CARE HOMES FOR OLDER PEOPLE
The Beeches 88-90 Oswald Road Scunthorpe DN15 7PA Lead Inspector
Bev Hill Unannounced 20 May 2005 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 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. The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service The Beeches Address 88-90 Oswald Road, Scunthorpe, DN15 7PA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01724 858381 Statepalm Ltd Carly Hill CRH 23 Category(ies) of OP 23 registration, with number of places The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 25.1.05 Brief Description of the Service: The Beeches is registered to provide residential care and support to twentythree service users. The home is situated close to the town centre of Scunthorpe within easy reach of the high street and local amenities. The accommodation is provided over three floors serviced by a passenger lift. The home has four shared bedrooms and fourteen single bedrooms over the first two floors and an additional bedroom on the third floor. All bedrooms have en-suite toilet and washbasin facilities and are furnished to a good standard. There are three bathrooms, two of which have hoists. There is a large lounge separated into four distinct individual sections incorporating a dining area with two tables and chairs, two lounge areas and a further smaller lounge area. There is an additional lounge attached to the bedroom on the third floor. The home has a small garden to the front of the building and an enclosed courtyard accessed from one of the lounges. There is parking for two cars at the front and more spaces at the rear. The Beeches has a homely feel, is nicely decorated and is well maintained.
The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted nine hours on 20th May 2005. In January 2005 the Commission received a complaint regarding the care the home provided to a person who lived there. This complaint was found to be correct and the home had to make changes about the way they provided care. This inspection was very important to check that the changes that were needed had been made. The Inspector spoke to the new proprietors who bought the home in January 2005 to find out what changes they had made to the running of the home. The Inspector also spoke to the manager and two of the care staff members who were on duty at the time of the inspection. Throughout the day the Inspector spoke to eight people who lived in The Beeches and checked out with the relatives of two people what they thought about the care provided. The inspector looked at a range of paperwork in relation to staff training, fire records, care plans, activity records, complaints and the servicing of equipment. They also checked that people who lived in the home had the opportunity to suggest changes and were listened to. The Inspector completed a partial tour of the building. What the service does well:
All areas were very clean and tidy and the home had a welcoming and homely feel. The new proprietors have spent a lot of time at the home introducing themselves to the people who live there and discussing changes with them and the staff team. Although the complaint was about care provided before the new proprietors took over they have dealt with things quickly to make sure that poor care does not happen again. The three separate lounge areas means that people can choose whether they want to sit near a TV or in a quieter area. The lounges were nicely decorated. Most people spoken to stated that the meals were very nice and the menus were varied. They offered a choice at each meal and people felt they had plenty to eat. Kitchen staff visited each person in the morning to find out which choice they wanted for lunch. There was a large bowl of fresh fruit available for people to help themselves. The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 6 People spoken to were very positive about the staff. They liked them and thought they were friendly and helpful. They knocked on doors before entering bedrooms and toilets. They said their relatives were always welcomed and offered refreshments. What has improved since the last inspection?
There had been lots of improvements since the last inspection as a result of the complaint and the change in ownership. These improvements meant the running of the home was much more closely supervised. The home had completed most of the tasks it had been required to do. All care plans had been re-written to ensure that staff members knew how to care for people. These had been signed and dated by staff and where possible by the person whom the care was intended for. Daily recording about the care given to people was more detailed. The manager was much more aware of the need to contact professionals quickly for advice and support, such as continence advisors, physiotherapists and district nurses. One district nurse spoken to was very pleased with the pressure area care a person had received and stated that staff had followed her instructions. The amount of activities provided by the staff had much improved and people spoken to stated they had the opportunity to join in if they chose to. An activity coordinator employed at the companies other two homes was soon to start working two hours a day at The Beeches which will improve things even further. The TV has been moved off the wall in the small lounge and placed on a chest. This means people do not have to hurt their necks looking up at it. The new proprietors employed a Training and Development Manager who worked between all three homes. She had ensured that staff received training in pressure area care and updated their moving and handling skills. All the kitchen staff had undertaken a Level 2 Foundation in Food Hygiene. In times of staff shortages the new proprietors had measures in place to ensure that the right amount of staff needed to care for people was always available. People who live at the home have more opportunity to have a say in how the home is run. Different types of meetings are held to discuss general issues and also specific quality issues like menu choices or the activity programme. Staff members had been given responsibility for completing written checks on the building, for example, cleanliness, maintenance of equipment, kitchen hygiene, fire alarm checks, bathing rotas and health and safety issues. These checks were discussed with the proprietors at monthly managers meetings.
The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 7 All complaints, however small they were considered to be, were written down and dealt with. These were also discussed each month with the proprietors. The home had developed a checklist for completion if any person was admitted to hospital. It detailed what information and belongings were sent with them with an escort and what had happened to necessitate admission to hospital. It also ensured that attention had been paid to hygiene and dress whilst awaiting transport. 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 Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4 The service users had their needs assessed prior to entering the home by the manager and the Care Management Team when funded by them. The home did not always obtain the Care Management assessment, which could mean that vital information is missed. The home was able to meet the needs of current service users. EVIDENCE: The manager stated that she completed all assessments for potential service users prior to admission. Visits were made to service users own homes, hospital or other residential care homes and information gathered by talking to service users, their relatives and other carers. The information enabled the home to determine whether they could meet assessed needs. One care file examined had a new pre-admission assessment completed, which had been signed by the service user. The new pre-admission documentation contained all the required information. There was not consistent evidence that assessments completed by Care Management were obtained by the home prior to admission. These were
The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 10 important as they provided vital information for the care planning stage. However the home had obtained care plans completed by Care Management. The manager used to formally write to potential service users following the assessment stating that the home was able to meet their needs. However this had not been completed for the new admission as the service user had signed the assessment and the manager thought this was sufficient. The home needs to re-start the formal written correspondence regarding their ability or not to meet assessed needs. The home had equipment in place to support people with moving and handling needs and specialist equipment was accessed via the district nursing services. The issue of one service user not being able to access bathing facilities had been resolved. Staff members spoken to were aware of the needs of service users. They had received training for their role and task. The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 10 Although some changes in need had not been updated onto plans, monthly evaluations were not always clear and in one case an assessed need had been omitted, which could mean service users would not receive the correct care, there had been some improvements in the care plans. Generally the health care needs of service users were met and risk assessments were in place, although one service user needed a specific risk assessment. This shortfall potentially placed them at risk. Staff members were aware of the importance of respecting privacy and dignity and they carried out care tasks in a way that reflected these values. The lack of a call bell in the lounge area meant that service users had to call out and at times wait longer than necessary to have support. EVIDENCE: The case tracking of two service users was completed and another care file examined briefly. The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 12 Some service users spoken to were aware of their care plan and had signed it, whereas others were not so sure what it meant. All felt their needs were being met. Care plans had been re-written using the format that brought The Beeches into line with the company’s two other homes. For new admissions an initial care plan was written, which was a tick box form that related to activities of living such as personal care, moving and handling, bathing, dressing, eating etc and detailed how much support the person needed from staff. This was used for the first couple of days until a fuller care plan was produced after staff had gotten to know the service user. This ensured that staff members were aware of basic support required from admission. There had been some improvement in care plans since the last inspection; they were signed and dated on formulation and were evaluated, although this sometimes took the form of a diary entry rather than assessing whether the care plan was still valid. Generally changes in need were updated in the care plans but this did not always occur consistently. For example one service user initially required support to manage their continence. This had been resolved but the care plan still referred to continence issues. In one care file an assessed need for pain control had not been care planned, which could lead to staff not being aware of specific instructions. Risk assessments were in place for most activities, such as moving and handling, use of a hoist, bath hoist and wheelchairs, pressure area care and bedrails. However one service user had a specific health condition and a risk assessment was not in place. This shortfall could affect the health, privacy and dignity of the service user. Staff members were more aware of the need to liaise quickly with professionals for advice and support and a log was maintained of any professionals instructions in the care plan. Examination of the daily records regarding the care provided was more comprehensive. This meant that staff knew if there were any issues to monitor during their shift. Although medication was not assessed at this inspection the Inspector was advised by a service user that they had ran out of their pain control medication that day and although it was ordered they would not receive a supply for two days. This was not acceptable and the manager resolved the issue during the inspection. The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 15 The social activity programme had been improved providing a range of activities and stimulation for people. Individual social needs assessments and the provision of an activities coordinator would further enhance social care provision. Meals were well cooked and presented, with choices and alternatives available. The preparation of meals for the second sitting needs attention to ensure they are as fresh as the first sitting. EVIDENCE: There had been a big improvement in the amount of activities on offer for service users to participate in. People spoken to described these as sing-alongs, ball games, baking, dominoes, manicures, knitting, drawing and colouring and quizzes. Activity logs maintained by staff evidenced that some people had gone for walks with staff, one had gone to the pub with their daughter and a staff member for support and one person regularly goes to a Mothers Union group with her friend. A visiting entertainer had been to the home recently and an exercise to music session was commissioned once a month. Some service users spoke of having one to one chats with staff and some preferred not to join in many activities but to sit quietly and read or chat to
The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 14 other people. TV’s and music equipment were provided and the home had a selection of books and videos. The proprietors employed an activity coordinator for their two other homes and were currently negotiating for her to include two hours a day at The Beeches. This would further enhance the activities provided and ensure that one staff member had overall responsibility for assessing social needs, planning activities and implementing them. The social needs assessments, when completed, will make sure that the home provides activities that people like and are able to participate in. There was evidence that three service users of the Catholic Faith had watched the Popes funeral with staff. A priest visited the home to perform Holy Communion for them and provided spiritual support. People spoken to liked the meals provided and felt they had enough choice and variety. Menus were on display in one of the lounges but not everyone was aware of it. However they said the kitchen staff came round each day to see which choice they wanted at lunchtime. People felt they had enough to eat and drink. A large bowl of fresh fruit was available for service users to help themselves. The dining area had two large tables to seat six at each and as the home is registered for twenty-three service users it meant that there had to be two sittings. Three people, who had eaten previously at the second sitting, stated that sometimes the food had to be warmed up for them. This affected their enjoyment of the meal. The dining area space could be better utilised with smaller tables and chairs. Some people preferred to have their meal whilst sitting in their chairs and tables had been provided for this. This was an improvement since the last inspection. Staff were observed supporting people to eat in a sensitive manner, sitting by their side and engaging in conversation. The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 There had been improvements in the overall management of complaints, which provided a system of checking that complainants were satisfied. Service users were aware of whom to complain to. Staff members were aware of adult protection policy and procedures and had received training. EVIDENCE: The home had a complaints policy and procedure that detailed how complaints were dealt with and timescales for resolution. There was also reference regarding contacting the Commission for Social Care Inspection and the Local Authority should the complainant be unhappy with the outcome of any investigation completed by the home. The complaints procedure was on display and included in the service user guide in each bedroom. One formal complaint regarding care practices prior to the new proprietors had been investigated by the Commission for Social Care Inspection and upheld and requirements issued. Since the last inspection the home had documented two minor issues dealt with as ‘niggles’. These had been recorded appropriately and resolved to the complainant’s satisfaction. All service users spoken to stated they would complain to the manager, who they mentioned by name, staff members or their relatives. All staff had completed adult protection training and were aware of policies and procedures. When spoken to they were aware of what to do in the event of
The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 16 suspected abuse and who to report it to. The manager had not completed any local authority training in adult protection but was aware of local multi-agency policies regarding referral and investigation. The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26 The home provided clean, comfortable and hygienic surroundings. EVIDENCE: The home was noted to be clean and tidy and free from any offensive odours. Service users spoken to were happy with the cleanliness of their rooms and the home generally. The home employed two domestic staff and one laundry worker who worked hard to maintain the high standards. The home had a policy and procedure in place for the prevention of the spread of infection and gloves, anti-bacterial hand wash and aprons were available for staff. The home had a laundry facility with one commercial washing machine, which was fitted with a high temperature sluicing/disinfecting cycle to launder soiled linen and one drier. One person spoken to stated that laundry sometimes went missing but usually turned up. The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 The staffing levels were appropriate for the current dependency levels of the service users who lived at the home. A system of alerting staff was required for the lounge areas. There was evidence that new staff would receive induction to TOPPS standards and all staff had access to mandatory training. EVIDENCE: The home had seventeen service users resident at the time of inspection. The manager monitored dependency levels and these were discussed in management meetings with the proprietors. The home used calculations of staff hours required in line with the Residential Care Staffing Forum and were meeting requirements. There were three to four care staff members on duty during the mornings and three in the afternoon/evenings. An additional kitchen assistant was available over teatime for meal preparations. The home had two waking night staff each shift. The home also had two cooks, two further kitchen assistants, two domestics and one laundry worker. The manager was supernumerary and worked approximately 9-5pm Monday to Friday. Service users spoken to were complimentary about the staff stating they respected their privacy, were nice, helpful and patient, although they were busy and sometimes in a hurry. Some service users stated it was difficult
The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 19 catching staffs attention as there was no call bell in the lounge areas and sometimes they had to wait to go to the toilet. One relative fed back that they did not feel there were enough staff on duty at night and weekends. The home had a training plan that was in line with the companies two other homes. Core training was planned in three-day blocks at intervals throughout the year. The company employed a training and development manager for all three homes. All staff had completed fire, moving and handling and adult protection training. Out of twenty-four staff, twenty-two had completed infection control, twenty, first aid and twenty, basic food hygiene. All catering staff had completed the level 2 Foundation Course in food hygiene with Aaron Associates. All staff had completed training in pressure area care and staff that administered medication had completed an accredited medication course. The home has produced a five-week course for new staff as part of their induction. The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35 and 38 The manager was benefiting from a network of support provided by the proprietors, the company’s other home managers, the training and development manager and new systems implemented within the home. This provided a more structured approach to management of the home, which has benefited service users. The Registered person must complete monthly reports on the conduct of the home. The home had initiated the companies comprehensive quality assurance system that ensured service users views and those of other interested parties were listened to and acted upon. The home had a system of managing service users finances that kept them safe but accessible. The manager generally promoted the health, safety and welfare of service users. To ensure service users were not put at risk, a call bell system was required in the communal areas.
The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 21 EVIDENCE: The new proprietors visited the home frequently to meet with service users and staff and to support the manager. This was confirmed in discussions with people who lived and worked at the home. Service users spoken to stated they had been introduced to the new proprietor and his family and they were often in the home. Mrs. Kapil, one of the proprietors and a state registered nurse who used to manage one of the other company’s homes, visited The Beeches in a consultative and supportive capacity with regards to care plans, general health care and pressure area care. The manager stated she has benefited from the supportive network the proprietors and the companies other two homes managers have provided. Monthly management meetings have set agendas to discuss issues such as the environment, accidents within the home, complaints and niggles, dependency levels and other quality issues. This meant that specific areas were addressed quickly and the proprietors remained fully aware of issues affecting the home. Service user meetings and staff meetings were planned and carried out which meant that people were able to express their views about the running of the home. Information about these was on the notice board. The first quality circle meeting was held on 18.4.05 and in future will be held every two months. This meeting gives service users, relatives and staff the chance to meet and discuss specific issues. There was evidence that views from this meeting affected practice. The company had a comprehensive quality assurance system that had recently been implemented at The Beeches. This included questionnaires to service users, relatives and visiting professionals and self-auditing the services provided to people, the environment and the staff team. Three service users finances and the homes resident fund were examined and found to be correct. Individual records were maintained, two signatures obtained for all transaction and monies were held securely with restricted key access. The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 22 Maintenance and service records for moving and handling equipment, the boiler, gas and electrical appliances, nurse call system, emergency lighting, fire alarm system and the lift were all in place. Fire alarm tests and drills were completed. A visit from Environmental Health had produced no requirements and a stored water check for legionella was negative. Monthly hot water outlet checks were maintained and had appropriate temperatures. Staff had received mandatory training and a training plan was in place to ensure skills were updated as required. This was supplemented by supervision and appraisal systems. Individual risk assessments were completed generally, although it was noted that one service user did not have a risk assessment for a particular area of need. Accidents were audited to inform practice. There was evidence that the number of accidents had decreased since February 2005. Service users were unable to call for assistance, other than shouting out, whilst in the communal areas. This placed them at risk and potentially affected their privacy and dignity. The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 2
COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 2 3 x 3 x x 2 The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 24 yes Are there any outstanding requirements from the last inspection? 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 12 Regulation 12(1)(a)& 16(2)(m) Requirement The registered person must ensure that social needs assessments take account of service users current capabilities so activities can be tailored to meet individual needs. (Previous timescale of 15.10.04 not met). The registered person must ensure that care plans are evaluated consistently and updated when needs change. (Previous timescale of 25.1.05 not met). The registered person must ensure that the home obtains assessments completed by Care Management for service users funded by them. The registered person must formally writes to service users or their representative following assessment and prior to admission stating their ability to meet assessed needs. The registered person must ensure that all assessed needs are incorporated into care plans and that the care plans are monitored by the manager on a regular basis. Timescale for action 31 July 2005 2. 7 15 With immediate effect 3. 3 14(1)(b) 31 July 2005 4. 3 14(1)(d) With immediate effect 5. 7 15 31 July 2005 The Beeches J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 25 6. 8 12(1)(a)& 13(4) 7. 8 8. 10 9. 15 10. 38 11. 38 12. 32 The registered person must ensure a specific service user has a risk assessment for their particular health condition. 13(2) The registered person must improve the system of reordering non nomad medication to ensure adequate supplies. 12(1)(a) The registered person must ensure a quick response to calls for assistance from service users to prevent compromising privacy and dignity. 12(1)(a) The regsistered person must address the second sitting food preparation to ensure food is presented as freshly as the first. 12(1)(a) The registered person must ensure that service users have a means of calling for assistance in communal ares. 1291)(a)& The registered person must 13(4) ensure that risk assessments are in place for all service user activities or health conditions assessed as being at risk. 26 The registered person must complete monthly reports on the conduct of the home in line with Regulation 26 of the Care Homes Regulations. 30 June 2005 With immediate effect With immediate effect With immediate effect With immediate effect 31 July 2005 With immediate effect RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 15 18 Good Practice Recommendations The registered person should consider utilising the dining room space to better effect. The registered manager should consider completing the local authority adult protection training for further information.
J54 S62843 The Beeches V229361 20 May 05 stage 4.doc Version 1.30 Page 26 The Beeches Commission for Social Care Inspection Unit 3 Hesslewood County Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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