Care Home: Beechcroft Care Home

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What the care home does well Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 People told us they had a positive experience when moving into this service and that both the staff team and manager were helpful and supportive during this time. They have been provided with information about the service so they know what to expect and how much its costs to live here. People are confident that the service is able to support them and meet their needs. This is because a full assessment of their needs was completed before a decision was made if this service was the right place for them. People are consulted and involved in developing a care plan which tells the staff how to meet their needs. This is regularly reviewed so that it reflects peoples current support needs. People have access to recreational activities which they like to join in with. This includes trip outs, and various in-house activities including a Wii Nintendo, which is very popular with the people who live in this service. People have access to support that meets their preferences and comments made about the staff and care received includes some of the following: "The staff team are excellent, they are caring, and friendly; they treat me with respect and dignity when they help me". "The staff team are great I cannot fault them. They are always around when you need them and nothing is too much trouble for them". The visitors we spoke to during our visit made many positive comments about the service, one comment received was: "The staff team are really good and they provide my relative with a good standard of care. They welcome us into the home and are very friendly and keep us informed. I think this home is very homely and has a family atmosphere; this is why we choose it for our relative. We feel it is one of the best services we had visited, and we have not been proved wrong". The staff team are supported by a pro-active management team who listen to any concerns raised. Staff members have access to regular training, and supervision, to enable them to fulfil their roles. They are motivated and committed to ensuring people receive a good standard of care. The home is managed in people`s best interest and policies and procedures are in place to ensure the home is a safe place to live and work. What has improved since the last inspection? Each person that moves into this service has a range of risk assessments completed on their admission. This is to ensure that their healthcare needs are identified and monitored if this is required. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Improvements have been made to the way information about people and their requirements are communicated within the service. This is to ensure messages are left and responded to pro-actively. A system is now in place so that an audit of the medication systems and recording can be undertaken to ensure good practices are maintained and any shortfalls are identified and addressed on a weekly basis. The storage for controlled drugs has been checked and has been found to meet the new legal requirements. A delegate for the provider visits the service on a monthly basis, to monitor the standards in place and a report of the findings is completed and available in the service. What the care home could do better: We did not find any shortfalls during our visit and therefore no requirements have been made. We have made one good practice recommendation in relation to improving the security of the garden area. This will enable people to move freely in this area. Key inspection report CARE HOMES FOR OLDER PEOPLE Beechcroft Care Home Nursery Avenue West Hallam Derbyshire DE7 6JB Lead Inspector Claire Williams Key Unannounced Inspection 28th April 2009 09:00 DS0000035748.V375176.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechcroft Care Home Address Nursery Avenue West Hallam Derbyshire DE7 6JB 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) 01629 531305 paul.miller@derbyshire.gov.uk www.derbyshire.gov.uk Derbyshire County Council Mr Paul Miller Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Beechcroft Care Home DS0000035748.V375176.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 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 40 20th August 2008 Date of last inspection Brief Description of the Service: Beechcroft is situated within a residential area of West Hallam, near Ilkeston. The Home is owned by Derbyshire County Council and is registered to provide residential care for 40 older people, all within single rooms on the ground floor. It has a small car park at the front of the property. The Statement of purpose, service user guide and inspection report is made available to people who use the service and is kept in the foyer. The current fees for this service are £108.90 to £404.06 depending upon the outcome of a financial assessment. Extras include hairdressing, chiropodist and toiletries. A copy of the Commission’s inspection report is available from within the home. Beechcroft Care Home DS0000035748.V375176.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 the service is Two Star. This means the people who use the service experience good quality outcomes The focus of inspections undertaken by the Care Quality Commissions (CQC) is upon outcomes for people and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The inspection visit was unannounced and took place over a period of a day. In order to prepare for this visit we looked at all of the information that we have received since our last visit which was undertaken on 20/08/09. This includes: Notifications and information received from the service about events that have occurred. The Annual quality assurance (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Surveys returned to us by people using the service and from other people with an interest in the service. We did not receive any surveys from the staff or people who live in this service before the completion of this report. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of four people representing a cross section of the care needs of individuals within the service. Discussions were held with those individuals as able, together with a number of others about the care and services the home provides. These peoples care planning, and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their deployment, recruitment, induction, training and supervision, and records examined to support the procedures in place. We also had the opportunity to speak with six visitors were at the service during our visit. What the service does well: Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 6 People told us they had a positive experience when moving into this service and that both the staff team and manager were helpful and supportive during this time. They have been provided with information about the service so they know what to expect and how much its costs to live here. People are confident that the service is able to support them and meet their needs. This is because a full assessment of their needs was completed before a decision was made if this service was the right place for them. People are consulted and involved in developing a care plan which tells the staff how to meet their needs. This is regularly reviewed so that it reflects peoples current support needs. People have access to recreational activities which they like to join in with. This includes trip outs, and various in-house activities including a Wii Nintendo, which is very popular with the people who live in this service. People have access to support that meets their preferences and comments made about the staff and care received includes some of the following: “The staff team are excellent, they are caring, and friendly; they treat me with respect and dignity when they help me”. “The staff team are great I cannot fault them. They are always around when you need them and nothing is too much trouble for them”. The visitors we spoke to during our visit made many positive comments about the service, one comment received was: “The staff team are really good and they provide my relative with a good standard of care. They welcome us into the home and are very friendly and keep us informed. I think this home is very homely and has a family atmosphere; this is why we choose it for our relative. We feel it is one of the best services we had visited, and we have not been proved wrong”. The staff team are supported by a pro-active management team who listen to any concerns raised. Staff members have access to regular training, and supervision, to enable them to fulfil their roles. They are motivated and committed to ensuring people receive a good standard of care. The home is managed in people’s best interest and policies and procedures are in place to ensure the home is a safe place to live and work. What has improved since the last inspection? Each person that moves into this service has a range of risk assessments completed on their admission. This is to ensure that their healthcare needs are identified and monitored if this is required. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 7 Improvements have been made to the way information about people and their requirements are communicated within the service. This is to ensure messages are left and responded to pro-actively. A system is now in place so that an audit of the medication systems and recording can be undertaken to ensure good practices are maintained and any shortfalls are identified and addressed on a weekly basis. The storage for controlled drugs has been checked and has been found to meet the new legal requirements. A delegate for the provider visits the service on a monthly basis, to monitor the standards in place and a report of the findings is completed and available in the service. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Beechcroft Care Home DS0000035748.V375176.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 Beechcroft Care Home DS0000035748.V375176.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 1, and 3 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to the required information and assessment process in order to be assured their needs can be met by this service. EVIDENCE: In our annual quality assurance questionnaire completed by the service they told us how they ensure all people are assessed before they move into the service. They encourage trial visits to enable the staff to get to know the person and to share information about the service. People told us they continue to have access to information about the service, and they confirmed they have received a copy of the Service user guide. This document has been updated so people have access to current information about the service and the contact details for external organisations. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 10 Discussions with relatives also confirmed they had seen copies of this document. We looked at the files of two people who had recently moved into the service. Both files contained an assessment of their support needs, which had been used in order to develop a plan of care. We spoke to people and their relative’s about their admission and positive comments were made about this, which included: “The staff and manager were very friendly, helpful and supportive when I moved in and they helped me settle” “The staff were very accommodating and the manager was brilliant, as he sorted out furniture and made sure the rooms were comfortable for our relatives. Both people and their relatives told us the service was able to meet their needs and that it met their expectations. The home does not provide intermediate care and there were no individuals accommodated at the time of the site visit with diverse cultural or religious needs. The pre -admission documentation is currently being updated to include the six areas of diversity, so that is it inclusive to all people. Beechcroft Care Home DS0000035748.V375176.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 7, 8, 9, and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person has a plan of support which covers their personal, health and social care needs. This ensures support is provided based on their preferences. EVIDENCE: In our annual quality assurance questionnaire completed by the service they told us they now have care plans in place, which are tailored to individuals needs. They ensure these plans are reviewed regularly and people have access to healthcare professionals. They told us each person has a variety of risk assessments completed in order to monitor any health requirements. We looked at four people’s plans of care, which were completed in sufficient detail to inform the delivery of their support. They included peoples preferred daily living, personal care routines, and their support needs throughout the night. This ensures people receive individualised care which meets their expectations. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 12 Work has been undertaken to try and obtain information about people’s background and past life. This will assist with delivery of their care and enables the staff team to get to know the individual more. Each care plan that we sampled contained the required risk assessments that should be undertaken to monitor people’s mobility, pressure areas, nutrition and falls. These were reviewed as required. The care records that we sampled confirmed that contact with external healthcare services is routinely made. There was evidence in the files to support that the plan of care is reviewed both on a monthly and annual basis. Relatives we spoke to told us they are invited to these reviews with their family member’s permission. All people spoken to told us they continue to receive support which is provided in a safe, respectful and dignified manner, and our observations, supported this. Discussions with relatives also confirmed this to be the case. People and their relatives spoke positively about the staff team and comments made include; “We are more than satisfied with the care provided; the staff and manager do a very good job and work very hard.” “I like living here the staff are excellent and will do anything for you, I am well looked after very well, and I am very happy with the care I receive”. When we looked at the arrangements for the handling and management of peoples medicines by the service, we found these to be satisfactory and people were receiving their medication as perscribed. An audit system has been implemented, which means any shortfalls are now identified and addressed on a weekly basis. The service has obtained information in relation to people’s rights to make decisions and how to ensure their freedom of liberty within the service. The leaflets are available around the building, which empowers people to be informed about these issues. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 12- 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People find the lifestyle experienced in the service meets their expectations and preferences. EVIDENCE: In our annual quality assurance questionnaire completed by the service they told us they provide a range of activities which includes trips out and external entertainment. They encourage relatives to dine with people in the service. During our inspection we saw that information about planned activities is displayed on the notice board and also by way of a monthly planner, which included entertainments and trips out. People were observed attending a church service, and exercising during the morning, and the staff facilitated board games and jigsaws in the afternoon. People from another service visited the home to participant in the exercise session, and they also stayed for lunch. people told us; “it is nice to see some new faces and friends”. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 14 We saw many photos of various activities which people have participated in during the last year. Each person now has their own photo album which they fill with their photos as a memory of the places they have visited; one person told us this was good, as it enabled them to show their family members. During our tour of the home, we saw there is an activities room, which contained board games, art and crafts equipment, and a bar is available, for people to access. People told us they have access to a hairdresser, who visits the service and they told us they were satisfied with the service they received. We joined people for their lunch–time meal. The tables were set with tablecloths and condiments so people could help themselves. People told us they have choices, at each meal time and observations supported this. People said they enjoyed the meals provided, and that this provision was always discussed at the ‘residents meetings’. People and their relatives told us how they enjoyed being able to have a meal together especially Sunday lunch, and they said “this is one of the things that makes this place like home from home”. We undertook a brief tour of the kitchen and the cook told us she was aware of people’s dietary requirements. A record of people’s likes and dislikes was detailed in their care file for reference. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 16, and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems in place ensure people have confidence to raise their concerns, and are safeguarded from harm. EVIDENCE: In our annual quality assurance questionnaire completed by the service they told us their complaint procedure was displayed and a suggestion box is available for any comments or improvements people or their relatives wish to make. They told us they have regularly meetings with people so they can raise any issues they may have about the service provided. During our discussions with people they told us they knew how to complain and they said they would not hesitate to raise any issues with the staff team or manager. Relatives also told us if they cause for concern they would go straight to the manager in charge, who they had confidence in to address any issues immediately. People are able to access the procedure for complaints as it is displayed in several areas of the home, and in the service user guide. Staff members spoken with were conversant with the homes complaints procedure and their role and responsibilities concerned with dealing with complaints. They also told us about recent training they had received in relation to recognising abuse and safeguarding people from abuse. The staff Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 16 members were conversant with internal procedures to follow in the event of the suspected or witnessed abuse of any service user, and they understand the role of external agencies. A copy of the Multi-agency Safeguarding adult’s procedures was available in the service. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 19 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People benefit from living in a clean, safe and well maintained building that is homely in design and meets their needs. EVIDENCE: In our annual quality assurance questionnaire completed by the service they told us they provide a warm and homely environment. They encourage people to decorate and personalise their rooms, and consult them when the communal areas require redecoration, so people can choose the colours. We undertook a brief tour of the building and found all communal areas to be clean, comfortable, homely, warm and well lit. All areas were well furnished and decorated to a good standard. People told us they were satisfied with their Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 18 environment, which they said suited their needs. People had access to equipment which encourages and promotes their independence. We visited the bedrooms of the people whose care we looked at more closely and we found these to be well maintained, and personalised with their personal possessions. People have access to a large well maintained garden area, and some individuals assist in looking after the plants. The garden is not secure and leads onto the car park. During discussions with relatives they raised the issue of the security of this area. When we spoke to people about this, they told us they did feel safe in the garden, but thought it would be beneficial to make it more secure. During discussions with people and relatives they told us how they valued the small kitchenette where visitors can make their own drinks. They commented on how this provision increased their independence and created a homely atmosphere as people and their families can help themselves. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 27 to 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported by a competent staff team, who have been recruited to ensure they are safeguarded from any harm. EVIDENCE: In our annual quality assurance questionnaire completed by the home they told us they provide a highly trained professional staff group, and support professional development. During our visit we observed that there were sufficient staff members on each shift, to meet people’s needs. People and their relatives told us that enough staff are available at all times, but ‘more would always be better’ said one relative. People, their relatives and visitors commented positively about the standard of care provided and comments made included: “The staff are great, kind, and caring. I have every confidence they are fit for their jobs”. “the staff know what they are doing, and they are trained well” Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 20 “the staff keep us up to date and they are very proactive when my family feels unwell” Discussions with staff members confirmed that the staffing levels are sufficient to enable them to meet people’s needs and provide care in a relaxed way. The staff team demonstrated their commitment and motivation to ensuring people have a good standard of care. The staff training records are now stored electronically. We were able to see what training each staff member has achieved. The records and discussions with staff members demonstrated they have access to regular training; one staff member told us: “I have worked here nearly two years and I am now attending my third moving and handling session, the training is good and we have lots”. Regular training ensures staff members have the required skills and knowledge for their role. There were many examples of courses that were displayed in the office area which covered a variety of areas specific to this client group. The recruitment information for staff is now stored centrally, and access is now obtained electronically. We viewed the file for two of the most recently employed staff members. All of the required information was available and the required checks had been undertaken to ensure these individuals were suitable for their role. Both staff members are due to undertake an induction and are currently shadowing experienced staff to gain experience so they can fulfil their role and their responsibilities. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 31, 33, 35 36, and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Health, safety and welfare of people and staff is promoted and protected in this service. EVIDENCE: In our annual quality assurance questionnaire completed by the service they told us all of the managers are trained to a high standard, and have completed the required training so they can fulfil their role. They ensure all policies and procedures are adhered to in the service. They gave us some statistical information in the questionnaire relating to the servicing and maintenance of equipment at the home. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 22 The service continues to keep us informed of any significant events in the service. They completed their self assessment within the timescale provided and the information provided was detailed and comprehensive. Staff, people, and relatives spoken to said that they found the manager to be experienced, supportive and approachable. The staff members told us the service was well managed and they felt supported by the management team. Staff told us they felt valued and that everyone worked as part of a team. Some of the comments received include: “The manager is excellent, very helpful and pro-active in the way he responds and deals with issues”. The manager is very approachable, and supportive, he has an open door policy, and always has time for you”. “ “The manager is hands on and helps us when we need him. He is very good and supportive”. People have not yet completed the annual quality assurance survey, as they are trying to review the current system in place in response to feedback from people. We were told that they intend to look at the questions on the form next week, so that new surveys can be devised and distributed in the summer in order to obtain feedback about the service provision. People are consulted about the service through the provision of residents meetings. We looked at the minutes from the last meeting and this demonstrated that people are consulted about all aspects of the service. Relatives we spoke to told us they have now been invited to attend these meetings, which they commented; “are a good thing as we can discuss anything about the home”. There was evidence to support that staff meetings are undertaken on a regular basis. This enables the staff to be consulted about the service and to raise any issues. There was evidence in peoples files to support the staff have access to regular supervision, which provides them with ongoing support and direction in their role. Staff spoken with described satisfactory arrangements for ensuring safe working practises by way of training and provision of equipment. There are systems in place for looking after people’s money and when checked these were found to be satisfactory. People told us they can access their money when they choose to. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 23 A delegate of the provider undertakes monthly visits and completes a report of their findings. This is to monitor the standards in the service and ensure it is meeting people’s needs. The reports cover the required areas and indicated that standards have been maintained on a monthly basis. Beechcroft Care Home DS0000035748.V375176.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 Beechcroft Care Home DS0000035748.V375176.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. Refer to Standard OP7 OP19 Good Practice Recommendations Information about people’s ability to make decisions about their daily lives should be included in their care plans. An assessment should be undertaken of the security of the garden area, and people consulted about how this could be improved in order to minimise any potential risks. Beechcroft Care Home DS0000035748.V375176.R01.S.doc Version 5.2 Page 26 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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