorded as per day and date. Timescale of 24/02/06 not met. Special attention must be paid to ensuring that; Residents with dementia have adequate activity provision and stimulation even if this has to be on a one to one basis. And that all residents are encouraged to exercise as often as possible eg walking. The registered provider must produce a schedule of resident meetings. That these are held on a regular basis and that written records are made. Timescales of 24/02/06 and 20/07/06 not met. 20/12/06 19 OP12 12(2)12 (5)(a) 04/01/07 20 OP15 17(2) Sched 4(13) The registered provider must ensure that; Residents do not go without food and drink longer than 10 hours throughout the night. Example of where this could be seen as shortfalls could be the second breakfast sitting at 10.30 and lack of supper records. 15/12/06 21 OP15 12(4)(b) The registered provider must ensure that all menus are produced in a format appropriate to all residents. Timescale of 15/07/06 not met. 20/01/07 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 36 22 OP15 17(2) Sched 4 (13) 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. 15/12/06 23 OP16 22(3) The registered provider must ensure that all staff are trained to what they must do if they receive a complaint and what processes they must follow. Timescales of 22/07/05, 24/02/06 and 07/08/06 not fully met. This must done formally. 25/01/07 24 OP16 22(2) The registered provider must ensure that the complaints procedure is appropriate to the needs of the service users’ ( pictorial formats). Timescales of 22/07/05, 24/02/06 and 07/08/06 fully not met. Complaints information including a questionnaire have been issued to all residents in larger print which is positive. 25/01/07 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 37 25 OP18 13(6) The registered provider must revise the homes; Adult abuse policy in line with Department of Health guidance ’No Secrets’. And Sandwell MBC’s Adult Protection guidelines. Physical Intervention policy in line with Department of Health guidance. The registered provider must ensure that the homes’ procedure on whistle blowing is expanded to give details of who staff can contact if they have concerns as to practices ( This to include the CSCI’s telephone number). Timescales of 22/07/05,01/03/06 and 01/08/06 not met. The registered person must add to the homes missing persons procedure instruction for staff that if an incident of a resident going missing occurs that the CSCI must be informed in accordance with Regulation 37. The registered provider must ensure that all staff receive abuse awareness training. The registered provider said that 18 places have been approved for Dec 06 which is positivecertificates to evidence this will be looked at during the next inspection. 25/01/07 26 OP18 13(4)(c ) 25/01/07 27 OP18 13(6) 03/01/07 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 38 28 OP19 23(2)(d) The registered provider must 01/02/07 ensure that all landings and corridors to include skirting board, walls, doors are redecorated. This is in progress. The redecoration of the main stair and hallways is good. 29 OP19 23(2)(b) 23(2)(d) The registered provider must secure the input of an appropriately qualified surveyor or engineer to assess the windows/window frames throughout the home ( with the exception of the few that are made from UPVC) to ascertain whether they require redecoration or replacement. Timescales of 01/08/06 and 01/05/06 and 01/08/06 not met. The registered provider has obtained quotes and is having this work done in Spring 2007. 01/05/07 30 OP19 23(2)(l) The registered person must ensure that there is adequate space available for storage this to include incontinence pads which are stored in a cupboard under the stairs which could present as a fire risk. 25/12/06 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 39 31 OP21 23(2)(b) 23(2)(d) The registered provider must ensure that bathroom is redecorated and fixtures and fittings are in a good state of repair/in good working order. Timescales of 01/08/05 and 01/05/06 not fully met. It is pleasing however, that this is being worked on at the present time. 25/01/07 32 OP24 16(2)( c) The registered provider must add to bedroom audit processes the number of chair preferences and lockable facilities. 05/01/07 33 OP25 13(4)(a) The registered provider must; continue with her plans to have the radiators replaced by the second week in January at the latest. In the interim period regular risk assessments must be carried out and be FORWARDED TO THE CSCI by 18.12.06 (Timescales of 15/02/06, 15/08/06 not fully met). 15/01/07 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 40 34 OP25 13(4)(a) The registered provider must risk 17/12/06 assess each bathroom and toilet in respect of hot water pipes. These pipes must be suitably guarded. Timescales of 12/03/06 and 12/08/06 not fully met. 35 OP25 13(3) 13(4)(a) The registered provider must ensure that water from each hot water outlet remains within the scale of 38oc-43oc at all times. This to include en-suites. Timescales of 01/09/05, 15/02/06 not fully met. One was too high and a number too low. 15/12/06 36 OP26 13(3) The registered provider must ensure that stocks of clean bed linen/ towels are not stored in communal areas. Timescales of 01/02/05,08/07/05, 1/03/06 and 01/08/06 not fully met. Assisted bathroom top floor. 25/01/07 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 41 37 OP26 13(3) The registered provider must ensure that ; Policies on infection control. Laundry procedures. 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 and 01/08/06 not fully met. Also the following must be addressed; Hand wash signs are needed in the laundry. Disposable gloves must be used in the laundry. 30/01/07 38 OP26 13(3) 18(1)(a) The registered provider must recruit to ensure that additional cleaning hours ( to a minimum ) of 30 per week. 30/01/07 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 42 39 OP27 18(1)(a) The registered person/ manager must be able to evidence at all times that; Reviews of staffing levels using a recognised formula are being carried out to ensure that they are sufficient. That evidence is provided to the CSCI to show that this has been done. Consideration must be taken and care hours deducted for activities, laundry and catering duties. 12/01/07 40 OP29 13(6) 19(2) 41 OP30 13(6) 18(1)(a) The registered person must 25/12/06 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. The registered provider must 30/01/07 ensure that induction and foundation training are available. Timescales of 01/03/06 and 01/06/06 not fully met. 42 OP30 18(1)(a) The registered provider must provide evidence to the CSCI of training dates confirmed for staff in respect of dementia training ( accredited). Timescale of 15/02/06 and 25/08/06 not met. 30/01/07 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 43 43 44 OP30 OP31 18(1)(a) 8,9 The registered person must ensure that all staff receive stroke awareness training. The registered provider must employ a suitable manager for the home. Timescale of 30/09/06 not met. In the interim a letter confirming that (K) is that acting manager and a brief summary of her qualifications and experience to be sent to the Halesowen CSCI office. (By 03/01/07) As soon as it is known the position of the pending new plans regarding (SS) Halesowen CSCI office to be informed along with an application to CSCI Central Registration team for the proposed manager of The Beeches. 30/01/07 10/02/07 45 OP33 24 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. 01/02/07 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 44 46 OP35 13(6) 16(2)(l) The registered provider must ensure that a receipt is available for all expenditure of resident money. That these are numbered for ease of auditing and held on the resident finance sheet. Timescale of 07/07/06 not fully met. The chiropodist must also provide individual receipts. The registered provider must ensure that all care staff are supervised at least once every two months (six times per year). Timescales of 01/09/05, 01/06/06 and 01/09/06 not fully met. Work is in progress to meet this requirement. 15/12/06 47 OP36 18(2) 01/02/07 48 OP37 17(2) The registered provider must ensure that all of the required policies and procedures are in place, are up to date and are reviewed annually. Timescales of 28/08/05, 01/04/06 and 01/09/06 not fully met. 01/02/07 49 OP37 17(2) The registered person must ensure that hand over recording processes are Data Protection compatible. 20/12/06 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 45 50 OP38 18(1)(a) The registered provider must ensure the following; That all staff have had; Food hygiene training. First aid training. Infection control training Fire safety/fire drill training twice in any 12 month period. That all fire drills are recorded with staff names and signatures. Training Dates for fire drills and training must be provided to the CSCI by 20/12/06 Timescales of 20/08/06, 01/03/06 and 01/09/06 not met. 01/02/07 51 OP38 16(2)(j) The registered provider must ensure that; The food probe is collaborated regularly and records of these are maintained. Timescales of 01/08/05,d 15/02/06 and 15/07/06 not fully met. 30/12/06 52 OP38 13(4)(c ) 23(2)(c ) The registered provider must ensure that; Bedrails are checked weekly. Wheelchairs are checked at least monthly. That plans are made for an asbestos survey/ risk assessment of the home to be undertaken. 19/12/06 The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 46 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Beeches ( Rowley Regis) DS0000066557.V321373.R01.S.doc Version 5.2 Page 47 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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.V321373.R01.S.doc Version 5.2 Page 48 - 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. 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