Care Home: Beech Hill Grange Limited

Similar services:

• Maple Lodge
• Heathlands
• Aston Court Nursing Home
• Breme
• Ravenhurst
• Bank House
• Inspirations
• Ashcroft Hollow Nursing Home

What the care home does well Prospective residents are supplied with comprehensive written details to assist them in making an informed decision about coming to live at the home. The home gathers sufficient information about the prospective residents to enable them to meet the person`s needs at the time of admission.People`s health care needs are being well met so that their well-being is promoted. Medications are administered at the prescribed time to promote peoples health. The home provides a varied social activities programme that meets the needs of people and provides them with interests to improve the quality of their lives. A wholesome and varied diet is offered and specialist diets are catered for to meet the needs of the individuals. People who raise concerns or make a complaint are confident that their views will be listened to. A homely and comfortable living environment has been achieved for the people who live there so that they feel safe and well cared for. Comments from the people living at the home included: "I have been here a few years, it`s a lovely place. Nothing is too much trouble for them." "Its very nice here, I would recommend it to anyone." "I like living here, its very comfortable. The staff are very nice, always have time for you, don`t ever feel rushed." The Manager is experienced, skilled and knowledgeable and oversees the dayto-day management of the home so that it is run in the best interests of the people who live there. A quality assurance programme has been developed to evidence that continuous and sustained improvements are ongoing, and arrangements in respect of health & safety are robust and prevent the risk of injury occurring. What has improved since the last inspection? All the requirements from the last inspection have been met so that the home is run safely in a way that complies with the legislation. The Manager and the staff team have worked extremely hard to maintain a good standard of care for the people living at the home. The new care planning and risk assessing systems are much improved, and provide comprehensive guidance for the staff to ensure they have the information they need to meet the individual`s specific needs. The monthly wellness assessments undertaken by the nurses ensure that continuous monitoring of the individual`s health and welfare needs takes place. The staff training and development programme is improved and ensures that staff have the skills, knowledge and support they need to meet people`s needs. What the care home could do better: The home has been proactive in responding to residents feedback to improve the service, and it is hoped that they will continue to respond to feedback to make further improvements to the service. CARE HOMES FOR OLDER PEOPLE Beech Hill Grange Limited 1 Beech Hill Road Wylde Green Sutton Coldfield West Midlands B72 1DU Lead Inspector Sara Gibson Unannounced Inspection 19th June 2008 08:30 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 Hill Grange Limited DS0000024822.V365779.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 Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Hill Grange Limited Address 1 Beech Hill Road Wylde Green Sutton Coldfield West Midlands B72 1DU 0121 373 0200 0121 384 7500 rachel.gilbert2@btinternet.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Judith E Middleton Manager post vacant Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Old age, registration, with number not falling within any other category (36), of places Terminally ill over 65 years of age (36) Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the manager succesfully completes the Registered Managers Award (NVQ Level 4 in Care Management) or equivalent by April 2005 That one named person under 65 years of age at the time of admission can continue to be accommodated and cared for in this Home. 24th May 2007 Date of last inspection Brief Description of the Service: Beech Hill Grange provides accommodation and nursing care to thirty-six residents. The home is situated in Wylde Green with good access to nearby Sutton Coldfield and Birmingham city centre. There are bus routes in close proximity and off road parking at the front of the premises to accommodate ten vehicles. The premises consist of a converted and sympathetically extended residential property and blends well with the other residential properties in the area. The home has recently been extended to increase the communal areas, and the new conservatory accommodates the dining room. The ground floor also has two lounges, and the garden can be accessed from the conservatory. Bedrooms are located on the ground and first floors consisting of single and some shared rooms, those added at a later date have en-suite facilities. Communal toilets and assisted spa baths are available on each floor, and a call bell system is available in all areas. Kitchen and laundry services are provided on site. All areas of the home can be accessed by a passenger lift and there is a range of equipment to assist residents with mobility problems, pressurerelieving equipment for those prone to pressure sores and the majority of the beds are of the hospital type. The fee rate varies from £550 to £700 depending on the type of room available and the facilities in the room. The last CSCI inspection report is available in the home should residents or visitors wish to access it. Beech Hill Grange Limited DS0000024822.V365779.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 that the people who use this service experience good quality outcomes. The focus of our inspection is upon outcomes for people who live in the home and their views of the service provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and focuses on aspects of service provision that need further development. One inspector undertook the key fieldwork visit to the home, and the staff assisted throughout. The home did not know we were visiting on that day. There were thirty-four people living at the home on the day of the visit. Information was gathered from speaking to and observing people who lived at the home, three people were “case tracked”, and this involved discovering their experiences of living at the home by meeting and observing them, looking at medication and care files, and reviewing areas of the home relevant to these people, in order to focus on outcomes. Case tracking helps us to understand the experiences of people who use the service. Staff files, training records and health and safety files were also reviewed. Random questionnaires were sent out to staff and people who live at the home in order to gain their views about the service, however none had been returned at the time of writing this report. During our visit we spoke to four people who live at the home and seven staff members. Comments received about the home were generally positive. These will be included throughout the report. Prior to the inspection the home had completed an Annual Quality Assurance Assessment (AQAA) and returned it to us. This gave us some information about the home, staff and people who live there, improvements made, and plan for further improvements, which was taken into consideration. Regulation 37 reports about accidents and incidents in the home were reviewed in the planning of this visit. What the service does well: Prospective residents are supplied with comprehensive written details to assist them in making an informed decision about coming to live at the home. The home gathers sufficient information about the prospective residents to enable them to meet the person’s needs at the time of admission. Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 6 People’s health care needs are being well met so that their well-being is promoted. Medications are administered at the prescribed time to promote peoples health. The home provides a varied social activities programme that meets the needs of people and provides them with interests to improve the quality of their lives. A wholesome and varied diet is offered and specialist diets are catered for to meet the needs of the individuals. People who raise concerns or make a complaint are confident that their views will be listened to. A homely and comfortable living environment has been achieved for the people who live there so that they feel safe and well cared for. Comments from the people living at the home included: “I have been here a few years, it’s a lovely place. Nothing is too much trouble for them.” “Its very nice here, I would recommend it to anyone.” “I like living here, its very comfortable. The staff are very nice, always have time for you, don’t ever feel rushed.” The Manager is experienced, skilled and knowledgeable and oversees the dayto-day management of the home so that it is run in the best interests of the people who live there. A quality assurance programme has been developed to evidence that continuous and sustained improvements are ongoing, and arrangements in respect of health & safety are robust and prevent the risk of injury occurring. What has improved since the last inspection? All the requirements from the last inspection have been met so that the home is run safely in a way that complies with the legislation. The Manager and the staff team have worked extremely hard to maintain a good standard of care for the people living at the home. The new care planning and risk assessing systems are much improved, and provide comprehensive guidance for the staff to ensure they have the information they need to meet the individual’s specific needs. The monthly wellness assessments undertaken by the nurses ensure that continuous monitoring of the individual’s health and welfare needs takes place. The staff training and development programme is improved and ensures that staff have the skills, knowledge and support they need to meet people’s needs. Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beech Hill Grange Limited DS0000024822.V365779.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 Hill Grange Limited DS0000024822.V365779.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): 1,3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are supplied with comprehensive written details to assist them in making an informed decision about coming to live at the home. The home gathers sufficient information about the prospective residents to enable the prospective service user to be confident that their needs will be met. EVIDENCE: The home understands the importance of having sufficient information when choosing a care home. They have developed clear information to help prospective individuals choose a home that will meet their needs and preferences. The information is contained in the home’s Statement of Purpose which clearly sets out the home’s aims and objectives, and is supported by a Service User Guide that details what services the home can provide, the qualifications and Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 10 experience of the staff, and what levels of service the prospective resident can expect, it also includes photographs of the home and is laid out in an easy to read guide. The guide can be made available in other formats such as large print, other languages and Braille. Prospective residents are given a copy of the guide, and people living at the home also have a copy for them to refer to if needed. The certificate of registration and public liability insurance certificate are on display, and a copy of the previous inspection report is available for people to access if they wish. Admissions are not made to the home until a full needs assessment has been undertaken. This assessment is carried out by a senior member of staff, and involves the individual and their family. The assessment is very comprehensive and once completed gives a very good picture of the individual and their specific needs. The assessment takes into account the individuals diagnosis and reason for admission, and looks at their mobility, cognitive reasoning, skin integrity, continence, and communication, eating habits and sleep pattern plus numerous other areas. Three assessments were looked at and were comprehensively completed by members of the nursing staff. The home does not offer intermediate care services. Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health care needs are being well met so that their wellbeing is promoted. Medications are administered at the prescribed time to promote peoples health. EVIDENCE: People living at the home receive individualised personal and healthcare support based on their specific needs as discussed during the pre-assessment. Their needs including specialist health, nursing and dietary requirements are identified and clearly recorded in a care plan to ensure that staff have the information required to meet those needs. Staff said: “Care plans are very good, informative and easy to use, very helpful if we have a new resident.” During the inspection three peoples care plans were examined in detail, and a further two were partly looked at. The care plans were detailed, informative and provided good guidance for staff to enable them to meet the needs of the Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 12 individual person. Each care plan has areas relating to the tasks care staff carry out and tasks for the nursing staff. The care plans seen stated the individual identified need, the plan for meeting the need, the agreed goals or outcomes and the date for review of the plan and covers all aspects of daily living. Short-term plans are introduced into the individuals file for their care if they have a chest infection or urinary infection, or are being treated with a course of antibiotics. Care plans state the individuals preferred choices, for example: “Mrs A needs full assistance to dress. She likes to wear dresses or skirts with a cardigan, vest and petticoat with knee high tights and slippers. She has glasses but declines to wear them.” Individuals and their families are involved in the care planning process and participate in monthly reviews to ensure specific needs are identified. The care plans foster individuality, freedom of choice, independence and dignity. Each month one of the homes nursing team undertakes a Monthly Wellness Assessment with each person living at the home. This assessment covers all areas including mobility, skin integrity, continence, sleep patterns, eating, and weight and pain control. Any changes identified during this assessment are noted in the care plan and risk assessments to ensure the individuals needs are continuously met. Daily handover sheets are given to each member of staff at the beginning of their shift that gives them information on each individual, their specific needs, dietary requirements, and information on any specific tasks that need to be carried out. The staff find these sheets useful to refer to at a glance. Risk assessments for moving and handling, pain, falls, medication, nutrition, pressure sores, use of bed rails and wound assessing were seen in the care plans. Risk assessments are comprehensive and specific to the individual person. Reviews are undertaken monthly or as changes occur to ensure people living at the home are safe, potential risks are minimised and staff have the current guidance to follow. The home maintains good contact with other health professionals such as district nurses, tissue viability nurses, continence nurses, physiotherapists and they have a very good link with the Alzheimer’s Society for guidance on dementia care. The contact with the health professionals extends to advice, information and training for staff. Medication practices are safe. There had been an issue at the last inspection where the morning medication round was taking too long and people were not receiving their medication at the appropriate time. The home has now rectified this issue and people now receive their medication appropriately. Nursing staff administer the medication and observe each person whilst they are taking their Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 13 medication, the medication administration chart is then signed and dated to say the medication has been taken. This is good practice and ensures medication is taken safely and appropriately. Medication administration charts were looked at, and all were found to be completed correctly, with no hand written entries. The home had recently undergone an external pharmacy inspection and no issues had been identified. People were supported by staff to choose clothing appropriate for the time of the year which reflected individual cultural, gender and personal preferences. Staff were observed assisting individuals in a sensitive manner, giving choices about the food they ate, whether they would like a bath or shower, and encouraging people to participate in the activities on offer. Beech Hill Grange Limited DS0000024822.V365779.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 good. This judgement has been made using available evidence including a visit to this service. The home provides a varied social activities programme that meets the needs of people and provides them with activities and interests to improve the quality of their lives. A wholesome and varied diet is offered and specialist diets are catered for to meet the needs of the individuals. EVIDENCE: The reception area of the home has an information board on display for the people living at the home. The board displays information on activities, dates of residents meetings, minutes of the last resident meeting, a report giving feedback on the last satisfaction survey carried out, information on advocates and dates of future church services so that people know what is happening in the home. The home has a dedicated Activity Co-ordinator to support people with their interests. There is a programme of activities taking place seven days a week, and this programme is displayed in the reception area. Activities include: Board games, crafts & cards, flower arranging, exercise classes, crossword club, dominoes, bingo, knit & knatter, the Saturday quiz, music, manicures, Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 15 Friday film night, classical music plus monthly church services for Catholics and Methodists. People at the home said: “The activities are very good there is always something to do, lots going on.” “The activities are very good, I enjoy the quizzes and the crosswords.” There is a dedicated activity room in the home that is very popular with the people living there. External tutors come in weekly to teach art, and there are a number of paintings on display done by some very talented residents. Fortnightly ladies clubs and gentleman’s clubs are held with activities specific to gender. These have proven to be very popular with the people living at the home. Residents and relatives meeting are held every two months. At the last meeting fifteen residents and relatives participated, and the minutes of the meeting demonstrate that staff listen and respond to residents suggestions The family input at the home is very good. Family and friends are encouraged to visit, to have a meal at the home and to participate in the activities. A number of the people living at the home often go out with visitors for the day. This allows close relationships to be maintained, and gives the people living at the home a sense of “family life”. One person said: “My family visit every week, and they take me out.” Varied diets are catered for at the home including diabetic, soft, gluten free and cultural meals. The menu’s are extensive and are changed every four weeks. On the day of inspection the menu included juice, cereals, grapefruit or prunes, full English breakfast, toast, tea and coffee at breakfast. For lunch there was a choice of sherry or fruit juice, sausages with onion gravy, creamed potatoes and vegetables or cold poached salmon with savoury rice. Summer fruits pudding, lemon meringue pie, and cheese and biscuits were on offer for dessert. At teatime people could choose from mushroom soup, sandwiches, spaghetti bolognaises, bread and jam, bananas, trifle, jelly, fruit and cream, and cakes and pastries. People living at the home said: “The food is fantastic, lots of choice and well cooked.” “The food is lovely, good choices.” “The food is lovely, very tasty, always served nicely. I have no complaints at all.” A new large conservatory has been built and is used as the dining room; it is fitted to a very high standard, and provides a very pleasant dining experience. Tables are beautifully laid with matching tablecloths, linen napkins, and condiments on the tables to enhance the social aspects of mealtimes. Beech Hill Grange Limited DS0000024822.V365779.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. People who raise concerns or make a complaint are confident that these will be dealt with effectively and their views listened to. Staff have access to the policy regarding adult protection and receive training to ensure that they possess the knowledge and skills to respond appropriately to allegations of abuse. EVIDENCE: The complaints procedure at the home is robust. There is a clear complaints policy on display in the home and all complaints are documented. The home has received nineteen complaints in the last year, although they are mainly grumbles rather than complaints. When the Manager took up her post last year she wanted to show residents, families and staff that any concerns are taken seriously, are comprehensively detailed, followed up and acted upon. So she uses the concerns received as examples to learn from in staff meetings and supervision sessions. Care staff spoken to said” Residents don’t really complain, if they did, depending on the complaint we would try and sort it out there and then, or refer it to the Manager.” Protection of Vulnerable Adults (POVA) policies are clear and detailed. Adult Protection and Whistle blowing policies are available for staff to access at any time. Staff have received training in POVA including whistle blowing. Staff Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 17 spoken to said “We would report any concerns to the Manager”. The staff had a good awareness of POVA, and stated that the Manager is very approachable and would be easy to talk to if they had any concerns. Beech Hill Grange Limited DS0000024822.V365779.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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A homely and comfortable living environment has been achieved for the people who live there so that they feel safe and well cared for. EVIDENCE: Information for the people living in the home was displayed around the home including activity programmes, advocacy information, and photo boards with the staff teams listed. In the reception area there is a suggestions box with comment cards available for anyone to use, and evidence of the homes insurance and CSCI registration certificates are on display. There is signage throughout home to guide people to the appropriate areas. The home is decorated, furnished and fitted to a very high standard. Maintenance issues and repairs are attended to promptly and the general Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 19 housekeeping is of a good standard, no odours were present and it was all very clean and fresh. New assisted spa bathrooms have been fitted on each floor, which have improved the opportunities for people to have their personal hygiene needs met in a relaxing environment. It was noted that personal toiletries were left in the bathroom and not returned to the individual’s bedroom, this could lead to the toiletries being used for other people, and a potential risk of cross infection. Toilet areas are clean with wash hand basins complete with paper towels and liquid soap to safely manage infection control. The bedrooms seen during the inspection were spacious and comfortable, and had been personalised with the individuals own photos and ornaments, and in some cases items of their own furniture to reflect their personal taste, gender and culture. One person said: “My room is very nice, very comfortable. I’ve got a lot of my own things in there like photos and ornaments.” The only issue of note is that the Managers office is located on the third floor and is not accessible to residents as it is up a narrow steep flight of stairs. The Manager has identified this as a problem, and is working with the owner of the home to locate a more suitable area for the office. The garden area at the rear of the home is easily accessed, well tended and has a number of small seating areas for people living at the home to make use of. Beech Hill Grange Limited DS0000024822.V365779.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 good. This judgement has been made using available evidence including a visit to this service. Staffing levels are well maintained to ensure people living at the home receive care from appropriately trained and robustly recruited staff in a competent and safe manner. EVIDENCE: Staffing levels at the home are well maintained to meet the needs of the people living at the home. The rota was seen for the next month and shows that seven care assistants plus a Registered Nurse, Care Manager, Administrator and Manager are on duty during the day. The Care Manager stated that they always have an extra care assistant on duty in case of sickness, or an emergency. Staff are allocated to work in three teams in the home. Each team cares for twelve individuals in the home exclusively. Staff spoken to in each team know their residents very well, and the care given is of a high standard. Comments from people living at the home included: “Nothing is too much trouble for them.” “The girls are very kind and we have good fun.” “The staff are very nice, always have time for you, don’t ever feel rushed.” Robust recruitment procedures safeguard the people living at the home. Three care assistants and nurse’s recruitment files were sampled and all the relevant Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 21 checks had been carried out prior to the staff member starting work at the home. New staff undergo an induction programme and work with a more experienced staff member until they feel confident to work on their own. The Manager is in the process of rewriting the induction programme based on the “Skills for Care” modules to ensure that all areas of care practice are covered during the induction. The culture and gender mix of the staff team reflected the culture and gender mix of the people living at the home so that care is provided in an understanding way. From talking to staff and observing them during the day it was evident that staff morale was good, and the interaction with the people living at the home was excellent. Staff spoken to said that there was a good staff team at the home and they all worked well together to achieve the best outcomes for the people living at the home. Comments included: “It’s a very busy home, with a good staff team, lovely residents and families.” “Excellent staff team”. The staff training and development programme at the home is very good. Training for staff in the last year has included: Dementia Care, Understanding Alzheimer’s, Infection control, Adult Protection, Palliative Care, Dining Services, Role of the Designated Carer, Catheter Care, Food Safety, Fire Safety, Fire Evacuation, Manual Handling, Understanding Parkinson’s Disease and Tissue Viability. Specialist training for the nursing staff has included: Administration of Medication, Venepuncture, Diabetes Monitoring, Using Syringe Drivers and PEG Feeds. Future training planned includes: Dementia Care, Food Safety, Care Planning, Infection Control, Manual Handling and Protection Of Vulnerable Adults. The training takes place “in-house”, with input from the Tissue Viability Nurse, Continence Nurse, Parkinson’s Nurse and Alzheimer’s Society, and at external training venues. Staff comments included: “Good training, have had lots to help me do my job better.” “I feel very well supported, we have an excellent staff team, and lots of in house and external training.” Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager is experienced and possesses the skills and knowledge to oversee the day-to-day management of the home, and ensures that residents needs and views are responded to. EVIDENCE: The Manager has been in post for the last twelve months, and has made a number of improvements to the service, such as, introducing new care plans and monthly wellness assessments, and developing the staff training programme. The Manager is capable, efficient, and proactive and has a number of years experience in care. Staff feel very well supported and managed and are very appreciative of the Manager. Comments from staff Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 23 included: “In all the time I have been at the home this is the best manager we have had.” “Manager is very supportive.” “Approachable management team, able to talk to them.” “The Manager is excellent, very positive and encouraging.” Staff and resident/relative meetings are held monthly and minutes are documented. Resident and relative satisfaction questionnaires are sent out and a full report on the responses has been compiled and is available in reception. The overall results show that people living at the home are very satisfied with their care. People living at the home have access to their personal monies seven days a week, as one of three key holders to the safe is on duty. Finances are secure, with receipts and transactions listed. A robust audit trail is maintained. There is a well-planned staff supervision programme in place, with monthly supervisions taking place. The Care Manager carries out the care assistant supervisions, and the Manager does the nursing staff. The supervision sessions are well documented, and staff have the chance to discuss care issues, air any concerns they may have, gain feedback from their mentor and residents, and identify any training needs they may have. This further safeguards the people living at the home by ensuring that staff have the skills, knowledge and support they need to meet people’s needs. General arrangements for health and safety are good. Maintenance checks are carried out on schedule to ensure equipment is safe to use, and maintenance issues and repairs are responded to promptly. Weekly tests of the fire alarm take place, and staff had recently undertaken a fire drill and were familiar with the procedure to follow in the event of a fire. Reports of accidents involving residents are completed, and appropriate actions are taken following accidents to ensure good outcomes for the individual. A falls report and accident audit are undertaken each month in order to reduce the risk of similar accidents occurring again. Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP1 OP12 OP21 Good Practice Recommendations Contact details for the Commission for Social Care Inspection should be included in the Service User Guide under the Complaints section. A plan of activities should be developed for those people who are cared for in bed to enable them to fully participate in the homes extensive activity programme. Personal toiletries should be removed from the bathroom to avoid the risk of cross infection. Beech Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection West Midlands Office West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Hill Grange Limited DS0000024822.V365779.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!