Care Home: Beech Grove Care Home

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What the care home does well Current and prospective residents were provided with appropriate written information. This ensured the residents were aware of the services and facilities available in the home. The admission procedure involved an assessment of people`s needs. This enabled the registered manager and prospective residents to determine whether or not their needs could be met within the home. Each resident had a care plan, which provided clear guidance for staff on how best to meet the residents` needs. The daily routines were flexible and designed to meet the wishes of the residents, many of the residents chose to have a lie in and breakfast was served throughout the morning to suit their preferences. The residents spoken to felt they were well cared for and the staff respected their rights to privacy and dignity. One resident wrote in a questionnaire, "Nothing is too muchtrouble for the manager and staff and they work hard to provide a comfortable and friendly atmosphere. I am very happy here". Activities were arranged in line with the needs and choices of the residents, which included trips out on a regular basis into the local area. The residents particularly enjoyed the monthly trip on a canal boat. Varied and wellpresented meals were served. All residents spoken to described the meals as "very good" and "lovely". Visitors were welcome in the home at any time and residents were supported to maintain good contact with their family and friends. The relatives who made comments on the questionnaires were satisfied with the quality of care provided, one person commented, "It is such a relief knowing that my mother has such a caring home". The residents were aware of the complaints procedure and knew who to talk to in the event of a concern. Residents` meetings were held on a regular basis, which gave the residents the opportunity to discuss all aspects of life in the home. The residents were provided with clean comfortable bedrooms. The residents could personalise their rooms, with their own belongings. The sitting and dining areas were decorated in a homely fashion, with a variety of armchairs, footstools, side tables, ornaments and pictures. A good percentage of staff had achieved NVQ level 2 or above. This qualification provided the staff with the necessary knowledge to carry out their role effectively. The registered manager had developed a quality assurance system, which was based on the outcomes for the people living in the home. This meant the residents and their relatives were able to have some input into the future development of the service. What has improved since the last inspection? Following a change in the company name of the registered provider this home is categorised as a new service. What the care home could do better: Accurate records must be maintained in respect to the administration of antibiotic medication. This is to ensure the records precisely reflect the medication received by the residents. All records and checks for new members of staff must be collated and maintained in line with the Care Homes Regulations 2001. This includes obtaining two written references, prior to employment. This is to ensure the staff are properly vetted and the residents are fully protected.The registered manager must ensure the gas installations are tested on an annual basis or as recommended by a gas engineer, to ensure the safety of the residents. CARE HOMES FOR OLDER PEOPLE Beech Grove Care Home St Pauls Street Low Moor Clitheroe Lancashire BB7 2LS Lead Inspector Mrs Julie Playfer Unannounced Inspection 09:15 2nd July 2008 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 Beech Grove Care Home DS0000071171.V364394.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. Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Grove Care Home Address St Pauls Street Low Moor Clitheroe Lancashire BB7 2LS 01200 426057 01200 443695 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) Roseberry Care Centres UK Ltd Mrs Carol Ratcliffe Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: Old Age, not falling within any other category, Code OP - maximum number of places 33 The maximum number of service users who can be accommodated is: 33 New Service 2. Date of last inspection Brief Description of the Service: Beech Grove Residential Home is registered with the Commission for Social Care Inspection to provide personal care and accommodation for 33 Older People. The home is a detached property set in its own grounds in a residential area of Clitheroe. There are private gardens at the rear and raised flower beds at the front of the home with bench seating outside for residents. Ample car parking space is available at the front of the home. Accommodation is provided on two floors in twenty-nine single rooms, ten of which have ensuite facilities and two shared bedrooms with ensuite facilities. A passenger lift provides access to the first floor. There are two lounges and one dining room, leading to a dining room/conservatory. All areas were well maintained. Toilets and bathrooms were within easy reach of the residents’ accommodation. The home is situated close to local facilities and is approximately 15 minutes walk away from Clitheroe town centre. A bus service is available near to the gates of the home. At the time of the inspection, the fees ranged from £346.00 to £390.00 per week. Additional charges were payable for hairdressing, toiletries and personal newspapers. Information was made available to current and prospective residents in the form of a brochure, service users guide and statement of purpose. Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience Good quality outcomes. A key unannounced inspection, which included a visit to the home, was conducted at Beech Grove on 2nd July 2008. At the time of the inspection there were 30 people accommodated in the home, plus one person in hospital. The inspection comprised of spending time with the residents, looking round the home, reading some of the residents’ care records and other documents and discussion with the staff and the registered manager. As part of the inspection process we (the commission) used “case tracking” as a means of gathering information. This process allows us to focus on a small group of people living at the home, to assess the quality of the service provided. Prior to the inspection, the registered manager completed an Annual Quality Assurance Assessment known as AQAA, which is a detailed self assessment questionnaire covering all aspects of the management of the home. This provided useful information and evidence for the inspection. Satisfaction questionnaires were sent to the home for distribution to the staff and the residents. Nine questionnaires were returned from people living in the home and three questionnaires were received from staff. It was noted that many of the residents’ relatives had assisted their family member to complete a questionnaire and many had added their own comments about the home. The responses from the questionnaires were collated and contributed towards the overall findings. What the service does well: Current and prospective residents were provided with appropriate written information. This ensured the residents were aware of the services and facilities available in the home. The admission procedure involved an assessment of people’s needs. This enabled the registered manager and prospective residents to determine whether or not their needs could be met within the home. Each resident had a care plan, which provided clear guidance for staff on how best to meet the residents’ needs. The daily routines were flexible and designed to meet the wishes of the residents, many of the residents chose to have a lie in and breakfast was served throughout the morning to suit their preferences. The residents spoken to felt they were well cared for and the staff respected their rights to privacy and dignity. One resident wrote in a questionnaire, “Nothing is too much Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 6 trouble for the manager and staff and they work hard to provide a comfortable and friendly atmosphere. I am very happy here”. Activities were arranged in line with the needs and choices of the residents, which included trips out on a regular basis into the local area. The residents particularly enjoyed the monthly trip on a canal boat. Varied and wellpresented meals were served. All residents spoken to described the meals as “very good” and “lovely”. Visitors were welcome in the home at any time and residents were supported to maintain good contact with their family and friends. The relatives who made comments on the questionnaires were satisfied with the quality of care provided, one person commented, “It is such a relief knowing that my mother has such a caring home”. The residents were aware of the complaints procedure and knew who to talk to in the event of a concern. Residents’ meetings were held on a regular basis, which gave the residents the opportunity to discuss all aspects of life in the home. The residents were provided with clean comfortable bedrooms. The residents could personalise their rooms, with their own belongings. The sitting and dining areas were decorated in a homely fashion, with a variety of armchairs, footstools, side tables, ornaments and pictures. A good percentage of staff had achieved NVQ level 2 or above. This qualification provided the staff with the necessary knowledge to carry out their role effectively. The registered manager had developed a quality assurance system, which was based on the outcomes for the people living in the home. This meant the residents and their relatives were able to have some input into the future development of the service. What has improved since the last inspection? What they could do better: Accurate records must be maintained in respect to the administration of antibiotic medication. This is to ensure the records precisely reflect the medication received by the residents. All records and checks for new members of staff must be collated and maintained in line with the Care Homes Regulations 2001. This includes obtaining two written references, prior to employment. This is to ensure the staff are properly vetted and the residents are fully protected. Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 7 The registered manager must ensure the gas installations are tested on an annual basis or as recommended by a gas engineer, to ensure the safety of the residents. 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. Beech Grove Care Home DS0000071171.V364394.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 Beech Grove Care Home DS0000071171.V364394.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): 1, 2, 3, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home had their needs properly assessed and they were provided with appropriate written information to enable them to make an informed choice about where to live. EVIDENCE: Written information was available for the residents in the form of a statement of purpose and service users guide. The guide had been distributed to each resident and was available for reference in the entrance hall. People spoken to confirmed they had received a copy of the service users guide and said that it was easy to read and understand. A brochure had also been produced which offered current and prospective residents with a useful overview of the services and facilities available in the home. The service users guide included the necessary information to cover regulatory requirements. All the residents who completed a questionnaire indicated they received enough information prior to Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 10 moving into the home. Copies of the last inspection report were available for reference on a notice board in the entrance hall. From the personal files seen it was evident that the residents had been issued with a contract. The contracts had been signed by the residents and/or their representative and included information about the level and payment of fees and the rights of the residents. The contract was easy to read and was presented in a clear format. This meant the residents and their relatives were aware of the terms and conditions of residence. The ‘case tracking’ process demonstrated that the residents had their needs assessed prior to admission by a social worker and/or manager and a member of the staff team. Wherever possible the member of staff was on duty when the person was admitted to the home to provide the prospective resident with reassurance and support. Copies of the preadmission assessments were seen on the residents’ files. The assessments covered a range of individual needs and all sections of the assessments had been completed. The registered manager confirmed that admissions were not made to the home in the absence of a full needs assessment. This meant the registered manager was confident that the staff had the necessary skills and knowledge to meet the assessed needs of the prospective resident. Copies of letters were seen of the residents’ files to indicate the registered person had informed prospective residents in writing, that having considered the assessment, their needs could be met in the home. The registered manager said that prospective residents were encouraged to spend time in the home prior to making the decision to move in. This enabled the resident to meet other residents and staff and experience life in the home. A relative who had made comments on a resident’s questionnaire stated, “Having visited several homes, I knew immediately I walked into Beech Grove that this was the right one, the atmosphere and friendliness was just right”. Following admission, the contract stated that a trial period of six weeks was offered to every resident, so that both parties could make sure the placement was successful and the resident’s individual needs could be met. Beech Grove Care Home DS0000071171.V364394.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): 6, 7, 8, 9 and 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 received by residents was based on their individual assessed needs. Care practice took full account of the residents’ privacy and dignity. EVIDENCE: Three people’s files were looked at in detail as part of the case tracking process. All three files seen contained a care plan, which was based on the person’s assessment of needs. Personal profiles known as person centred care assessments had been incorporated into the care plan documentation and provided details about past life experience, important events and likes and dislikes. This information was useful for staff to stimulate meaningful conversations with each resident. The plans were supported by daily records of personal care, which provided information on changing needs and any recurring difficulties. These records were detailed and the residents’ needs were described in respectful and sensitive terms. Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 12 The main care plan was supplemented by a daily living plan, which provided information about each resident’s preferred routines and their social/emotional and religious/cultural needs. All staff who completed a questionnaire indicated that they were “always” given up to date information about the needs of the residents. One person wrote, “Care plans are updated and reviewed monthly or as care changes”. This meant the staff had access to information about the residents’ currents needs and how best to meet these needs. The residents confirmed they were involved in the care planning process and recalled discussing their care needs with a member of staff. The residents had also signed their care plans wherever possible to indicate their agreement and participation. This gave the residents the opportunity to have an active input into the delivery of the care. Written evidence seen in the residents’ files demonstrated that the care plans were reviewed each month and the care plans had been updated in line with changing needs. Healthcare needs were considered during the assessment process and there were records to indicate that the residents accessed NHS services and received specialist support as necessary, for instance the District Nursing Team. Charts were maintained to monitor the residents’ weight, to ensure any fluctuations were noted and acted upon. The registered manager also regularly analysed the number and frequency of falls, in order to identify any pattern and thus put arrangements in place to avoid further accidents. Risk assessments in respect to moving and handling, pressure sores, falls and nutrition had been incorporated into the care plan records. The risk assessments were supported with risk management strategies, to provide staff with guidance on how to manage and reduce any identified risks. The residents spoken to felt the staff respected their rights to privacy and dignity and all made complimentary remarks about the staff, for instance one person said, “All the staff are very good, I like them all”. The residents, who completed a questionnaire, indicated that they received the care and support they needed. One person commented, “Staff always have time to explain things”. The staff were observed to interact with the residents in a positive manner and they referred to the residents in their preferred term of address. Discussions with staff demonstrated an awareness of treating people with respect and considering their dignity when providing personal care. Policies and procedures were in place to cover all aspects of the management of medicines and were available for staff reference in the medical room and the policy and procedure file. The home operated a monitored dosage system of medication, which was dispensed into blister by the local pharmacist. All staff designated to administer medication had completed accredited medication Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 13 training. Appropriate records were maintained in respect to the receipt, administration and disposal of medication and charts had been placed in residents’ bedrooms to record the administration of prescribed creams. However, it was noted that accurate records had not always been maintained in relation to the administration of antibiotic medication and there were no protocols seen in respect to the administration of variable dose and “as necessary” medication. Suitable arrangements were in place for the storage and administration of controlled drugs. Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The residents were supported to live a full and stimulating lifestyle and maintain good relationships with their families. EVIDENCE: The residents’ preferences in respect of social activities were recorded and considered as part of the assessment process. A broad range of activities were planned and implemented by the staff and the activities coordinator. The activities coordinator was new to the home and had recently introduced new activities such as Tai Chi. Other activities included bingo, dominoes, quizzes, card games, jigsaws and discussion groups. A volunteer also ran a gardening club and residents were able to join in with planting or just watch if they wished to. The residents could go on monthly canal trips and other trips out of the home to places of interest such as Eddisford Bridge. One resident who completed a questionnaire commented, “I particularly enjoy the trips out, such as the canal boat trip”. Residents spoken to during the inspection said they enjoyed participating in the various activities, one person commented, “The canal trip is marvellous and I enjoy the whist drives”. The residents were Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 15 consulted at monthly meetings about what activities they wished to pursue the following month. Information about forthcoming activities was displayed on a notice board in the corridor. On the day of the inspection the residents were observed to be watching television, reading magazines and chatting to staff. In the afternoon the residents listened to music outside in the garden and participated in Tai Chi. The residents were supported to continue with their chosen religion. Representatives from local churches visited the home on a regular basis and an ecumenical service was held on the last Friday of every month for all those residents, who wished to participate. The routines were flexible and were primarily designed to meet the needs of the residents. The residents spoken to said they had a choice in the times they got up and went to bed. One person said, “I can do as I like, I get up when it suits and I go to bed when I’m tired”. The staff were observed to seek the residents’ views throughout the inspection and the residents spoken to said they felt comfortable to comment on life in the home. The residents had the opportunity to develop and maintain important personal and family relationships. There were no restrictions placed on visiting times and residents were able to receive their guests in the privacy of their own rooms, should they wish to do so. The relatives who commented on the questionnaires were satisfied with the overall standard of care, one person wrote, “In the time that my mother has been at the home, I have been impressed by the patient attention she has received”. Similar comments were received from relatives during the inspection, one person said, “They have been so good, the care has been brilliant”. All the residents spoken to said they liked the food provided. There was a choice of food and residents were asked prior to each meal what choice they wished to make. Breakfast was served throughout the morning to suit the preferences of residents, who wished to have a lie in. The menu was displayed on the wall in the dining room. Menu planning was discussed with the residents at the monthly meetings and all residents were able to make suggestions for forthcoming meals. The meal served on the day inspection looked appetising and was well presented. Residents were given sensitive and appropriate support to eat their meals. Drinks and snacks were served throughout the day and at other times on request. Residents were observed asking for drinks during the inspection and were promptly served by staff. Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to express their views and had access to a clear complaints procedure. Policies and procedures were in place to respond effectively to any allegations or suspicions of abuse. EVIDENCE: Both informal and formal arrangements were in place to ensure the registered manager and staff listened to and acted on the views and concerns of residents. This was achieved during daily conversation, one to one discussion, satisfaction questionnaires and residents’ meetings. The residents spoken to said, they felt comfortable expressing their views and were aware of whom to speak to in the event of a concern. The complaints procedure was included in the statement of purpose and service users guide and was also displayed in the entrance hall and on a wall going into the dining room. The residents had been issued with their personal copy of the complaints procedure as part of the service users guide. The procedure contained the necessary information and included the relevant telephone numbers should a resident wish to raise a concern. Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 17 According to information supplied in the AQAA the registered manager had not received any complaints during the last twelve months. An appropriate recording system was in place in the event of a complaint being made. The policies and procedures for safeguarding vulnerable adults were available and provided guidance to staff should they suspect or witness any harmful practice. However, the procedure required updating to include the role of the Commission and details about the referral process to the POVA (Protection of Vulnerable Adults) list. Information about safeguarding vulnerable adults was incorporated into the induction training and staff received specific tuition as part of their NVQ training and by means of a training DVD, which incorporated a questionnaire to test understanding. The staff also had access to a whistle blowing procedure. The procedures associated with the protection of vulnerable adults had been fully discussed at staff meetings, to ensure staff were aware of how and where to direct any concerns. Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 18 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, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents were provided with a clean, pleasant and well-maintained environment, which promoted their comfort and independence. EVIDENCE: Beech Grove is a detached property set in its own grounds. The original building is 130 years old and was built as a vicarage to serve St Paul’s church. The home is located close to local shops and the bus stops just outside the main gate. Accommodation is provided in twenty- nine single bedrooms, ten of which have ensuite facilities and two shared bedrooms, with ensuite facilities. Shared space is provided in two lounges, a dining room leading to a dining room/conservatory. The toilets and bathrooms are within easy reach of the residents’ accommodation. The residents had free movement around the home and were able to choose where they wished to spend their time. Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 19 Residents were observed to be sitting in different parts of the home during the inspection. It was evident from a partial tour of the premises that residents had personalised their rooms with their own belongings and decoration was a good standard throughout. The residents said they liked their bedroom, one person said, “My room is very nice, I’m happy with it”. According to information supplied in the AQAA the residents could choose the colour they preferred for the walls, carpet and curtains. Residents could also request to move rooms, depending on availability. Several improvements had been made to the premises over the last twelve months. Most of the home had been redecorated and new carpets and furniture had been purchased as necessary. All radiators had been fitted with guards and the emergency lighting system had been upgraded. In addition an external facility for smokers had been installed in the garden and the tiling had been replaced in the toilets. Established arrangements were in place to report repairs and routine maintenance appropriate records were maintained of the work completed. A person was employed for 30 hours a week to carry out the general maintenance. This meant any routine problems with the building were promptly rectified. The home was clean and odour free at the time of the inspection. The residents spoken to said that a good level of hygiene was maintained at all times. Beech Grove Care Home DS0000071171.V364394.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the residents benefited from well trained staff, the recruitment systems did not always ensure that staff were fully vetted before commencing work in the home. EVIDENCE: A staff duty roster was drawn up in advance and provided a record of the staffing levels deployed in the home. The roster seen indicated that four care staff, plus a manager were on duty during most of the waking day and three members of staff were on waking watch duty. The registered manager confirmed that all staff providing personal care were aged over 18 and all staff left in charge of the building were aged over 21. According to the information provided in the AQAA, there was a low turnover of staff and agency staff were not employed in the home. A recruitment and selection procedure was available and a checklist was used to track documentation required for the recruitment of new staff. However, the procedure required updating to fully reflect current regulatory requirements. The files of two new members of staff were looked at in detail. It was evident both applicants had completed an application form, provided a full working history and had attended the home for an interview. CRB (Criminal Records Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 21 Bureau) and POVA checks had also been obtained. However, it was noted that the references for one person had been obtained after she had commenced working in the home. This meant the necessary checks had not been in place at the time of employment. Further to this, correspondence was received by the manager after the inspection, to confirm that stringent arrangements had been put into place to prevent a reoccurrence of this situation. Arrangements were in place for all new employees to undertake an in house induction programme and complete a “Skills for Care” induction. The latter provided underpinning knowledge for NVQ level 2. According to information supplied by the registered manager, 12 out of 14 members of staff had achieved NVQ level 2 or above, which equated to 86 of the overall staff team. All the staff who completed a questionnaire confirmed they received training relevant to their role and all commented that they were well supported by the management team with any training needs. Staff attended both internal and external training courses and had at least three paid days training a year. The manager was able to track staff training by the means of a board, which was displayed in the office. The information on the board showed at a glance what the training had been completed and what training required updating. Beech Grove Care Home DS0000071171.V364394.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, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management and administration practices were effective in ensuring the home was run in the best interests of the residents. EVIDENCE: The registered manager had overall responsibility for the management of the home and had completed the Registered Manager’s Award and NVQ level 4 in Care and Management. The manager had been registered at Beech Grove for five years and prior to this had several years experience working in various residential settings. The registered manager had completed several courses over the last 12 months to update her knowledge and skills. Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 23 The management approach was consultative and there were established ways of working to consult the staff and residents on an ongoing basis. Relationships within the home were positive and staff spoke to and about the residents with respect. One member of staff who completed a questionnaire commented, “Our service meets the needs of the residents, everyone is treated as an individual with different needs. I am well supported by our manager and we all work well together as a team”. There was a programme in place for staff supervision and the topics discussed during supervision were recorded on a suitable format. The registered manager had delegated the responsibilities for supervision to senior staff, who had been assigned specific groups of staff. In addition to supervision, staff were given the opportunity to attend regular staff meetings and had an appraisal of their overall work performance once a year. The service achieved an ISO 9001 Award in 2001, which is reaccredited on an annual basis. The registered manager had developed a comprehensive quality assurance system to monitor the quality of the service received by people living in the home. Satisfaction questionnaires had been distributed to residents, their relatives and visiting professional staff each quarter. The results of the questionnaires had been collated and fed back to all interested parties, to inform them of the outcome of the survey. Audit systems were in place to monitor many operational aspects of the home, for instance care plans, supervision, accidents and health and safety. A development/business plan had been produced setting out the objectives for the forthcoming year based on the results of the quality monitoring process. This document linked with the AQAA questionnaire submitted to the Commission. All sections of the AQAA were fully completed and the information provided gave a clear picture of the current situation within the service and the planned areas for development. Appropriate arrangements were in place for handling money, which had been deposited with the home by or on behalf of a resident. A random check of monies was found to be correct. Records were also maintained by the company’s administrator in respect to the amount of fees charged and received. The residents’ personal finances were regularly audited on an unannounced basis by the Regional Accountant. There was a set of health and safety procedures available, which included the safe storage of hazardous substances. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. Documentation seen during the inspection and information supplied by the registered manager indicated the electrical and fire systems were serviced at regular intervals. However, it was noted that the gas safety certificate expired in January 2008. Further to this, correspondence was received from Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 24 the registered manager after the inspection to confirm the gas installations had been tested and the safety certificate had been renewed. The fire log demonstrated the staff had received instruction about the fire procedures during their induction and they had participated in regular fire drills. Following recommendations made by a Fire Officer, the intumescent strips on some doors had been replaced. The strips swell in the event of a fire and close any gaps between the door and frame to minimise fire penetration. Risk assessments had been completed in respect to safe working practice topics. Arrangements were in place to record accidents and incidents in the home and the Commission had been notified as appropriate of any significant event in the home. Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 4 X 3 Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 (2) Requirement Timescale for action 02/07/08 2 OP29 3 OP38 Accurate records must be maintained at all times in respect to the administration of antibiotic medication. This is to ensure the record precisely reflects the medication received by the residents. 17, 18, 19 All records and checks for new 02/07/08 Schedule members of staff must be 2 (as collated and maintained in line amended) with the Care Homes Regulations 2001. This includes obtaining two written references, prior to employment. This is to ensure the staff are properly vetted and the residents are fully protected. 13 (4) (c) The registered manager must 20/07/08 ensure the gas installations are tested on an annual basis or as recommended by a gas engineer, to ensure the safety of the residents. Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 27 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 OP9 Good Practice Recommendations Protocols should be drawn up to set out the criteria for all variable dose and “as necessary” medication. This is to ensure such medication is administered consistently in line with the residents’ needs. The safeguarding adults procedure should be updated to include information on the role of the Commission and the referral process to the POVA list. This is to ensure the correct response is made in the event of an alert. The recruitment and selection procedure should be updated to reflect all current regulatory requirements. This is to ensure a robust procedure is followed when recruiting new staff. 2 OP18 3 OP29 Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Beech Grove Care Home DS0000071171.V364394.R01.S.doc Version 5.2 Page 29 - 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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