Inspection on 25/05/08 for Beech Haven

This is the latest available inspection report for this service, carried out on 25th May 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beech Haven 17/01/07

Beech Haven 29/08/06

Beech Haven 15/11/05

Beech Haven 10/05/05

Beech Haven 17/08/04

Beech Haven 26/04/04

Beech Haven 08/09/03

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Beech Haven 15-19 Gordon Road Ealing London W5 2AD Lead Inspector Ms Jane Collisson Key Unannounced Inspection 09:35a 25th 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 Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Haven Address 15-19 Gordon Road Ealing London W5 2AD 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) 0208 991 0658 0208 991 0658 beechhaven@myway.com Mrs Phaik Choo Scarman Mr John Scarman Mrs Phaik Choo Scarman Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability over 65 years of age (0) of places Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user with Dementia can be accommodated, as agreed by the Commission for Social Care Inspection, on 19th January 2006. The service user may remain resident until such time when the home is unable to meet the individual service users assessed needs and care plan and for as long as there is no deterioration which affects the well being of other service users. The home must advise CSCI when the service user no longer resides at the home. 9th May 2007 Date of last inspection Brief Description of the Service: Beech Haven is a private care home for thirty older people. It was first registered in 1986 under the Registered Homes Act 1984. The Registered Providers are Mr and Mrs Scarman and Mrs Scarman is the Registered Manager. Currently the home is registered for older people only, including those with physical disabilities. The home is three large attached houses, in a residential area near to Ealing Broadway. The home has easy access to shopping facilities and local amenities, including places of worship. An underground and main line station and several bus routes are close by, and the North Circular Road and A40 are within a few minutes’ drive. The accommodation consists of thirty single bedrooms, which are on three floors. Nine have en-suite toilets. There is a large lounge/dining room that is equipped to comfortably accommodate everyone for their meals. The lounge overlooks an attractive enclosed garden to the rear of the home. The main kitchen is off the dining room. There is a small lounge situated at the entrance of the home. This can be used as a quiet area, to see visitors, or for meetings. There are adequate bathroom and toilet facilities on each floor. A passenger lift is provided and there are ramps to access the home and garden. To the front of the home there are parking spaces for several cars. The fees for the home are from £520 to £700 per week. Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. We visited this home for an unannounced inspection on Sunday 25th May 2008 from 9.35am until 3.30pm. One of the Registered Providers was present and the Registered Manager came to the home shortly afterwards. There were four members of staff on duty. The home had eighteen people being accommodated, including one who was on respite. The majority of the people living in the home were met on the first day of the inspection. Three people had visitors during the morning. Those people met were positive about the support they receive from the home’s staff. One person said that the staff were “very kind” and another said that their relative had settled well into the home. We made a further visit on the 2nd June to look at further records, including some which had not been available or up-to-date on the first visit. The inspection took a total of eight hours. We examined a variety of records during the inspection, including care plans, medication records, complaints, staff, training and maintenance files. We toured the home and saw all of the communal areas and some bedrooms. Some people prefer to stay in their rooms and two were seen privately. Other people were seen, and spoken with, in the main lounge and the dining room on both occasions. We found that, since the last inspection, new carpets had been laid on one of the staircases and hallway. The Registered Provider informed us that further improvements are planned to the dining room. New tables and chairs had been delivered, but were not yet in use, and the new lounge chairs were due to arrive the following week. Some improvements have been made the bathrooms to make them more homely. One of the Registered Providers had completed the 2007 Annual Quality Assurance Assessment, as required by the Commission for Social Care Inspection, and was in the process of sending the 2008 version. The Assessment contains information about the home, future plans, its residents and staff, and details of maintenance, and will be used to support this inspection. We were informed that there were no specific cultural needs being met at the present time and none of the people spoken to raised any unmet needs. People are able to have their religious needs met by having visits to the home or visiting the religious establishment of their choice. Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 6 The Registered Providers have made efforts to meet all of the outstanding requirements. There were ten requirements at the previous inspection and these have been met. Five have been made at this inspection. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose does not fully demonstrate how the needs of people of people whose needs fall within its registration categories of old age and physical disabilities. People should not be admitted whose primary need is outside of these categories. Where people have other needs, such as dementia care, the Statement of Purpose needs to show that these can be met by staffing levels, training, activities and the home’s environment. Risk assessments are in place, and risks identified, but they are sometimes general and need to be more relevant to the person assessed. People are not always satisfied with the variety of meals provided, or the way in which they are served. A better variety of menu needs to be offered to ensure that there is the opportunity to choose. People need to be aware of the choices through access to information. Where there are incidents which may be issues under the safeguarding adults procedures, these must be reported to the Commission for Social Care Inspection. Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 7 To support the safety of people who wish to keep their bedroom doors open, and promote their choice, suitable devices need to be fitted so that the doors will close when the fire alarms are activated. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 (6 does not apply) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a Statement of Purpose but this does not fully demonstrate how the varied needs of people are met. Admissions are not made to the home until an assessment has been undertaken by the Manager. Prospective residents are given the opportunity to spend time in the home. New residents are provided with a statement of terms and conditions or a contract. EVIDENCE: The Registered Providers had updated the Statement of Purpose in line with a previous requirement. The home does not have a category for dementia care but the Registered Providers said that they try to accommodate people who may develop the illness after admittance to the home. However, it was noted that at least one person has been admitted with diagnosed dementia. The home must ensure that people are admitted who fall within its category of registration and their primary reasons for being admitted should be because of old age or physical disabilities and not dementia. The Registered Providers Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 10 said that the Statement of Purpose would be amended to ensure that this is clear. The Registered Providers said that the Statement of Purpose and other information can be provided in large print if it is required. The majority of the people living in the home are privately funded. Therefore, most of the assessments are carried out by the Registered Provider/Manager. Examples of these were seen. A small sample of local authority assessments were seen where they are the commissioners. The facility to visit the home prior to admission is offered to all prospective residents but one person confirmed that they had chosen not to do so as the home appeared to offer what they needed. The home does not offer Intermediate Care, so this National Minimum Standard could not be assessed. Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are being developed to be more person centred, easier to understand and which look at all areas of the person’s life, including their preferences. The care plans are reviewed regularly and involve the person and their representatives, as appropriate. Risk assessments are completed but they are sometimes general and not specific to the individual person. The medication administration is generally satisfactory. EVIDENCE: We found, since the last inspection in May 2007, that there have been improvements in the care plans. One of the Registered Providers explained that they had changed them to be more “person centred” and he was getting them all put on the computer for easier reading. People are offered a copy but not all choose to have them. It was noted on the care plans that they had been read by the person or their relative. In some cases, the Registered Providers had read them to the person for their agreement and this was recorded. We examined five of the care plans and found them improved, although not all are yet typed. Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 12 Care plans are reviewed by the person’s key worker on a monthly basis. A person’s annual review was seen to have taken place between the two visits to the home and a number of alterations had been recorded, which will be incorporated into the care plan. The person’s family had been involved as the care staff said that the person is unable to speak for themselves. Some of the items on the care plan which were to be changed were those on food. The care plans include details of any cultural needs that that person may have. The Registered Providers, and the people spoken to, reported that there were no special needs at the present time. We found that improvement have been made to the risk assessment procedures but some of the risk assessments were rather general and did not appear to be specific to the person. The Registered Providers were aware that more work was needed to improve these. We saw information in the care plans about health needs. In some instances, medical professionals visiting the home recorded the outcome of the visits on a “clinical note” sheet. Since it was discussed at previous inspections that the notes were not always legible, there is now a chronological list for all the medical and health visits made to the home or arising from visits to hospital or the general practitioner. A list of health needs was seen in some of the files, such as the regularity of visits, but these were not fully completed. It was discussed with one of the senior staff and, by the second visit, these have been completed. We examined a sample and saw that these detailed the health needs that the person has, when they was last met and the timescale for future appointments. The home has a weekly filled dosette box system for its medication, provided by a local pharmacy. The medication checked was satisfactory but the medication given that morning, for one person, was not signed for. The Registered Manager was informed and it was ascertained that the person had forgotten to sign. Although it was not recorded that the staff member concerned had medication training, the Registered Providers said that the staff member would have had the training in the past. The person was to be included on the medication training arranged for the staff team, with the local pharmacist, later in the week. The Registered Providers confirmed that there had been no other medication errors. The people living in the home that we spoke to during the inspection were generally very happy with the way in which personal care support is provided. One person confirmed that same gender care is provided in line with her wishes. Not all of the people in the home are able to communicate their wishes but most have family and friends to support them. They are involved in supporting the person with their care plan where they cannot do this for themselves. Beech Haven DS0000027723.V362091.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are mainly involved in activities of their own choice and according to their individual interests. People have the opportunity to maintain friendships and family relationships and see visitors in private. The meals are not always sufficiently varied to provide a good choice or enable people to know what is available. EVIDENCE: The home has a large lounge, which is also the dining area. Not everyone stays in the lounge after meals and the preferences of those people who choose to stay in their rooms are respected. People said that it is important for them to be able to do so if they wish. The Registered Providers said that a pianist visits occasionally and one of the staff provides some activities. There had also been an entertainer in the home between the inspection visits. The number of people who chose to stay in the lounge is relatively small. The Registered Providers said they have plans to install a 40” wide screen television for people to watch. The housing had been placed on the wall so that it can be seen from a distance. However, the Registered Providers had postponed its installation until an integrated high definition television is Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 14 available. There is, however, a television in this area for people who wish to watch it. In additional to this area of the lounge, there is another area where people can sit more quietly and one person was enjoying reading. The dining area can also be used for activities, such as reading newspapers or games. The staff had photocopied a crossword for those who wished to do complete one. There is a small lounge which is used for meetings, but tends not to be used by the residents. Many of the people have relatives or friends who visit them. Three people had visitors during the first day of the inspection and all of them saw their visitors in their rooms. Those spoken to were happy with the care that their relative receives. Two people go out unaccompanied and are able to visit the local facilities. We have had discussions at previous inspections with the Registered Providers about enabling people to be more involved in choosing their meals. The Registered Provider told us in the 2007 Annual Quality Assurance Assessment that he intends still to improve the dining area and also said, on this visit, that he has the tables and chairs for this. The tables are smaller than those already in place. He also intends to have table cloths to improve the look of the dining area. No menu is displayed in a format that people would be able to easily access. The meal on the day of the first visit was roast beef. One person, who is a non-meat eater, had an alternative of fish. We reported to the Registered Providers that not everyone we spoke to was happy with food on offer, the choice or the variety. Among the comments from residents was that the same vegetable was served for several days running. Another person said that the staff did not ask whether a small or large portion was wanted. It was observed that some people did not want the food because of this and it was being wasted. This is an area which has been highlighted before. The meal on the second visit was a choice of two casseroles, pork or chicken, with the same vegetables. On the samples of menu seen, we found that the second choice was often a vegetarian option, such as a vegetarian cutlet or jacket potato, which does not provide a real alterative. After discussion with the Registered Providers, they said that they would look more thoroughly at the menu and the way in which food is served to the people living in the home. The Registered Providers had recognised in the home’s Assessment that the experience could be improved but had only just started to address this. Beech Haven DS0000027723.V362091.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. 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. There is a low incident of complaints and people say they would raise a serious complaint but not everyone would raise a smaller concern. Staff have training on safeguarding adults but the Registered Providers have not always reported appropriately. EVIDENCE: The home has a complaints procedure included in its Service Users Guide. People spoken to said that they would make a complaint should there be a reason for this. Two people did not feel that they would like to make complaints about the food, but did believe that it could be improved. We found that there were two recorded complaints since the last inspection. One concerned the use of a telephone and the other was about the food. These were recorded as having been dealt with promptly. There have been no safeguarding issues raised with the Commission for Social Care Inspection. One of the Registered Providers said that an issue had been reported to the Local Authority, which was subsequently not pursued. We discussed with the Registered Provider that this should have been reported to the Commission for Social Care Inspection under Regulation 37. Staff have all undertaken safeguarding adults training within the last three years. Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 16 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, 21, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical environment generally meets the needs of the people who live there. The home is comfortable and has a programme to improve the decoration, fixtures and fittings but people would benefit if the changes were made within a reasonable timeframe. The bathrooms and toilets are fitted with appropriate aids to meet the needs of the people who use the service, and are in sufficient numbers at present. The home was clean and tidy. EVIDENCE: We toured the building as part of the inspection and saw all of the communal areas and some of the bedrooms. There is a large L-shaped lounge which has a television area, a quieter area and the dining room. The kitchen is located just off the dining area. We discussed with the Registered Provider his plans for improving the lounge, with new dining furniture, and armchairs which were due to arrive the Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 17 following week. He also discussed putting new carpet in the area and generally brightening the lounge. The lounge overlooks a large and well maintained garden and there are doors for easy access. One person was sitting out at the first visit, after lunch, and said she enjoys the opportunity to be in the fresh air. The requirement to have new carpets in one of the halls and staircases has now been completed. There are four assisted bathrooms, for the use of up to thirty residents. However, one was not in use at the time of the inspection but the Registered Providers said that it is to be returned to use. There are no separate shower facilities, but all of the baths have shower attachments. Some bathrooms have been decorated. In two toilets, we found that the doors did not have workable locks, which does not enhance dignity and privacy. The Registered Providers were informed about this and action was taken on the second visit to replace them. The bedrooms seen on this inspection were bright and personalised. People confirmed that their beds were comfortable and they had what they required, including small items of furniture from their previous homes. The home was found to be clean and tidy. However, the people living in the home would benefit if the work in the areas planned for upgrading, such as the dining area, large lounge and one of the bathrooms, is carried out within the near future. Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service undertakes regular staff training and tries to delivers a programme that meets any statutory requirements. There is a consistent staff team. Staffing rotas take into account the needs and routines of the people using the service. People using the service report that staff are kind and meet their needs. The home’s recruitment procedure meets statutory requirements but the subsequent record keeping needs improvement. EVIDENCE: There were eighteen people living in the home at the time of the inspection. They have the support of four staff during the early shift, three during the later shift and two waking night staff. The Registered Provider said that this is the staffing level with the current number of vacancies but it would be increased if there were more people admitted to the home. The Registered Provider/Manager’s hours have not been included in the rota and she was advised that these need to be. This was actioned by the time of the second visit. The other Registered Provider is in the home on a very regular basis, but is involved in training and administration, rather than care work. One of the Registered Providers is trained to undertake moving and handling training. The training records were initially not up-to-date but an updated copy was provided on the second visit. Certificates are available in individual files but, because it was not possible to check all of these, the Registered Providers Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 19 were asked to bring the summary up-to-date to evidence that all of the staff have the required training. They did so by the second visit to the home. Staff were all seen to have up-to-date training in manual handling, first aid, fire safety, infection control and safeguarding adults. Induction records, which meet the Common Induction Standards and are in the form of workbooks, were seen for the newer staff. The requirement for the staff to have had food hygiene training has been completed. The Registered Provider said that the cook and Registered Manager had been on training for nutrition. We examined a sample of the home’s recruitment files. A number of staff have come from abroad and did not have previous employers from whom references could be obtained. All of those seen were from friends or excolleagues. Criminal Records Bureau disclosure checks have been obtained, although one of these was not in the file and was seen on the second visit. Several of the staff require visas to work in the country. Although information had been recorded when they were employed, this was found to be out-of-date for five staff. The Registered Provider was asked to get this information from the staff concerned. By the second visit to the home, the information for all of the staff had been obtained. The Registered Provider produced a table of the evidence to show that the staff have the right to work which he said he will now keep up to date. Six of the staff team have National Vocational Qualifications at Level 2 and Level 3. One senior care staff member has Level 4. A further five are undertaking the qualification and two are due to start. The Registered Provider/Manager was due to undertake the training to become a National Vocational Qualification assessor. Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All sections of the Annual Quality Assurance Assessment had been completed and the information gives a reasonable picture of the current situation within the service. The home has a pleasant and relaxed atmosphere which the people living in the home appreciate. The Registered Providers have the required qualifications and experience to run the home. Quality assurance is undertaken to see where there are shortfalls in the service. Staff benefit from regular one-to-one supervision. EVIDENCE: Both of the Registered Providers, one of whom is the Registered Manager, have the National Vocational Qualification at Level 4 and have managed the home for many years. The Registered Manager is a former nurse. Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 21 The home has provided continuity for the people living in the home by retaining a consistent staff team. The home has a relaxed atmosphere which is appreciated by the people spoken to. In respect of a requirement made in 2007, to have a system to review the quality of care, the Registered Providers provided us with the results of the surveys. A thorough assessment of the home had been undertaken, which identified the Standards which have been met and those which needed to be completed. The Commission for Social Care Inspection’s Annual Quality Assurance Assessments had been completed for 2007. This provided us with information about the management, its future plans and statistical information about the home. This had broadly been met but some of the environmental changes still need to be completed The Registered Provider had completed the 2008 AQAA but it had not yet been received by the Commission for Social Care Inspection. The Registered Providers confirmed that they do not manage any of the personal finances for the people living in the home. These are dealt with by the people themselves or the representatives. We found that regular supervision has been carried out with the staff, which are recorded and a record kept of the number undertaken. The Registered Providers said they aim to meet the National Minimum Standards of six sessions a year. The Registered Providers had recorded that the policies and procedures of the home were last reviewed in 2007. We found that there have been improvements to the record keeping, but sufficient monitoring is needed to ensure they are up-to-date. In particular, the staff and training records needed attention. One of the Registered Providers was in the process of completing the Annual Quality Assurance Assessment for 2008. The 2007 Annual Quality Assurance Assessment was completed and has broadly been met but. One person was seen to like the bedroom door kept open and the Registered Provider was asked to ensure that a device was fitted so that the door did not require propping open and he agreed to do this. These devices, which provide for the door to close when the fire alarm is activated, are fitted in other areas of the home. We checked a range of records, including fridge, freezer and water temperatures for May 2008. The fire alarm systems are checked weekly and regular fire drills take place, with the participants recorded. Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 22 Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 23 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 2 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 X X 3 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 3 3 X 3 3 3 2 Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 24 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 OP1 Regulation 4 (1) Requirement The Registered Providers must ensure that it is clarified in the Statement of Purpose how the needs of people within its category of registration are being met. The Registered Providers must ensure that all of the risk assessments are relevant to the individual residents in the home. The Registered Providers must ensure that there is a varied choice of food, including specialist diets, provided and that every effort is made to ensure that people are made fully aware of the choices. The Registered Providers must ensure that they report all incidents as require under Regulation 37. The Registered Providers must ensure that, where people living in the home wish to have their doors kept open, devices are fitted that enabled the doors to close in the event of the fire alarm being activated. Timescale for action 31/07/08 2. OP7 13 (4) 31/07/08 3. OP15 16 (2) (i) 31/07/08 4. OP18 37 30/06/08 5. OP38 13 (4) 31/07/08 Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 25 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 Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beech Haven DS0000027723.V362091.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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