Care Home: Beeches Retirement Home

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What the care home does well The home provides residents with a homely, relaxed and caring environment. Residents are enabled where possible to exercise choice and control over their lives whilst resident in the home. Residents spoke positively about their experiences at the home.Beeches Retirement HomeDS0000021045.V375732.R01.S.docVersion 5.2Staff was observed to deliver care with dignity and respect. Residents spoken with felt the care provided respected their privacy and dignity and were happy with the overall care provided. Residents live in a clean and homely environment, with their private accommodation personalised to suit their taste. What has improved since the last inspection? The home continues to undergo ongoing refurbishment. The AQAA detailed that during the last twelve months the corridor hallway areas have started to be redecorated with the second floor and half of the first floor having been completed and the remaining work will be completed by July 2009. All the residents are being given the option of new bedroom furniture and many are taking up this offer and to have digital television and radio in their bedrooms to allow residents more choice of programmes to watch and listen to. A new boiler, washing machine and tumble dryer have been purchased. New dining furniture and arm chairs have been provided. The sample of resident’s documentation had a photograph in place, a recorded risk assessment in relation to falls and where residents go out from the home independently. Storage and recording is now in place for control drugs to meet the new requirements. New staff has not commenced working in the home until a Criminal Records Bureau (CRB) and or a POVA First check has been received. Photographic evidence of staff members is held at the home. To protect residents and staff. Staff are benefiting from regular and structured supervision. Residents are benefiting from more activities being provided and the AQAA details this as an area which over the next twelve months will continue to be developed. The outcome from the homes quality monitoring process has started to be collated and is available to read in the home. What the care home could do better: Staff should continue to complete the required training/updates in moving and handling, basic food hygiene and first aid to ensure staff have the skills to meet the needs of the residents and to protect residents and staff. Residents and staff would benefit from further development of the homes policies and procedures to ensure the health and safety of residents and staff. Recording in the home should continue to be developed to fully evidence procedures in the home. Advice should be sought as to the required frequency of the updating of the environmental risk assessment to ensure the environment continues to be safe for the residents and staff working in the home.Beeches Retirement HomeDS0000021045.V375732.R01.S.doc Version 5.2 Staff recruitment procedures should be more robust in the collection of two written references prior to a member of staff working in the home to protect residents and staff. Key inspection report CARE HOMES FOR OLDER PEOPLE Beeches Retirement Home 4 De Roos Road Eastbourne East Sussex BN21 2QA Lead Inspector Judy Gossedge Key Unannounced Inspection 12th June 2009 11:10 DS0000021045.V375732.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. Beeches Retirement Home DS0000021045.V375732.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 Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beeches Retirement Home Address 4 De Roos Road Eastbourne East Sussex BN21 2QA 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) 01323 731307 beechesretirementhome@aol.com Mrs Joan Sinclair Mr Darren Sinclair Mr Darren Sinclair Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 20. Date of last inspection 31st July 2008 Brief Description of the Service: Beeches retirement home is a detached two-storey Victorian property set in its own grounds in a residential area near to Eastbourne town centre. The home is registered to provide care and accommodation for up to twenty older people. Accommodation is presented across three floors with a shaft lift providing level access to most parts of the first floor and an additional chair lift fitted to a small flight of stairs. Access to the second floor is by way of a stairway and residents accessing the two bedrooms on this floor will need to be fully mobile. Resident’s private accommodation consists of twenty single bedrooms; all have toilet and wash-hand-basin en-suite facilities with some having their own bathroom. Communal facilities include a dining room, lounge and conservatory. There is a rear secure garden, which has seating and a barbeque area. The home aims to provide a homely and friendly service with the emphasis on comfort and care. The range of fees charged at the time of the inspection is from £350.00 to £450.00 which includes personal toiletries and in-house activities. Additional charges are made for hairdressing, chiropody, newspapers and dry cleaning. There is a detailed Statement of Purpose, Service Users Guide and a copy of the last inspection report available to read in the home. Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 5 Beeches Retirement Home DS0000021045.V375732.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. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations`2001 uses the term ‘service users’ to describe those living in care home settings. For the purpose of this report, those living at Beeches will be referred to as ’residents.’ The Provider had been asked to complete an Annual Quality Assurance Assessment (AQAA), information from which is quoted in this report. This unannounced inspection took place between 11.10 am and 4.10 pm, over five hours on 12 June 2009. A further visit was made on 16 June 2009 to look at records not available to view on the day. The communal areas and a selection of resident’s bedrooms were viewed and a selection of care records was inspected and is detailed in the report. Twenty people were resident, three residents were spoken with individually in their bedroom, two in the hallway and a number were spoken with as part of the inspection process. The care that four of the residents received was reviewed. The opportunity was also taken to observe the interaction between staff and residents in the communal areas. Three care workers, two individually and one as part of the inspection process and the deputy manager were all spoken with. The Registered Manager who is also one of the Registered Providers was not working in the home on the day of the inspection and was subsequently spoken with over the telephone. Eight residents and five care workers surveys were sent out on this occasion and four residents and two care workers surveys were completed and returned. A social care professional was spoken with over the telephone after the inspection. What the service does well: The home provides residents with a homely, relaxed and caring environment. Residents are enabled where possible to exercise choice and control over their lives whilst resident in the home. Residents spoke positively about their experiences at the home. Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 7 Staff was observed to deliver care with dignity and respect. Residents spoken with felt the care provided respected their privacy and dignity and were happy with the overall care provided. Residents live in a clean and homely environment, with their private accommodation personalised to suit their taste. What has improved since the last inspection? What they could do better: Staff should continue to complete the required training/updates in moving and handling, basic food hygiene and first aid to ensure staff have the skills to meet the needs of the residents and to protect residents and staff. Residents and staff would benefit from further development of the homes policies and procedures to ensure the health and safety of residents and staff. Recording in the home should continue to be developed to fully evidence procedures in the home. Advice should be sought as to the required frequency of the updating of the environmental risk assessment to ensure the environment continues to be safe for the residents and staff working in the home. Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 8 Staff recruitment procedures should be more robust in the collection of two written references prior to a member of staff working in the home to protect residents and staff. 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. Beeches Retirement Home DS0000021045.V375732.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 Beeches Retirement Home DS0000021045.V375732.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. 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. There is detailed information about the home available for residents and their representatives to view. Potential new residents are individually assessed prior to an admission to ensure that their care needs can be met in the home. Intermediate care is not provided in the home. EVIDENCE: A copy of the Statement of Purpose and Service User’s Guide are available to read in the entrance of the home. The documents were read, are detailed and recorded they have been reviewed. Both documents were in need of some minor updates which the deputy manager stated would be addressed. Three of the residents surveys stated they had received enough information about the home and one commented, ‘chose here as it was near and convenient for friend to visit.’ One new resident spoken with had come straight from hospital Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 11 and had not been able to visit the home. A copy of the last inspection report is also available to read in the home. The AQAA detailed that a full and comprehensive pre-admission assessment is completed. The deputy manager stated that herself or the Manager visits all potential new residents prior to any admission, and that a detailed preadmission and assessment format, which is in place, is completed. This is to ensure individual residents care needs can be met in the home and to provide staff with information on the care to be provided. A copy of the assessment undertaken by the local authority is also sometimes received and available to reference. The documentation for two new residents admitted to the home since the last inspection was viewed and there was detailed pre-admission information in place. Intermediate care is not provided in the home. Beeches Retirement Home DS0000021045.V375732.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents are protected by a detailed individual plan of care being in place, where all their personal, social and health care needs are identified at the start of their stay and which informs staff of the care, which needs to be provided and with supporting risk assessments completed. Medication policies and procedures are in place. EVIDENCE: The AQAA detailed that all of the residents have a comprehensive care plan in place. Four of the residents individual care plans were viewed. All were detailed and gave clear guidance to staff of the care to be provided, resident’s health care requirements, dietary needs, and social and leisure interests. All of the residents have a risk assessment completed in relation to falls or where residents go out from the home independently. The content of some of the risk assessments where residents go out independently varied and should Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 13 continue to be developed to give staff guidance as to how to manage any identified risks. This was discussed with the deputy manager, who agreed to address this. These documents recorded they had been regularly reviewed. The four resident’s surveys and the residents spoken with stated they always received the care and support that they needed. The two care workers surveys stated that they always received up-to date information about the residents and one commented, ‘the home gives the care to the clients in an understanding and proffessional way. They are cared for as if they are in their own home. We are all one big family.’ Records viewed detailed that residents are registered with a local General Practitioner (GP) and have access to other health care professionals, including district nurses, via the surgeries. It was noted, in care plans that were examined, those appointments with or visits by health care professionals are recorded. All of the residents spoken with confirmed that their health care needs were met in the home. The atmosphere of the home was comfortable, open and relaxed and residents are encouraged to remain independent and to exercise choice over their daily lives. Staff was observed to deliver care with dignity and respect. The residents spoken with felt the care provided respected their privacy and dignity, and that they were pleased with the overall care provided in the home. The AQAA detailed that medication policies and procedures are in place, which includes receiving, recording, storage, handling, administration and disposal of medicine. Residents are able to self medicate under the risk management assessment framework. None of the residents self medicated at the time of the inspection. That a pharmacist regularly visits, the records were not viewed on this occasion and all of the staff who administers medication has received medication training. Medication is stored in a locked trolley and sample of the recording of medication administered was viewed. Where medication is kept in a refrigerator the deputy manager stated that a risk assessment would be completed immediately and the storage reviewed where indicated. So a Requirement has not been made on this occasion. A list of signatures of staff who administer medication was not in place. The deputy manager stated this would be addressed to ensure a clearer audit trail of administration to protect residents is in place. All the residents spoken with stated their medication needs were met in the home. Two care workers spoken with who administered medication confirmed that they had received medication training. Beeches Retirement Home DS0000021045.V375732.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 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. Where possible residents are enabled to exercise choice in their lives whist resident in the home, there are opportunities to participate in social and recreational activities provided, residents are encouraged to maintain contact with family and friends as they wish and a varied diet is provided. EVIDENCE: The AQAA detailed that a varied and flexible activity programme is in place, and following listening to what the residents want have increased the social activities provided. Over the next twelve months there are further plans to introduce more singers and entertainers. That residents have access to the internet access to which it is also planned will be improved over the next twelve months. Resident’s social interests are recorded on their individual care plans. This was discussed with the deputy manager as an area to continue to be developed. The deputy manager agreed to address this. A copy of the monthly activities programme is available to view in the home and is also offered to the residents. The deputy manager has previously stated that there Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 15 could be changes to the planned activities as residents are asked on the day what activity they would like to participate in. Some residents go out and access local activities in the community and on the day two residents went out independently to the seafront. A large DVD collection is available for residents to view. The AQAA details that residents are able to have visitors in private at any reasonable time, either in their own room or in any of the communal areas. Guests are made welcome, offered light refreshment and on occasion can eat with their friend or family member at no extra cost. The residents spoken with who had visitors confirmed there was flexible visiting, that staff are very welcoming and they could see their relative or friend in private if they wished. A monthly service is available for residents to attend if they wish, and the AQAA details and information is in the home to ensure that residents are aware they will be assisted to meet their individual religious and spiritual needs if they wish. The care and support provided was observed to enable residents where possible to exercise choice whilst at Beeches. The four residents files viewed, staff and the residents spoken with confirmed this. Residents are able to bring pets into the home on a trial basis with a view to being permanent providing other residents are in agreement if it will be in communal areas. A rotating menu is place, which the deputy manager stated has been seasonally varied and was seen to identify the choices available at all meals. Soup is now available at tea along with sandwiches and a hot meal option. The Manager stated that he was in the process of recruiting a full-time chef/cook and that over the next twelve months menus will be reviewed again and two further improvements being considered is to provide a cooked breakfast option and the introduction of themed days using recipes from other countries. Lunch on the day was fish in sauce, fish fingers or omelette, with chips, mashed potatoes and peas, followed by apple sponge or tinned fruit with cream or ice cream. Special diets are catered for. Residents were observed eating their lunch in the dining room and it was a relaxed environment taking into account the different length of time that individual resident would need to finish their meal. Records are kept of food consumed individually by each resident to ensure they are receiving an adequate diet. The residents spoken with were all happy with the meals provided. Beeches Retirement Home DS0000021045.V375732.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Policies and procedures are in place to enable residents or their representatives to raise any concerns about the care being provided and to ensure that residents are protected from abuse. EVIDENCE: The AQAA details that there is a complaints policy and procedure in place and that no complaints had been received during the last year. The CQC have not been made aware of any concerns in relation to the care provided at Beeches. A copy of the policy and procedure is detailed in the Service Users Guide. This was read and although the main policy details a response time the timescale within which a complaint will be acknowledged in the Service Users Guide had been omitted. This was discussed with the deputy manager who stated that this would be addressed. All of the residents spoken with stated they knew who to speak to and how to make a complaint. Both the care workers surveys stated they knew what to do if a resident has any concerns. The AQAA detailed that there are policies and procedures in place in relation to the protection of vulnerable adults. The deputy manager has stated that a copy of the East and West Sussex County Council, Brighton and Hove safeguarding adults’ procedures is available to reference in the home. Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 17 The AQAA details that staff has regular training in adult abuse basic awareness, the sample of staff training records viewed recorded staff had attended this training and two care workers spoken with confirmed an awareness of the policies and procedures to protect residents. Beeches Retirement Home DS0000021045.V375732.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents live in a clean and homely environment, decorated and furnished to a good standard. The home ensures that resident’s private accommodation is equipped to provide comfort and privacy and to meet the assessed needs of those people residing in the room. EVIDENCE: The home is decorated and furnished in a homely style, with a good standard of the décor, carpeting and furnishings. The AQAA detailed that during the last twelve months the corridor hallway areas have started to be redecorated with the second floor and half of the first floor having been completed and the remaining work will be completed by July 2009. All the residents are being given the option of new bedroom furniture and many are taking up this offer Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 19 and to have digital television and radio in their bedrooms to allow residents more choice of programmes to watch or listen to. A new boiler, washing machine and tumble dryer have been purchased. New dining furniture and arm chairs have been provided. There was a range of individual aids and adaptations to assist resident’s mobility and independence, including a passenger and chair lifts, raised toilet seats, walking aids, assisted baths and grab rails. Fitted throughout the home are call points, which enable assistance to be summoned when, pressed. A digital telephone system has been installed which allows residents to make and receive calls anywhere in the home. There are twenty single bedrooms on all floors in the home. Two new bedrooms were built on the second floor of the home in 2008. A number of bedrooms were viewed and displayed resident’s individual styles and interests. All the residents spoken with were happy with their accommodation. The Manager has previously stated that on moving in to the home residents can have their room decorated to their own choice and can furnish it with their own effects. All of the bedrooms have en-suite facilities of a toilet and wash-handbasin and some have their own bathroom. Bathroom facilities are provided throughout the home. Residents are able to control the temperature in their own bedrooms. A sample of records were viewed of regular testing of the hot water temperatures at outlets accessed by residents to ensure it is maintained close to the recommended safe temperature of 43 degrees centigrade. All the residents spoken with confirmed there is adequate heating and hot water in the home. A passenger lift is available from the ground floor providing level access to most parts of the first floor and additional chair lifts are fitted to small flights of stairs. Access to the second floor is by way of a stairway and residents accessing the two bedrooms on this floor will need to be fully mobile. There is one lounge with a large conservatory and a separate dining room on the ground floor. There is a small rear well maintained garden, which has a patio, barbeque and seating areas, making this an attractive area to use and overlook. The AQAA details that it is planned to put more plants and shrubs in the garden and fit a ramp from the lounge to the conservatory to aid access for all residents. The AQAA details that there is a policy and action plan in place for managing infection control. The home was clean and free from offensive odours at the time of the inspection. All of the resident’s spoken with stated home was always fresh and clean. The AQAA detailed that nine staff had received training in the prevention of infection and the management of infection control. Staff confirmed that there was good access to protective clothing, liquid soap and Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 20 paper towels. The deputy manager stated that further guidance to ensure that the COSHH information held in the home met current requirements to safeguard residents and staff has been taken and the information updated accordingly. A sample of recording was viewed of routine fire checks that had been carried out in the home. Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 21 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): 27, 28, 29 and 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. A robust recruitment procedure should continue to be developed to ensure residents are in safe hands at all times. Staff are being provided with the required training or updates to ensure they have the skills to meet all the residents care needs. EVIDENCE: The AQAA details that staff levels are calculated according to the needs of the residents and the general function of the home and are kept under review to ensure the care needs of individual residents continues to be met. The staff rota was read and care workers spoken with confirmed the staffing levels in place. All staff was found to have a good rapport with residents, which promoted a relaxed atmosphere in the home. The deputy manager was on duty during the day, with three care workers on duty during the morning, two care workers on duty during the afternoon and at night the home was due to deploy one ‘waking night’ member of staff. Agency staff is used to work in the home and the deputy manager stated that she requests care workers who had previously worked in the home and know the residents. A designated care worker, the deputy manager or the Manager undertakes the cooking in the Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 22 home. Since the last inspection a domestic member of staff has been recruited to undertake domestic tasks in the home for fifteen hours a week, and the Manager stated he is in the process of recruiting a cook/chef to work full time in the home. Three of the residents surveys stated staff were always available and one usually, and comments received were, ‘yes, very efficient,’ and ‘yes I ask for something and they do it.’ Both the care workers surveys stated information systems always work well, and there is usually enough staff to meet resident’s needs. The AQAA detailed that ten of the twelve care workers working in the home holds an NVQ Level 2 in care. The AQAA detailed that the procedures followed for the recruitment of staff is an area which has been improved over the last twelve months. That new staff working in the home has had satisfactory pre-employment checks. The documentation was viewed for the three new members of staff, who had been recruited since the last inspection. The records were well structured. All demonstrated the completion of an application form, all had two written references in place, but for two members of staff two verbal references had been sought, but one of the written references had not been received until after the member of staff had commenced working in the home. This was discussed with the Manager who stated that the recruitment practice would be further reviewed to ensure that two written references were in place prior to a member of staff commencing work in the home, so a further Requirement has not been made. All had completed a Criminal Records Bureau (CRB) and a Pova First check. A sample of staff documentation was viewed and all had had a CRB check completed. Both of the care workers surveys stated that recruitment checks were carried out before they started work. The deputy manager evidenced that induction training for new members of staff is in place and stated that this meets the requirements of the General Skills for Care induction standards. The AQAA details that the induction is started and now completed within the required timescale. Records viewed for the three new members of staff recorded that two care workers had completed this induction and for the third it was not applicable. Both of the care workers surveys stated the induction covered everything very well. Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 23 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): 31, 33, 35, 36, 37 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 management team has strived to create an atmosphere within the home, which is open, relaxed, homely and caring. Quality assurance systems in the home enable ongoing feedback about the care provided in the home and systems are in place to ensure a safe environment for staff and residents. EVIDENCE: Mr Darren Sinclair is the Provider/Registered Manager for the home and has completed the Registered Managers Award and NVQ Level 4 in Care. There have also been further training opportunities which the Registered Manager has attended. There is a deputy manager to support the Manager, who is also Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 24 in the process of completing the Registered Managers Award and NVQ Level 4 in care. The deputy manager was knowledgeable on the daily running of a service for older people and showed much commitment to ensuring good standards of care was maintained. A quality assurance system has been developed. It was evidenced that feedback about the care provided at the home has been sought from residents, relatives and representatives through surveys and residents meetings and the deputy manager evidenced that health care professionals who attend the home are in the process of being surveyed. The minutes from a previous residents meeting was read, and the deputy manager stated the minutes from the latest meeting were still in the process of being written up. Feedback from the outcome of the quality assurance process undertaken in the home has been collated and is available to read with other documentation in the hallway. The content of this should continue to be developed to fully detail the outcome of the quality assurance process. The AQAA details that the homes quality assurance is an area which it is planned to improve and build on over the next twelve months and to use the information in a positive and constructive way. The AQAA detailed that policies and procedures are in place, but not all are in place as required and to protect residents and staff. This was discussed during the last inspection and a Requirement has been made on this occasion. Residents are encouraged to retain control of their own finances for as long as they are able to do so and if unable then this responsibility is taken on by a relative or another responsible person external to the home. The deputy manager reported that they do sometimes hold small amounts of money for a few residents, and that a receipting system is in place. The recording was not viewed on this occasion. Staff spoken with and the sample records viewed confirmed that staff supervision occurs to meet the requirements. Both care workers surveys stated they meet with their manager regularly and often and always has enough support. All the care workers spoken with confirmed they had regular supervision with their manager. The AQAA detailed that staff access to in-house and external training has been developed over the last twelve months. A sample of staff training records was viewed and a training matrix is being developed. Not all the staff has undertaken all the required training such as moving and handling, basic food hygiene and first aid. But there was evidence of a plan of training which has enabled care workers to complete or is due to be provided for staff to ensure that they have all received the required training to protect residents and staff. An environmental risk assessment of the building was undertaken of the building in 2007 by an external agency. This should be subject to review and a Requirement has been made to seek advice as to the frequency of any review should be undertaken. A sample of records was viewed of regular Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 25 environmental and fire checks of the environment. The AQAA detailed that some the maintenance of equipment and services has been carried out. The AQAA did not record the date of the certificate to evidence a check of the electrical circuits. The Manager stated that this was due for renewal and external contractors are currently working in the home to address this. The Manager has previously stated the emergency call system is run by batteries which are regularly checked each month and a sample of the records were viewed. A fire risk assessment of the building was undertaken of the building in 2008 by an external agency. A sample of records was viewed of fire training and fire drills undertaken by staff in the home. Two care workers spoken with confirmed they had undertaken this training. A sample of recording was viewed of incidents and accidents, which had occurred in the home. Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 26 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 2 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 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 2 2 Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 27 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 OP37 Regulation 17 Requirement That all the required policies and procedures are in place. To protect residents and staff. That advice is sought from the Health and Safety Executive as to the frequency environmental risk assessments should be reviewed. To ensure the continued safety of residents and staff. Timescale for action 30/09/09 2. OP38 13 31/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beeches Retirement Home DS0000021045.V375732.R01.S.doc Version 5.2 Page 28 Care Quality Commission South East 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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