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Inspection on 04/11/09 for Beechcroft Nursing & Residential Home

Also see our care home review for Beechcroft Nursing & Residential Home for more information

This is the latest available inspection report for this service, carried out on 4th November 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

A system was in place to record people’s needs and wishes prior to them moving into the home. Activities were available for most people to participate in and a new activities programme was being developed. People were supported by staff who knew them well. People told us that there was always someone to talk to if they were not happy and the majority of people knew how to make a formal complaint about the service. The living environment was clean, comfortable and tidy. People told us that they receive the medical support they require.Beechcroft Nursing & Residential HomeDS0000005171.V378300.R01.S.docVersion 5.2Systems were in place for the safe management of people’s finances. Health and Safety policies and procedures were in place to protect people’s health, safety and wellbeing.

What has improved since the last inspection?

The service has an ongoing refurbishment and redecoration programme. We observed staff asking people in their bedrooms whether they wished for their bedroom door to be left open or closed.

What the care home could do better:

To help ensure that people receive the care and support they require all information in the care plans and risk assessment must be up to date and consistent. For the health, safety and wellbeing of all, medication must be stored and managed appropriately at all times. To help ensure that all adult protection concerns are managed appropriately all potential concerns must be reported under the local safeguarding procedures. All staff must have an awareness of what constitutes a referral under safeguarding procedures.

Key inspection report CARE HOMES FOR OLDER PEOPLE Beechcroft Nursing & Residential Home Lapwing Grove Palacefields Runcorn Cheshire WA7 2TP Lead Inspector Adele Berriman Key Unannounced Inspection 4th November 2009 10:00 DS0000005171.V378300.R01.S.do c Version 5.3 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 Nursing & Residential Home DS0000005171.V378300.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 Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechcroft Nursing & Residential Home Address Lapwing Grove Palacefields Runcorn Cheshire WA7 2TP 01928 718141 01928 714573 beechcroft@schealthcare.co.uk www.schealthcare.co.uk Southern Cross Care Homes No 3 Limited 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) Manager post vacant Care Home 67 Category(ies) of Old age, not falling within any other category registration, with number (67) of places Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either Whose primary care needs on admission to the home fall within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 67 10th April 2008 Date of last inspection Brief Description of the Service: Beechcroft is a care home that provides nursing and personal care for 67 older people. The home is in the Palacefields area of Runcorn, in a quiet cul-de-sac, close to churches, a pub and local shops. The home was opened in 1989 and consists of two single storey purpose built units providing personal care and care with nursing to people. All bedrooms apart from one are single and six have en-suite facilities. The grounds are landscaped and well appointed, with good access for people with a disability. There are additional charges for hairdressing, toiletries, newspapers and outside social activities, for example cost of transport and theatre tickets. Beechcroft Nursing & Residential Home DS0000005171.V378300.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 1 star. This means that people who use the service experience adequate quality outcomes. As part of this key inspection we carried out an unannounced visit to Beechcroft on 4th November 2009. During our visit we spoke to people who lived at the home, a visitor, the manager and the area manager for Southern Cross Healthcare. We looked at a selection of records, policies and procedures, care plans and staff files. We also toured some areas of the building to assess the environment. Prior to our visit the manager of the service had completed an Annual Quality Assurance Assessment (AQAA). This self assessment form gave them the opportunity to tell us what they did well, what they could do better, what improvements they had made in the past 12 months and their future plans for improvement. The AQAA contained most of the information that we asked for. The assessment also contained some numerical information that we asked for. Five people who live at Beechcroft and six staff completed a survey form and told us their views on life a Beechcroft. Information from these survey forms is contained in this report. What the service does well: A system was in place to record people’s needs and wishes prior to them moving into the home. Activities were available for most people to participate in and a new activities programme was being developed. People were supported by staff who knew them well. People told us that there was always someone to talk to if they were not happy and the majority of people knew how to make a formal complaint about the service. The living environment was clean, comfortable and tidy. People told us that they receive the medical support they require. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.2 Page 6 Systems were in place for the safe management of people’s finances. Health and Safety policies and procedures were in place to protect people’s health, safety and wellbeing. What has improved since the last inspection? 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 Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.2 Page 7 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 Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 8 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): 2 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 moving into Beechcroft are given information, and have their needs assessed so they will know if their needs can be met. EVIDENCE: We saw that a pre admission assessment was carried out prior to a person moving into Beechcroft. The purpose of this assessment was to ensure that the staff were aware of people’s individual needs and to ensure that the home had the facilities to meet the these needs. We saw that information gained during the pre admission assessment process was recorded on a set format. The document gave the opportunity to record brief details about people’s care and health needs within their day to day life. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 9 We looked at several people’s personal files which contained pre admission assessments. In addition to the pre admission assessment they also develop a draft care plan so that staff are able to deliver the care and support that people need from the day that they move into Beechcroft. We saw that a draft care plan was not completed for one person who had recently moved into the home. To help ensure that people receive the care and support they require, detailed information should be available about how their needs and wishes are to be met. We spoke to a relative of a person who had recently moved into the home. They told us that they had been given information about Beechcroft and that staff had visited their relative in hospital to carry out an assessment of their needs. They told us that prior to their relative moving in they had visited the home to have a look around. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 10 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 & 10 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care planning and risk assessment records should be developed to ensure they contain people’s assessed and changing needs. EVIDENCE: We saw that each person had their own file that their contained their personal information, pre admission information and their care plan. We looked at six people’s care plans and saw that they gave the opportunity to record people’s day to day care and nursing needs. We saw that the information written in the care plans varied in detail. For example, one care plan stated ‘at risk of falls and injury’ but no further information was available to inform staff on how falls or injury could be minimised. We saw that there was little information completed in one person’s care plan who had recently Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 11 moved into the home. To help ensure that people receive the care and support they require a detailed up to date care plan must be available. We saw that risk assessments specific to individuals’ needs formed part of people’s care plans. Some of the assessments that we saw considered the use of bed rails, moving and handling, nutrition and the environment. Not all of the information in the care plans and changes to people’s needs had been considered in the risk assessments. For example, we saw one risk assessment for maintaining a safe environment that had not considered that the person used bedrails and protective covers whilst in bed at night. Another risk assessment failed to consider information from a nutritional screening tool that formed part of the person’s care plan. A further assessment stated that the individuals’ nutritional intake was at risk, however, this risk was not reflected in the person’s care plan which stated ‘has a normal diet.’ Care plans and risk assessments must contain up to date information about people’s care and support needs to help ensure that people receive the care and support they require. We saw the format for the care plans gave the opportunity to record whether the person was for resuscitation in the event of a situation occurring. We saw a note on one person’s file that stated ‘not for resus’. The entry into the file had been made in 2004 and had not been signed by the person themselves. We saw no evidence that this decision had been reviewed. To help ensure that people’s rights are acknowledged at all times, records must demonstrate that people’s capacity to make decision under the Mental Capacity Act 2005 framework have been considered. The majority of staff who completed a survey form told us that they are always given up to date information about the needs of the people they care for. We saw records that demonstrated that people had regular access to local health care professionals. The majority of people who completed a survey form told us that they always receive the care and support they need. People told us that the home always makes sure that they get the medical care they need. We saw that they had policies and procedures for the safe administration, storage and management of medication. We saw that all medication administered was recorded on a Medication Administration Record (MAR). We looked at a selection of MAR’s and they were signed appropriately. We saw that medication audits took place on a monthly basis and an action plan was in place for any discrepancies found during the audits. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 12 During our visit we observed an open medication trolley being left unattended on several occasions. For the health, safety and wellbeing of all, it is essential that medication is stored securely at all times. The majority of people who completed a survey form told us that staff always listen and act on what they say. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 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): 12,13,14 & 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. Most people were able to take part in activities that suited their lifestyle. EVIDENCE: We saw that they had recently employed an activities coordinator. They told us that the coordinator was in the process of arranging activities for everyone and that whilst these arrangements were being made a temporary activities programme had been developed. We saw that these activities included bake time, crossword, water colours, bowls, watching a film, card making, karaoke, drawing and bingo. Most people who completed a survey form told us that the home usually arranges activities that they can take part in. One person told us that there should be more activities available for people who have difficulties with their sight. They told us that a PAT dog and its owner visit Beechcroft on a weekly basis. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 14 One person told us that they liked to watch the birds and local wildlife through their patio windows in their room. They told us that staff had supported them in developing bird tables and flower pots to make the view from their room more colourful and interesting. They told us ministers visit the home on a weekly basis to enable people to take communion. In addition, two people also visit the local multi denominational church on a weekly basis. One person told us that they just ask the staff if they want to visit the local church. They told us that visitors were welcome at anytime and that to encourage relatives’ participation in the home, meetings for residents and their families took place. One relative told us that they would like to attend the meetings however, they were unable to attend at evening time. Another person told us that staff contact them to tell them when their relative was not well, had had a fall or the results of a doctors appointment. They told us that they appreciate this information. We observed staff knocking on people’s doors before entering and asking the person if they wanted their door closed or open to their room. We saw that several bedroom doors were fitted with locks. People told us that they were not offered keys to their room. To promote choice and privacy, where possible, people should be offered a key to their bedroom. We saw that meals were served in dining areas attached to communal lounges. A four week menu was in place which demonstrated that the main cooked meal of the day was served at lunchtime and a lighter meal was served at teatime. Breakfast was not displayed on the menus. The menu did not contain information about the choice of meals available for people requiring a pureed diet. To help and assist people in choosing what they wish to eat a detailed menu should be available that demonstrates the choice of meals available to people. They told us that people were asked their choice of menu the previous day. On the day that we visited we saw a meal of sausage casserole, mashed potato, carrots and peas or salmon salad being served. The food was well presented and looked appetising. People who completed a survey form told us that they usually liked the meals at the home. Three staff who completed a survey form made comments about the quality of food made available to people. They told us that the home could improve the food served. One staff member wrote “the food is poor and there is no choice” Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 15 and another staff member wrote that improvement was needed in the meals served “especially for nursing clients.” To help ensure that people are given a choice of what they want to eat a regular review of the menus should take place. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 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 & 18 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies and procedures were in place to safeguard people. Staffs’ lack of awareness of these policies may result in situations not being dealt with appropriately. EVIDENCE: We saw that information relating to the home’s complaints procedure was available. They told us in their AQAA that people were provided with a copy of the procedure when they moved into the home. We saw that they had a register available to record any complaints that had been made. They told us in their AQAA that they had received seven complaints since we last visited. The majority of the complaints were upheld and resolved within 28 days. They told us that their plans over the next 12 months were to reduce the number of complaints made about the service by improving communication with people. People who completed a survey form told us that there was always someone they could speak to if they were not happy. The majority of people told us that knew how to make a formal complaint about the service. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 17 We saw that they had policies and procedures in place for the protection of vulnerable people. A copy of Halton Social Services safeguarding procedures was also available. During our visit we saw information on a record that demonstrated that a person had bruising. This situation had not been referred to Halton Social Services under their safeguarding procedures. To help ensure that people are protected from harm, all potential safeguarding situations must be referred under the local safeguarding procedures to ensure that they are dealt with appropriately. The training matrix made available to us demonstrated that 20 of staff had received training on the Safeguarding of Vulnerable Adults within the last 12 months. To help ensure that adult protection situations are managed appropriately, all staff should receive regular training in recognising and referring safeguarding situations. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 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 & 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. Beechcroft provides a safe and comfortable home that is well maintained. EVIDENCE: They told us that they had a programme of ongoing maintenance and refurbishment which included bedrooms being decorated when they become vacant. They told us in their AQAA that their plans for the next 12 months included increasing the number of planted areas in the garden and to provide a small greenhouse. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 19 We looked at a selection of dining rooms, lounges and bathrooms that were for communal use. We saw that they were clean and tidy and contained furniture and equipment to meet people’s needs. We visited several bedrooms. We saw that the majority of bedrooms were personalised with people’s individual personal effects and equipment, for example, one bedroom contained a small fridge and kettle. One bedroom that we saw contained a divan bed that was ripped on the side. The manager told us that she would address this issue immediately. Most areas of the home that we visited were clean, tidy and free from offensive odour. The majority of people who completed a survey form told us that the home was always fresh and clean. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at Beechcroft are supported by a staff team that know them well. To ensure that people continue to receive this support, staff should receive regular up to date training for their role. EVIDENCE: We saw that a team of carers, a qualified nurse, domestic staff and a cook were on duty to meet the needs of the people living at Beechcroft. The manager of the service also was present for the majority of our visit. Throughout our visit we observed that the staff team were extremely busy carrying out their role. We saw that morning medication was still being administered at 11am. The service should ensure that sufficient numbers of staff are available at all times to help ensure that people’s needs can be met. People who completed survey forms told us that staff were usually available. The majority of staff who completed a survey form told us that there were usually enough staff to meet people’s individual needs, one staff member told us that there usually were. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 21 People told us positive things about the staff team. These comments included “caring and efficient” and “staff are really nice.” They told us that they were in the process of recruiting qualified nurses so that two qualified nurses would be on duty throughout the day to meet the needs of people. We looked at the files of five staff, all of which had been recruited since we last visited. We saw that the files contained the required recruitment information including application forms, written references and evidence of appropriate POVA 1st register and Criminal Record Bureau disclosure checks. All staff who completed a survey form told us that their employer carried out employment checks before they started work. They told us in their AQAA that they had a staff development programme that meets the National Minimum Standards and that over 50 of staff had completed induction training recommended by Skills for Care. We saw a staff training matrix that demonstrated that in the last 12 months under half of the staff had completed training in fire safety, fire drills, food hygiene, moving and handling, Control of Substances Hazardous to Health, health and safety, POVA, infection control, nutrition, pressure care, dementia awareness and the safe use of bed rails. The training matrix demonstrated that the majority of staff had received training in care planning and the safe handling of medicines. To help ensure that care and support are delivered appropriately staff should receive regular up to date training for their role. The majority of staff who completed a survey form told us that they were given training that was relevant to their role and that helps them understand people’s individual needs. They told us in their AQAA that seven staff had completed a National Vocational Qualification level 2 or above. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 & 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. Beechcroft is managed with policies and procedures in place to help ensure that the health and safety of people is promoted. EVIDENCE: The manager of the service had several years experience in working in a social care environment. She demonstrated an awareness of what changes needed to be made to improve the service. They told us in their AQAA that their plans Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 23 for the next 12 months included the continued development of staff competences and to develop a more open communication with the staff team. The manager was in the process of registering as the manager of the service with the Care Quality Commission. To monitor quality assurance within Beechcroft they told us that they regularly sent out surveys to people and their families and meetings were planned for people and their families. In addition, we saw that a representative from Southern Cross Healthcare visits the home on a regular basis and that the organisation carried out regular audits throughout the service. We saw that systems were in place to safeguard people’s money. We saw that on occasions clinically trained staff had received supervision from a person not clinically trained. To help ensure that people receive the care and support they require staff should be supervised by a person suitably trained in the role. Several staff who completed a staff survey form told us that they were regularly given enough support from their manager, others said that often were and one person told us that they sometimes were given enough support. A written Health and Safety procedure was available and we saw that policies and procedures were in place to support the health, safety and wellbeing of people. Maintenance records demonstrated that regular monitoring took place of facilities and appliances throughout the building. Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 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 X 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 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. 1. Standard OP7 Regulation 15 Requirement Care plans and individual risk assessments must contain detailed up to date information about people’s needs and lifestyle choices. The registered person must make suitable arrangements for the appropriate administration and storage of medication. This is so that medication is stored appropriately and that people receive their medication when it is prescribed. To help ensure that all adult protection concerns are managed appropriately all potential concerns must be reported under the local authority safeguarding procedures. All staff must have an awareness of what constitutes a safeguarding referral under the local safeguarding procedures. Timescale for action 25/01/10 2. OP9 13 14/01/10 3. OP19 13 14/01/10 Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 26 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. Refer to Standard OP3 Good Practice Recommendations Pre admission information should be detailed to help ensure that people receive the care and support they require. People’s care plans should consider the individual’s rights and choices under the Mental capacity Act 2005 framework. To help ensure that a accurate medication records are maintained all topical applications must be recorded when applied. To promote choice and independence, when possible, people should be encouraged to have a key to their own room. Keys to rooms should be available and accessible to staff for access in the event of an emergency. 5. OP15 A review of the menu should take place to ensure that it contains information about people’s choice of all meals throughout the day for all types of diet A regular review of the number of staff available to support people should take place. This will help ensure that people receive the care and support they require. 50 of care staff should attain a National Vocational Qualification at Level 2. A review of all staff training should take place to ensure that all staff have regular access to training needed for them to carry out their role. 2. 3. OP7 OP9 4. OP14 6. 7. 8. OP27 OP28 OP30 Beechcroft Nursing & Residential Home DS0000005171.V378300.R01.S.doc Version 5.3 Page 27 Care Quality Commission North West 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. 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