Care Home: Beechcroft

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What the care home does well Staff members who were observed and those who were interviewed by the Inspector, demonstrated a caring and professional attitude towards the care of residents. Information about residents is readily accessible to care staff but kept securely to maintain confidentiality and overall, was up to date comprehensive and properly recorded. The healthcare needs of residents are closely monitored, and any changes in conditions promptly responded to by appropriate access to community based health services. Two residents were case tracked in order to assess whether the staff were attending to the needs identified within care plans. Evidence was available that care plans were personalised and provided comprehensive information on individual needs and advice to care staff as to how to best implement care. It was pleasing to note that the newly appointed gardener/handyman was developing ideas to encourage some residents to become involved in the garden areas and had already communicated with residents about this. This is commendable. What has improved since the last inspection? A copy of the updated Service Users` Guide had been made available to each resident. Seven requirements made in relation to the environment of the home had been implemented since the previous inspection and evidence was available that further improvements identified by the new owners were being planned. A previous requirement to implement a survey in respect of relatives/advocates and outside professionals involved with residents was being planned and relatives/residents meetings were underway on a planned and regular basis. This will further improve monitoring of the performance of the home and regular residents/relatives meetings must also be set up. Two previous requirements to do with the need for Legionella testing and the provision of specific fire drills for night- time care staff were complied with. CARE HOMES FOR OLDER PEOPLE Beechcroft 327-329 Brownhill Road Catford London SE6 1AL Lead Inspector Keith Izzard Key Unannounced Inspection 09:30 21st April & 6th May 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 Beechcroft DS0000071079.V361816.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. Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechcroft Address 327-329 Brownhill Road Catford London SE6 1AL 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) 020 8461 2437 020 8698 6269 beechcroftlondon@schealthcare.co.uk www.southerncrosshealthcare.co.uk Southern Cross BC OpCo Ltd Mrs Cynthia Omilegan Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability (30) of places Beechcroft DS0000071079.V361816.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 with Nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following categories: Old Age, not falling within any other category, Code OP - maximum number of places 30 2. Physical Disability, Code PD, maximum number of places 30 The maximum number of service users who can be accommodated is: 30 01/06/07 Date of last inspection Brief Description of the Service: Beechcroft Care Centre is a care home providing nursing care and accommodation for 26 older people. The home changed management in November 2007 and is now owned by Southern Cross Healthcare, who are a large care provider with homes throughout the UK. The home is located between Hither Green and Catford. It is close to local shops and to public transport. The home is not purpose built or designed. It comprises of two large houses that have been adapted and linked together internally. It consists of a ground floor and a first floor, with parking for up to eight cars to the front of the building. Some areas of the corridors, due to the design, are quite narrow and restrictive. There are now 26 single bedrooms, of which four have en-suite facilities as four of the rooms, that were previously double rooms, have been made into single rooms to comply with the National Minimum Standards. A passenger lift is available. There is a secure garden at the rear of the property, it is well maintained and is reasonably accessible for residents from various parts of the building. Information about the service provided is made available to current and potential service users in the homes Statement of Purpose and Service Users Guide. Both documents have recently been updated and copies of the latter document, given, individually, to residents. Copies of the Statement of Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 5 Purpose are retained on the nurse station and residents and relatives are made aware of its availability for reference. At 6th May 2008, the home’s fees ranged from £475.00 - £610.00 per week. This fee covers all of the home’s charges including the provision of meals. In addition to this residents have to pay for their own personal expenses such as hairdressing, transport and personal shopping. Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 6 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. This was an unannounced inspection completed over two separate days on 21/05/08 and 06/06/08. The previous full inspection was an unannounced inspection on 01/06/07. The inspection included a complete tour of the premises, inspecting records, and during this time a number of residents and staff were spoken to briefly and two staff members and two residents spoken to at length. Two residents care files were tracked and the files of three staff members recently employed were examined in respect of recruitment practice and records of training provided. All areas of the building were seen and were clean and free from unpleasant odour. It was evident that residents had been given the opportunity to bring in personal possessions to personalise their bedrooms and overall the home had a more homely appearance as efforts had been made redecorate and refurbish the interior and also the garden /patio area. Maintenance and Health and Safety matters had been attended to in accordance with the Standards. Residents were seen to be comfortable and good interaction was observed between staff and residents, who appeared cared for and appropriately dressed for the warm weather. Drinks were readily available and staff members were observed to be ensuring that residents were encouraged to drink fluids because of the warm weather. Service users spoken to stated that staff members were caring and helpful and all staff members interviewed were positive about the inspection process and assisted the Inspectors in a helpful and constructive way. What the service does well: Staff members who were observed and those who were interviewed by the Inspector, demonstrated a caring and professional attitude towards the care of Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 7 residents. Information about residents is readily accessible to care staff but kept securely to maintain confidentiality and overall, was up to date comprehensive and properly recorded. The healthcare needs of residents are closely monitored, and any changes in conditions promptly responded to by appropriate access to community based health services. Two residents were case tracked in order to assess whether the staff were attending to the needs identified within care plans. Evidence was available that care plans were personalised and provided comprehensive information on individual needs and advice to care staff as to how to best implement care. It was pleasing to note that the newly appointed gardener/handyman was developing ideas to encourage some residents to become involved in the garden areas and had already communicated with residents about this. This is commendable. What has improved since the last inspection? What they could do better: Four requirements were made: Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 8 Efforts must be made to consult residents about the programme of activities provided. This should reflect their interests, and an activity coordinator be appointed. The sealing around the floor/wall in both the toilets adjacent to the sitting room must be replaced and locks on the doors attended to and a new toilet seat in bathroom 1. Staff references must be verified by ensuring a company stamp or formal letterhead is provided. Specialist baths must be inspected on a six monthly basis to ensure safe continued operation Three recommendations were made: Care staff members should be provided with training in the provision of activities for residents. Recommendations were made to upgrade the way complaints are recorded in the complaints log for the home. It is a restated recommendation that the laundry floor be resurfaced. 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. Beechcroft DS0000071079.V361816.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 Beechcroft DS0000071079.V361816.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&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of purpose and Service User Guide had been recently updated. All resident’s needs are assessed before moving into the home, and residents are supported to make an informed choice having been assured that the home can meet their needs. EVIDENCE: Standard 1 This Standard was reassessed on this occasion following a requirement made at the previous inspection in June 2007 to update both documents and distribute them both to residents individually and copies to be sent to CSCI. This Standard was met as the requirement was complied with. Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 11 Standard 3 All residents have a social services needs assessment provided to the home before admission. This assists with making a judgement as to the home’s ability to meet the residents assessed needs. In addition, the home carries out it’s own detailed assessment to make sure that all assessed needs are current and relevant to the care the home is able to provide. All needs assessments undertaken were carried out by qualified nursing staff, usually, including the Registered Manager. Some residents and family confirmed that they had been asked about their needs before moving into the home and they were very happy that their needs were being provided for. Assessments comprehensively recorded health care and specialist needs such diet/feeding, mobility, skin care, medication and highlighted areas requiring special attention. Standard 6 This Standard was not assessed at this inspection, as the home does not provide, an intermediate care service. Beechcroft DS0000071079.V361816.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans indicated that resident’s health and care needs were met. Medicines were safely managed. Two residents and two visitors commented that staff members were sensitive to residents’ dignity and privacy. EVIDENCE: Standard 7 Two individual care plans were examined in detail and the care of those residents case tracked. This established that the care needs described in the plans was provided appropriately. It was noted that residents’ care plans were a continuation and development of initial assessment information. Improvements had been made in gathering information about individual residents life histories, as an aid to planning activities and to facilitate individual communication with residents. The residents and a relative who were interviewed commented that they appreciated staff efforts in this area Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 13 and that they have been asked for information in compiling these histories in order to assist staff to understand who residents are and their life experiences, thereby facilitating more meaningful communication. Care plans were therefore more person centred as is appropriate and as required to meet the Standard. All care plans are reviewed monthly and all residents have had formal annual reviews. The manager stated that good progress had been made in adapting care records to the format required by the new owners, we acknowledged that this was a considerable task and that a small number of records were in transition. The evidence available was that staff members had worked hard to implement these as well as the different policies and procedures of the new owners. Standard 8 Many of the residents living at the home need significant personal care support, in moving and transferring. Written guidance is provided on all care plans to clarify the best and most person centred way to physically assist residents and updated verbally at handover sessions in response to any sudden change of need. Nursing assessments include details of medical history also medication, assessment of pressure areas, falls risk assessments, skin care, moving and handling needs, continence care, communication needs and social preferences. A separate section includes dietary information, and a monthly weight record. The Tissue Viability Nurse regularly visits the home on a monthly basis, or more often, as required. A CSCI questionnaire returned by the nurse stated that staff members were improving in their referring of service users for her advice, that general health care needs were being met, but staff members could broaden their requests for her advice for example, skin problem and greater utilisation of the Podiatry service. There was good evidence for appropriate intervention from other health professionals, including the G.P., Chiropodist, Optician and a Community Psychiatric Nurse, the latter called in, to assess a resident who staff were concerned about because of depression and suicidal thoughts. Standard 9 The medication system was examined and was appropriately organised. Medication was stored in a locked cabinet within the lockable clinical room and quantities and dosage of medication tallied with the MAR sheets examined and the amount remaining within the storage system. The home had a policy and procedure for medication that was comprehensive and only staff members who had received training were allowed to deal with medication. The manager stated that advice was readily available from the supplying Pharmacist and had a homely remedies procedure in place signed by the GP for the home. The home had received an audit visit from the Boots the supplying Pharmacist in April 2008 approximately two weeks prior to this inspection. Whilst several recommendations were made it was noted, overall, that the administration of medicines was well organised and with policies and procedures in place and a Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 14 positive report was given. We noted that the recommendations made had either been responded to already or were underway. Standard 10 All bedrooms are now single occupancy. Care plans seen included guidance on how to respect resident’s dignity and privacy. For example staff members ensured that bedroom toilet and bathroom doors were closed when giving personal and involved residents in choosing what to wear. Several staff members were seen acting appropriately with residents care. Two residents and a visiting relative stated that staff members were caring in their approach in those areas. Beechcroft DS0000071079.V361816.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): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provision of suitable and varied regular activities requires some attention as soon as possible. Residents maintain contact with family and friends, and are encouraged to exercise choice and control over their lives. Meals served are varied and appetising, service users are involved in planning the menus for the home. EVIDENCE: Standards 12-14 Residents are enabled to maintain their personal choice in terms of when they get up and go to bed and what they will do with their time during the day. Meals are served at set times during the day but individual requests for variations can be accommodated in order to facilitate outings or appointments for residents going outside of the home. Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 16 Residents can choose to have privacy in their own rooms or to participate with others in the communal areas. Access is available to a library service including “talking books,” Dial a Ride and a visiting Deacon for religious services. There are group activities arranged at the home, such as are bingo, quizzes and live entertainment. It was pleasing to note that the newly appointed gardener/handyman was developing ideas to encourage some residents to become involved in the garden areas and had already communicated with residents about this. This is commendable. A weekly plan showing activities that are available is produced, however it was acknowledged by two residents and several staff members and relatives that, activities are limited and that the home would benefit from the appointment of an activities coordinator in order to assist care staff members who are primarily concerned with personal care tasks and have difficulty in maintaining an adequate level of activities for residents. Information on individual residents life histories has been compiled with their consent and involvement, to improve staff knowledge and to aid planning. Following the change of ownership the manager stated that the regional manager had already identified a shortfall in activities provision and that serious consideration would be given to appointing an activities coordinator, we concurred with this view. Care staff members would also benefit from some training in the provision of activities. See Requirement 1 & Recommendation 1 Two residents interviewed were aware that records were retained about them. And stated that the way that their care was provided had been discussed with them by care staff and felt that their views had been incorporated in the way care was given. Standard 15 The menus produced over a period of four weeks were examined and showed that a varied and nutritious diet was provided. Tables were set appropriately and staff members were observed discreetly assisting those residents who needed help or encouragement to eat. Residents are able to choose to eat in their own rooms if they wish and a choice or alternative dish is always available and regular snacks and drinks made available. Culturally appropriate and other special health diets can be catered for, and whilst three residents are of Afro/Caribbean origin, neither, required a culturally appropriate diet on a regular basis, but appreciated the efforts made by the chef to occasionally provide this, for variety. The manager reported that the chef regularly talks to individual residents to ascertain their views on the food provided, this is commendable. The manager stated that a previous recommendation that the chef records these occasions and attends residents meetings from time to time was being implemented. Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 17 Beechcroft DS0000071079.V361816.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 good. This judgement has been made using available evidence including a visit to this service. Complaints to the home had been dealt with satisfactorily, but attention was needed to improve the recording procedure. Service users legal rights were protected and they are protected from abuse. EVIDENCE: Standard 16 There is a clear and up to date complaints policy and this is clearly displayed in the front entrance area with the registration and insurance liability certificates for the home. As stated within Standard 1, all residents have access to the complaints policy within the recently updated Service User Guides. Since the previous inspection in June 2007 four complaints were received by the home and were dealt with in accordance with the Standard and appropriate action taken to prevent reoccurrence. In addition, a complaint to do with alleged reduced staffing levels was made direct to CSCI, we investigated this and no evidence was found to substantiate the complaint. Two residents and a relative who were seen on the days of inspection confirmed that they had been informed how to complain if they needed to and that the manager is always available to discuss and problems with them. A new complaints log had been introduced because of the change of ownership of Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 19 the home. We recommended that all complaints are sequentially filed in date order and that a separation exists between individual complaints and are indexed. Each complaint should commence with the initial complaint referral followed by an initial acknowledgement of receipt. This should be followed by the investigation details, followed by the response to the complainant that clearly identifies the outcomes and whether the complaints were substantiated, or not, or partially substantiated, and what action is proposed by the manager to minimise further occurrence. See Recommendation 2 Standard 18 The home has an updated the Safeguarding Adults policy. It dovetails with the Local Authority’s policy. This policy is clearly written and staff interviewed had a clear understanding of Safeguarding Adults Procedures and had received training in this area. Two staff members we interviewed were confident that any allegations made would be dealt with appropriately and felt that the manager was very approachable, would listen to any concerns expressed by staff members and act promptly to address any issues. Since the previous inspection three referrals had been made to the local authority in respect of Safeguarding adults matters. One, resulting from an anonymous referral that was investigated by the local authority was not substantiated. Although, highlighted an issue regarding the procedure for checking references received prior to commencement of employment. See Standard 29 & Requirement 3 Also, an issue regarding the staffing advice given to the manager by the head office of the previous owner, this is now superseded given the subsequent change of ownership of the home. The manager nevertheless acknowledged that she had, as a result, gained a better understanding of the requirements of those staff employed whilst under a probationary period. The second Safeguarding matter was in respect of an investigation following bruising to a resident. The matter was currently being investigated under Safeguarding Adults procedures but had not been concluded at the time of the inspection. This matter will be reported to CSCI and should the outcome prove significant, then this will be reported on at the next inspection, the matter would be addressed by the home, immediately, and monitored by CSCI. A third Safeguarding Adults referral had been made to the local authority, this in response to an alleged incident of verbal abuse by a member of staff toward a resident in the home. The investigation of this matter was currently being delayed as the member of staff had gone off sick having been suspended from duty. The system for dealing with residents’ finances/ valuables we examined noting that it was accountable, appropriate and well organised, as stated in Standard 35. Beechcroft DS0000071079.V361816.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe environment but further work is required to improve the overall quality of the environment, although some improvements are evident. Residents have access to communal indoor and outdoor facilities, and the home is clean and hygienic. EVIDENCE: Standard 19 Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 21 As described in previous inspections, the home is of an older design. Although it safely accommodates wheelchairs, it was previously noted that lower parts of walls and doors and doorframes were regularly scratched and damaged along with other damage to doors and panels. A requirement to attend to these matters had been complied with. Two other requirements to deal with a foul drainage smell, replace a bathroom floor and blank off a cracked electrical socket had also been complied with. At this inspection it was noted that the sealing around the floor/wall in both the toilets adjacent to the sitting room needed replacement and locks on the doors attended to and a new toilet seat in bathroom 1. See Requirement 2 Overall, it was noted that the regional operations manager had visited the home and made recommendations for a number of improvements to be made to upgrade and improve the home. Standard 24 A previous requirement that a thorough review of the furnishings and fittings provided by the home in residents’ bedrooms should be conducted and replace a number of items that were showing signs of deterioration such as sinks areas cupboards and drawers was mostly complied with. Further work was underway or being planned in this area. Standard 26 It was evident that a good system of regular cleaning was being implemented. We interviewed a housekeeping staff member who was well versed in COSHH procedures and it was noted that hazardous cleaning materials were appropriately stored in locked cupboards. A previous recommendation that the laundry floor be resurfaced had not been attended to, however, the manager stated that this had been noted by the area operations manager and was scheduled for work to be done, later in the year. The laundry was well organised with adequate washing and drying facilities. Restated Recommendation 3 Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 22 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): 27-30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Home recruits skilled and competent nurses and care workers in suitable numbers to meet the needs of the service users. Overall, recruitment practices were well organised, excepting, that reference procedures must be improved. Staff members are competent to do their jobs and the level of training appropriate. EVIDENCE: Standard 27 Staffing levels remain unaltered since the last inspection. Rotas examined and staffing records indicated that there are sufficient numbers of suitably skilled staff employed at the home throughout the day and night at the home. The usual staff support provided is a minimum of: One registered nurse and three carers during daytime hours and one registered nurse and two carers at night. The manager reported that the home does not employ agency workers, only using regular bank workers in order to promote continuity of care for residents. Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 23 Staff members’ interaction with residents was observed on a number of occasions and seen to be both caring and professional. Staff members were observed to be communicating well; explaining to residents what they were doing and why. One visitor and two residents we interviewed said that staff members are kind and helpful. One relative and a visiting professionals said that staff members are approachable and that they had been advised in a positive way to raise any concerns with the homes manager or administrator if they ever felt this to be necessary. Standard 28 The home has a ratio of 75 qualified staff to level 2 or above, this is commendable. Standard 29 The manager stated staff files were currently being reorganised. Two staff files were examined in relation to recruitment, training and supervision. These indicated that each person had completed an application form and submitted the names of referees. Discussion took place with the manager regarding the need for references to be validated, as although the files looked at were fine an example had emerged referred to in a previous Standard where verification had not taken place. See Requirement 3 The manager agreed that in future compliments slips attached to references would be retained or company stamps requested. There was evidence that staff had provided proof of identity. Current photographs had been included in the staffing documentation. There was evidence that CRB/POVA checks were being undertaken. The homes interviewing panel consists of the registered manager and one other nurse or the administrator. Standard 30 A yearly planned training programme/ matrix was provided and accessible to staff. The programme included routine training such as moving and handling, fire safety adult protection, COSHH, medication supervisory skills and end of life care. Evidence was also available of training being planned for the future. Training records seen showed that staff members had received the training outlined above. Staff members that were interviewed said they received an adequate level of training to enable them to fulfil their roles and that they were encouraged to identify areas of training for themselves in addition to that provided by the organisation. Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 24 Beechcroft DS0000071079.V361816.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home run by a manager who is fit for the purpose and who benefit from the leadership and management approach of the home. Procedures are in place to monitor and develop the quality of care and the service provided in the home. Residents are safeguarded by the financial and Health and Safety procedures adopted by the home. EVIDENCE: Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 26 Standard 31 The manager is a Registered General Nurse and has also registered with CSCI. The manager had completed her NVQ4 in management and care. It was evident that both the residents and staff members interviewed felt positively about the manager and all stated she was very approachable, neither residents or staff members would hesitate to speak to her should they have any concerns regarding the running of the home or the welfare of residents. As the home no longer accommodates residents within double rooms and those rooms have been converted for single occupation only the overall number of residents accommodated has reduced from 30 to 26. Standard 33 The home is subject to an annual audit by the new owners Southern Cross also receives regular monthly visits from by the Regional Operations Manager and a report complied on the conduct and running of the home, as required under Regulation 26. These reports are retained in the home for inspection, as required. The manager stated that home is also monitored on a regular basis by the Commissioning unit from the London Borough of Lewisham. Annual surveys of residents’ views were completed and the manager was planning to extend this facility for relatives and visiting professionals. Residents and relatives meetings were underway, the minutes of which were seen and showed that opinions had been canvassed in an open way. Standard 35 Records pertaining to the personal allowances of three residents were examined the amount of money being held for each resident user tallied with The accounts Ledger book records seen. The system in operation was accurately recorded and a good audit trail was maintained. A lockable safe was available in the manager’s office. In respect of valuables belonging to residents it was noted that staff members had reported concerns regarding the safety of a resident’s rings and that the manager had suggested that these be safely retained by her daughter with the resident’s permission. The manager stated that this reflected the company policy to minimise liability for the safeguarding of valuables for residents. Standard 38 A sample of records to do with health and safety and maintenance checks were examined and found to be comprehensive and well documented. Records seen indicated that regular maintenance and safety checks had been carried out and substantiated the dates recorded within the pre- inspection questionnaire (AQAA) submitted by the manager. There was also evidence of safety checks to portable appliances and lifting and hoisting equipment being conducted with the exception of two special baths, this must now occur. Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 27 See Requirement 4 In response to a previous requirement, the home had arranged for testing for Legionella bacteria and a satisfactory report had been obtained. During the course of the inspection a number of fire exits and extinguishers were examined, there was evidence of routine checks taking place. Improvements had taken place in the recording of Fire drills and a previous requirement made in this area fully implemented. Beechcroft DS0000071079.V361816.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 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 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 29 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 OP12 Regulation 16 m & n Requirement Efforts must be made to consult residents about the programme of activities provided. This should reflect their interests, and an activity coordinator be appointed. The sealing around the floor/wall in both the toilets adjacent to the sitting room must be replaced and locks on the doors attended to and a new toilet seat in bathroom 1. Staff references must be verified by ensuring a company stamp or formal letterhead is provided. Specialist baths must be inspected on a six monthly basis to ensure safe continued operation Timescale for action 01/09/08 2 OP19 23 01/09/08 3 4 OP29 OP38 19 23 (2) c 01/08/08 01/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 30 No. 1 2 Refer to Standard OP12 OP16 Good Practice Recommendations Care staff members should be provided with training in the provision of activities for residents. It is recommended that all complaints are sequentially filed in date order and that a separation exists between individual complaints and are indexed. Each complaint should commence with the initial complaint referral followed by an initial acknowledgement of receipt. This should be followed by the investigation details, followed by the response to the complainant that clearly identifies the outcomes and whether the complaints were substantiated, or not, or partially substantiated, and what action is proposed by the manager to minimise further occurrence. It is a restated recommendation that the laundry floor be resurfaced. 3 OP26 Beechcroft DS0000071079.V361816.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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