Inspection on 18/08/08 for Edgbaston Beaumont

This is the latest available inspection report for this service, carried out on 18th August 2008.

CSCI 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 CSCI 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.

Other inspections for this house

Edgbaston Beaumont 14/02/07

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Edgbaston Beaumont 32 St James Road Edgbaston Birmingham West Midlands B15 2NX Lead Inspector Kulwant Ghuman Unannounced Inspection 18th August 2008 10:10 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 Edgbaston Beaumont DS0000069247.V370624.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. Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Edgbaston Beaumont Address 32 St James Road Edgbaston Birmingham West Midlands B15 2NX 0121 440 0421 0121 446 3333 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) www.barchester.com Barchester Healthcare Homes Ltd Mrs Diane Karen Bland Care Home 28 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (28) of places Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing (Code N) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 28 Old age, not falling within any other category (OP) 28 The maximum number of service users who can be accommodated is: 28 21st August 2007 2. Date of last inspection Brief Description of the Service: The home is well established and situated within the boundaries of Birmingham city centre with easy access to community facilities. Edgbaston Beaumont provides nursing care for up to twenty-eight persons above the age of 65 years who may suffer from dementia. Accommodation is provided in single en-suite rooms situated on the ground and first floors. A shaft lift provides assisted access to each floor. Communal toilets and bathrooms are strategically located on each floor, which include assisted bathing facilities. There is a lounge situated on the first floor as well as a main lounge, restaurant, conservatory and a further lounge located on the ground floor. These rooms are of a high standard, well appointed, furnished and maintained. There is a pleasant enclosed garden, which residents frequent during clement weather. The home also has a gym for use by residents and separate close care accommodation within the grounds and the nursing home building. There is ample parking available at the front of the premises. The spacious reception area is staffed during office hours Monday to Friday, and beverages are freely available to visitors and residents. The scale of charges for the home is: £700 - £950. Items not included in the charges were: hairdressing, newspapers, chiropody and transport. Edgbaston Beaumont DS0000069247.V370624.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 outcomes. Two inspectors carried out this inspection over one day during August 2008. The home did not know that we would be visiting the home that day. We were able to talk to the manager and 4 staff during the day, look at the care files of three people who lived in the home and the files of three people who worked in the home. We also spoke to three people who lived in the home and received completed questionnaires from 2 staff and 5 people who lived there. We were also able to walk around the home and observe interactions. The Annual Quality Assurance Assessment had not been completed as the visit the had been carried out before it was due to be returned to the commission. The completed AQAA was received a few days after the inspection and it gave some additional information. What the service does well: What has improved since the last inspection? Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 6 The home continues to upgrade the decor and furnishings in the home with 5 bedrooms having been completed since the last inspection ensuring people living in the home have a comfortable place to live. The views of the people living in the home have been listened to and changes have been made to the menus ensuring that there is more variety and that dishes people want to eat are included. A patio area has been developed for people living in the home to sit out on during the good weather. The service user guide and statement of purpose have been updated. The adult protection procedures have been updated. What they could do better: 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. Edgbaston Beaumont DS0000069247.V370624.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 Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 ,3 ,4 ,5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process ensures that people wanting to move into the home are able to make informed decisions about whether to move into the home and the home to ensure that their needs can be met. EVIDENCE: People wanting to move into the home receive a welcome pack. The information available tells them about what services they can expect from the home and can help people to make up their minds as to whether the home is suitable for them. The information had been updated since the last key inspection. People are able to visit the home and an assessment is carried out at that visit. The pre-admission assessment form enables information to be collected and together with the information obtained from the placing authority the home is able to decide whether the needs of people can be met before they move in. Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 9 The files of two people who had moved into the home since the last inspection were looked at. The admission process for both showed that good information had been collected whilst deciding whether the individuals’ needs could be met at the home. People are given a contract and this details the fees that are to be charged. The fees for nursing care are also specified. Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal, social and health care needs of the people living in the home were well planned for and met. People received their medicines as prescribed although some of the processes in respect of medication could be improved. Dignity, respect and privacy were maintained. EVIDENCE: Three files were looked at during the inspection. Two of these were in detail and showed that addition to the care plans there were total care assessments that gave information about the individuals needs. This covered areas including tissue viability, continence, mobility, sleep, medication, mood/behaviour and emotions. The care plans covered the above areas in greater detail and with instructions on how the needs were to be met. It was pleasing to note that the detail included in them was very personalised and gave information that was not just about the tasks that had to be carried out but about things that made them personal to the individual. For example, ‘ uses bubble bath, body spray and Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 11 talc. Likes to choose clothes. Likes to wear make up and jewellery. Likes having her hair brushed. Helps with agitation’. There were management strategies in place for all risks identified in individuals personal risk assessments. These included manual handling, tissue viability, nutrition, bed rails and behaviour. One person was left in a recliner chair for most of the day with her legs raised up. This positioning could potentially increase the risk for developing pressure ulcers and should not be left in this position for long periods of time. This could also be considered restraint. The care plans also said what the individuals could do for themselves and this helped them to maintain as much independence as possible. It was evident that the health needs of people were being attended. There was a GP attached to the home and the majority were registered with him but some people were registered with other GP’s enabling choice to be exercised. One person told us “ we are so well looked after its disgusting”. The home used the ‘faces pain rating scale’ to assess the level of pain that may be experienced by people who did not communicate verbally. The medication system was looked at. There were two medication trolleys in use, one for each floor. There was a mixture of boxed medicines and a monitored dosage system. There was a signature list of people who gave medicines out and copies of prescriptions against which the medicines could be checked. There were also photographs of the people for whom the medicines were prescribed to ensure that the right medicine was given to the right person. The homely remedies in use had been approved by the GP and recorded on the medical charts, with a reason, when given. The balances of all the medicines audited were correct except for one where the balance was short. There was a disposals bin in the medical room however it was not kept locked away. Some Oramorph had been disposed of in this bin. Although there is no requirement to treat Oramorph at low dosages as a controlled medicine it was considered good practice to do so in the same way as the home was managing Temazepam. The Oramorph had not been recorded anywhere. We were told that this was because the person for whom it had been prescribed had brought it with them. This still should have been recorded in order that an unbroken audit trail could be followed. Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 12 Requirements to improve the management of medication have been made during the past two inspections and the manager should make every effort to ensure that these issues are fully dealt with to ensure compliance with the regulations. It was pleasing to note that the home had been working closely with the hospice in relation preparing to meet the future pain relief needs for one of the people living in the home. There were no issues of privacy or dignity not being observed in the home. All bedrooms had en-suite facilities of toilet and wash had basin that promoted dignity in the home. Edgbaston Beaumont DS0000069247.V370624.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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most people living in the home could make choices about how they spent their time but some people had some limitations put them. There was good contact between the people living there and their friends and relatives. The people living in the home were receiving good choices at meal times and support was given with eating. EVIDENCE: Edgbaston Beaumont provides nursing care but there are also some bungalows and apartments where people could live with some support provided through a domiciliary care service. It was nice to see that the partners of some of the people living in the home lived in the supported accommodation and were able to spend a lot of time in the home either in bedrooms with the people living there, in the communal areas or having lunch in the restaurant. Five surveys were completed by people living in the home and returned to us. These surveys showed that they were happy with the services provided in the home. Some of the comments received included: Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 14 “I can always make decisions about what I do”. “This suits me fine. I can please myself as to what I do. Thank goodness”. “Sometimes they make suggestions, but I am never told I have to do anything. You can do as much or as little as you like”. These comments suggest that the home provides some activities but individuals can choose whether to take part or not and the people living there are quite content. Some of the identified activities in the service user guide were trips on the mini-bus, choir and slide shows, chess, scrabble, bingo, quizzes, library, church and shopping trips weekly. We were told that the mini-bus was used for the people living in the bungalows but not the people living in the home. This matter was raised with the manager who stated that people in the home were offered the trips out and often they said they would go but then decided not to go on the day. It is recommended that records are kept of when individuals have been offered opportunities but refuse to take part. It is also recommended that an activities programme based on the specific individual needs of people with dementia is put in place. This will ensure that each person living in the home has the opportunity to take part in activities suited to their likes and abilities. During the inspection it was noted that a couple of people were sitting with their legs raised in recliner chairs. For one person we were told that the individual would ‘jump out of the chair’ if the feet were not raised high. This could be seen as a form of restraint and alternative strategies should be sought. In cases, where a risk is identified, and this strategy is identified as being the only way to manage it, the management strategy must include that its use is recorded when it used, why and there must be time limits on the use of the strategy. The AQAA told us that a digital TV aerial had been purchased and the patio area completed so that people could sit out there in the sun. Upgrades to bedroom televisions has been requested for next years Capital programme. The AQAA also told us that at the request of the people living in the home changes had been made to the supper and lunch menus to include curry, pasta and some healthier sweets including fresh fruit. It was evident on the day of the inspection that people were able to make choices about when to get out of bed. Care plans seen also showed that people could make choices such as the clothes they wear and choices were available at mealtimes. Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 15 The menus seen showed that there were a variety of meals available. The main meal was served at lunch time which could eaten in the restaurant, in bedrooms or in lounge areas. There was a dining area that provided some privacy for people living in the home and their guests. Breakfast and tea were generally served in bedrooms. Supper was served later in the evenings and a snack box was available if anyone wanted a snack late in the evening. People who needed help to eat took their meals at the same time as everyone else. There were hostess staff to serve meals in the restaurant leaving care staff available to assist people to eat. During the inspection 6 people were seen to be provided help to eat. Appropriate protective clothing was available at meal times. One member of staff was seen helping someone to eat but she didn’t tell them what was happening and what was being given to them. This meant that the individual became a little agitated. Some good interactions were heard in a bedroom where someone was being assisted to eat where the room’s occupant was teaching the member of staff to speak French whilst she was helping him to eat. Staff also needed to be mindful about where drinks were being left. For example, during the tour of the building it was noted that a cup of tea was left for someone who was asleep in a chair in the lounge. A couple of hours later at one o’clock the cup of tea was still there and none had been drunk. The completed surveys said that people were either usually or always happy with the food. One commented “ The food is very good”. Edgbaston Beaumont DS0000069247.V370624.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home knew who to turn to if they were unhappy. Their views were listened to and acted on. Generally, policies and practices in the home ensured they were kept safe from harm. EVIDENCE: A copy of the complaints procedure was included in the welcome pack given to everyone moving into the home. There was one available in the entrance of the home. We were told that no complaints had been received in the home since the last inspection. No complaints had been received by the commission however some concerns had been raised by a relative of someone who had lived in the home twelve months earlier. The concerns were about the home not providing items in a timely manner such as the service user guide, a contract, a commode for the bedroom, belongings not being unpacked for several days, the key worker not being available, not being informed when the person living in the home was moved to the hospice and problems in repeat prescriptions being activated. These issues were discussed with the manager but they could not be investigated due to the length of time since they were alleged to have occurred. Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 17 During examination of the monthly visits by the providers representative it was noted that a verbal complaint had been received from a family. The report also indicated that the complaint had been resolved but not what the complaint was about. One of the surveys returned to the commission said ‘My complaint about the food was sympathetically receive’. There were no records about how these complaints had been resolved. A log of complaints should be kept so that the issues can be reviewed to see if there are any patterns or recurring themes that need to be addressed. People returning completed surveys told us that they new who to turn to if they were unhappy with anything. There had been an incident in the home where someone living in the home had had some money stolen. The police had been involved but the culprit was never identified. The requirement made regarding changes to the adult protection policy had been met. Discussions with staff indicated that they knew what their responsibilities were in respect of reporting allegations of abuse but they were not always clear of who would be informed by the manager. It is recommended that the issue is discussed with staff to enhance their understanding of the procedures. The AQAA told us that although staff received training in adult protection the home intended to improve the depth and knowledge of the training given. The recruitment procedures safeguarded the people living in the home. Edgbaston Beaumont DS0000069247.V370624.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises were well maintained, comfortable and clean. The needs of the people living in the home were well met. EVIDENCE: As at the last inspection the home was decorated and furnished to high standard. Internally it was bright, homely, clean and comfortable. During the inspection the communal areas were seen. There is a pleasant, hotel type reception area that is staffed during office hours. There is a supply of drinks available with comfortable seating. There were sitting areas on both floors that were comfortable and had equipment available such as television and radio. Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 19 The enclosed garden is pleasant and was shared with the people living in the bungalows. There was a small library where people could sit and borrow a range of books. All the bedrooms in the home were singly occupied and had an en-suite facility consisting of toilet and wash hand basin. The bedrooms seen were spacious and had been personalised to the occupants liking. Furniture was of good quality. The AQAA told us that 5 bedrooms had been refurnished and redecorated and that the home would continue with its programme of replacing curtains and continued cleaning. There were a range of assisted bathing facilities throughout the home. The home was accessible throughout for people with limited mobility. There was a passenger lift and ramped access on the ground floor to the gardens and the entrance to the home. There was an emergency call system in place but people living in the home wore neck pendants to ensure they could call for assistance when needed. There were pot disinfectors on each floor. Some pressure cushions were stored in the sluice rooms and this was not good for infection control. It was observed during the tour of the building that some wheelchairs were stored in the landing at the top of the stairs. They could become an obstruction in the event of an emergency and should be moved elsewhere. Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of the staff met the needs of the people living in the home. The staff were employed only after the appropriate checks had been undertaken and training was provided on an ongoing basis ensuring the people living in the home were safe. EVIDENCE: The AQAA told us that the numbers and skill mix of staff which are dictated by the total care assessments carried out for the people living in the home ensure that the needs of everyone are met. There were nurses and care staff on duty in the home with additional staff to carry out duties of laundry, cleaning, activities and ensuring food and drinks were delivered throughout the home on time. Looking at the staffing roster showed that there was a nurse on duty at all times during the day and night and in the mornings there were two nurses on duty. There were usually 4 care staff on duty but on occasions this fell to three. The manager must ensure that staffing levels do not fall below required levels. There were occasions when there were 5 care staff on duty and they would help out in the close care service. Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 21 In addition to the care staff there were ancillary staff to take care of cleaning, laundry, cooking and serving of food. There was a specific activities coordinator employed. The files of three staff were looked at. One person had transferred from another of the company’s home and the manager had checked with the manager of that home to ensure that there had been employment issues with the individual. Other checks were not needed as there had been no break in employment with the same employer. The other two files showed that all the required employment checks were in place before the individuals took up their employment. There were induction records in place although individuals were not always signed off by the manager as being competent to carry out their tasks unsupervised. Training was available and on the day of the inspection fire training was in place. There was some confusion in what the expectations were for staff in respect of getting people out of the home in the event of a fire. The manager was to pursue this issue. The AQAA stated that this issue was being attended to. Four staff were spoken with during the course of the inspection and it was noted that they knew about the individuals in their care and had good general knowledge about adult protection and the procedures in the home. They stated that they received good training on an on-going basis. The AQAA stated that 7 of the 17 care staff had achieved NVQ level 2 or above. This was not quite fifty percent of them and efforts should be made to ensure that more staff complete the NVQ level 2. Some staff indicated that staffing levels were not sufficient due to the high dependency levels of the people living in the home. Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is experienced and possesses the knowledge and skills to oversee the day to day running of the home. Arrangements are in place to protect people from the risks of injuries. People living in the home were happy. EVIDENCE: The home was managed, run and maintained well to ensure the comfort and safety of the people living there. The AQAA told us that monthly internal audits were carried out as directed by the Director of Quality of Care in addition to the monthly visits required by the Care Homes Regulations. A compliance officer has recently been appointed Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 23 who undertakes audits in line with the National Minimum Standards and Care Homes Regulations. There was a public liability insurance certificate displayed along with the certificate of registration in the entrance area of the home. Evidence seen on the day and information provided in the AQAA showed that equipment in the home was well maintained. The maintenance person was available to look after small repairs on an ongoing basis ensuring the premises were safe and well maintained. The home was subject to inspection from Ofsted due to the training provided in the home and we were told that a very good report was received from them. The home was not responsible for looking after the money of anyone living in the home. This was usually undertaken by the individuals, their families or there legal representatives. Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 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 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 1. OP9 13(2) The registered person must ensure that a record of all medication that is received into the home or that is to be disposed of is maintained and that the medication is kept securely in a locked cupboard. This will ensure that there is an unbroken audit trail for all medicines brought into the home and kept safely. 01/10/08 2. OP14 17(1)(a) Sch3 (3)(q) There must be a record kept of 01/10/08 any limitations agreed for a person living in the home as to their freedom of choice, liberty of movement and power to make decisions. Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 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 OP8 Good Practice Recommendations People living in the home should not be left in seated positions that increase their risk of developing pressure ulcers for long periods of time. This will ensure that the risk of developing pressure ulcers is minimised. Oramorph should be treated as a controlled medicine. This will ensure that the medication is kept accounted for at all times. Records should be kept of activities taken up and declined by people living in the home. Activities should be specific to the needs of the individuals. This will ensure that everyone is given an opportunity to take part if they want. A log of all complaints received should be kept showing what the complaint was and how it was investigated and the outcome. This will ensure that any patterns can be identified and that people living in the home are assured that their views are listened to and acted on. Pressure cushions should not be stored in the sluice rooms. This will ensure that good infection control practices are maintained. The manager should ensure that staffing levels do not fall below that are indicated by their own assessment of need. Wheelchairs should stop being stored at the top of stairs where they could become an obstruction. This will ensure that people can be safely evacuated in the event of an emergency. 2. 3. OP9 OP12 4. OP16 5. 6. 7. OP26 OP27 OP38 Edgbaston Beaumont DS0000069247.V370624.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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