CARE HOMES FOR OLDER PEOPLE
The Beeches 88-90 Oswald Road Scunthorpe North Lincolnshire DN15 7PA Lead Inspector
Wilma Crawford Unannounced Inspection 23rd July 2007 08:45 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 The Beeches DS0000062843.V346324.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. The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service The Beeches Address 88-90 Oswald Road Scunthorpe North Lincolnshire DN15 7PA 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) 01724 867261 01724 844103 thebeechescarehome@tiscali.co.uk Statepalm Ltd Position Vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places The Beeches DS0000062843.V346324.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 only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, nor falling within any other category - Code OP. The maximum number of service users who can be accommodated is: 40 27th July 2006 2. Date of last inspection Brief Description of the Service: The Beeches is registered to provide residential care and support to forty 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 forty single rooms with en-suite toilet and washbasin facilities over three floors and all are furnished to a good standard. There are five bathrooms, four of which have hoists. There are two large lounges separated into five distinct individual sections incorporating two dining areas with tables and chairs, two lounge areas a further smaller lounge area and a conservatory. There is an additional lounge attached to the bedroom on the third floor. The home has a garden to the front of the building and an enclosed courtyard accessed from one of the lounges. There is parking for a few cars at the front and more spaces at the rear. The Beeches has a homely feel, is well decorated and is maintained to a good standard. Information about the services the home provides is kept in each of the service users bedrooms. The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last key inspection of the home on 27th July 2007 including information gathered during a site visit to the home. The site visit was unannounced and took place over eight hours including preparation time. Four service users, two relatives, and three staff were spoken with during the inspection. The acting manager was available throughout. The main method of inspection used was called case tracking which involved selecting four service users and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The premises were looked at and the records of four service users and two staff were inspected. An Annual Quality Assurance Assessment document was provided by the home before this visit and information from this was included as part of the inspection process of this service. Comments from replies to surveys, to service users, staff relatives and professionals are also included in the report. The range of fees charged is £334 — £399 per week. Items not included in the fee are toiletries, chiropody, hairdressing, newspapers and magazines, various taxis and non-emergency escorts to appointments. The inspector also checked with service users to make sure that privacy and dignity was maintained, that people could make choices about aspects of their lives and that the home ensured they were protected and safe in a clean environment. The inspector also observed the way staff spoke to service users and supported them. What the service does well:
The Beeches offers a home where the preferences and wishes of each person are taken into account and respected. Residents are encouraged to make choices and they said they feel valued as individuals. The residents were very complimentary about the way the staff care for them and one person said ‘I left a place that I treasured and loved and didn’t think anything would compare, but this does’. Another commented ‘It’s just like being at home.’ ‘The staff are very supportive and, they keep me up to date, I attend reviews and any changes to my care I am the first to be consulted.’ Other comments included, ‘The staff practice is always very good, they are very kind.’ ‘There is always plenty going on and we are welcome to join in.’ ‘The staff are kindness itself, however, busy they are always kind and calm’ Relatives said ‘There is always special care taken to make sure clothes are well
The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 6 laundered and people’s clothing is well co-ordinated and they are well groomed. Their dignity is well maintained.’ The home provides a very clean, safe and homely environment for service users. People spoken with liked their home and were able to bring their belongings into their bedrooms. Private accommodation had been made available to offer a self-contained suite to a married couple. The home is very well organised and managed, with trained staff that are well supported and have a good knowledge of residents needs. The home a robust quality assurance system in place, which is based on seeking information from the manager, staff resident, relative and other visitors to the home. It is obtained through discussion, interviews and comment cards, depending on the individual needs of the person. A detailed report is completed from the information collated and areas, in which the home excels or identified areas that need to be improved, are included. The home has strong professional links with outside agencies and is involved in a couple of pilot schemes promoting good practice and positive care outcomes for people living in the home. One current scheme is where a District nurse is appointed to a home, to assist staff to help with the understanding of symptoms being presented, reducing the number of hospital admissions and obtaining GP consultations quickly. The meals provided were varied and well cooked and presented. One person said, ‘the meals are very good with good variety’, and another ‘you can’t fault it, there’s lots of choice and it’s well cooked’. People living in the home have the opportunity to engage in a well-organised activity programme, which they have contributed to the development of. The home actively encouraged people to give their views about how it was run, for example, by having quality circle meetings, residents and staff meetings, regular questionnaires about their services and a good complaints system. This was really important, as people need to feel safe about making complaints and to be sure that their suggestions will be listened to and acted upon. The home makes sure that only people with the correct references and Criminal Records Bureau checks were employed there and they provided good induction, training and ongoing supervision for staff. The acting manager has been well supported into her new role by both the proprietors and a mentor. The new extension has been opened gradually, with new staff being appointed and trained into their role, then a few new service users introduced to the home at a time, causing the least disruption for the current service users as possible. The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 7 Staff are well trained and have the necessary skills to support the people living in the home. The home has the local authority Quality Development Scheme at the gold level. What has improved since the last inspection? 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. The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 6 People who use this service experience good quality outcomes in this area. People are provided with information and their individual needs are assessed before admission to ensure they can be met. The judgement has been made using available evidence including a visit to this service. EVIDENCE: Evidence seen at this inspection in service users files and care plans showed that the home does not admit people without a care assessment being undertaken. Prospective service users are assessed very carefully due to the layout of the building and the vulnerability of the people living there. Prospective service users are also written to by the home confirming that they can meet their care needs or not. People are also encouraged to visit the home before they make a decision as to whether they wish to live there. During the site visit, prospective service users were seen visiting the home with their relatives, chatting to people living in the home and being shown around by the proprietor. Discussion with people living in the home and relatives also confirmed that this happened.
The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 10 Comments about the home included; ‘I have never had any grumbles about the staff or the care. This home is lovely, very homely and the staff are very good to my mum. I can’t speak highly enough about the staff.’ ‘We are involved in all aspects of our relatives care and we are very happy with the care provided.’ The home provides intermediate care for people who have been discharged from hospital, who require rehabilitation, before they are able to return home. The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10 People who use this service experience good quality outcomes in this area. People receive a high standard of care and health and personal care needs are routinely met. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans seen showed that they are developed from the initial needs assessment carried out by the home. Reviews of the plans are monthly to ensure that they are still current and any new issues have been addressed. Risk assessments are available, including a falls risk assessment. These show how each person has had risks assessed that are relevant to them. There is evidence that all residents have access to relevant health care professionals. Care plans evidence that health care professionals visit the home and that residents when required visit the hospital. A visitor commented that they are happy with the care provided and confirmed that their relatives see the GP, district nurses, and the chiropodist as they would were they living in their own home. People living in the home said that they were consulted about their care and were aware of their care plans. The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 12 The home is currently involved in two pilot projects, the first with the falls monitoring collaborative specialist, where a staff member will be trained as a falls champion and then train other staff and audit falls within the home, whilst continuing to liaise with the falls specialist. The second is where a district nurse is appointed to the home and who visits daily to advise on symptoms and ailments being experienced. This helps with the understanding of symptoms and has been shown to identify problems early on and treatment obtained promptly without the need for as many hospital admissions. Professional visitors to the home commented the staff at The Beeches were approachable and were receptive when new or different ideas were suggested to them. Staff were willing to take on board any comments or advice offered from professionals. Anything that was asked to be done by the staff, would be done. They also commented that the staff always attended training provided and sought appropriate advice. The care plans and risk assessments in the home were considered and detailed. Service users’ files also showed that personal care required is documented and mention is made of maintaining the residents dignity and privacy at all times. Daily entries had been made in care plans by care staff, which identified the care given. Care staff were seen to treat residents with respect and dignity during this inspection. The home’s accident book was examined and it was found that accidents occurring to residents have been recorded appropriately in their individual file and appropriate remedial action to prevent further problems arising. This information is also made available to the Commission by the home. The home uses an approved Monitored Dosage System for the administration of drugs. Medication records showed that all drugs administered were recorded on the resident’s individual records sheet. There were no gaps in recording seen. Any drugs that are refused are disposed of safely and returned to the chemist for disposal. All staff that are involved in the administration of medicines have received relevant training. Medication audits are undertaken on a regular basis, both in house and by an independent pharmacist The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use this service experience good quality outcomes in this area. People are offered a range of activities and relatives and friends are encouraged to be involved in the service. Food and drink provided are of a good standard. The judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users said that the food at this home is varied and well prepared. They particularly enjoy the full cooked breakfast. Menus were inspected and found to offer choices for all mealtimes. The menu is planned in consultation with people living in the home and there is always a minimum of two hot choices at mealtimes and special diets are catered for. The chef plans regular theme nights where samples of a selection of foods are prepared for the service users to try and anything that they like is introduced on to the menu. The homes pre-assessment forms were seen and included individuals’ dietary needs and listed their likes and dislikes. Staff spoken with, were aware of individuals personal likes and dislikes. Residents are able to take their meals in the dining rooms or as a tray service in the lounges or their rooms. The tables in the dining room were set with cloths, glasses and flowers and very well presented. Observations made by the inspector were that adequate
The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 14 numbers of staff are available at mealtimes to help people, and supported them in a patient and dignified manner. Four service users seen during this inspection commented that their visitors are always made welcome in the home and refreshments are made available. A resident confirmed that she could take her visitors to her bedroom. The homes signing in book was seen and showed that visitors attend this home in numbers at various times of the day. Residents and relatives meetings are held in the home and the outcome of these is used within the homes Quality Assurance Reviews. People living in the home and relatives are also consulted through the homes Quality Assurance process. Results from surveys and any relevant action plans are displayed on the homes notice board. One person said ‘I feel fully consulted about all aspects of my care and the day to day running of the home.’ The home undertakes a variety of activities for the stimulation of residents and a record of these is maintained. During the morning of the inspection a hairdresser was visiting the home and various table top games were being held. There is a varied activity programme available within the home and an activity coordinator available to support staff to facilitate this. The activity programme has been developed by asking people what they would like to do. Recent activities held includes; quizzes, a gardening group, St Patrick’s Day Celebration, visits from the sea cadets with old films, train trips to Cleethorpes, visits to the Museum, Craft , silver surfing web cam club for people with families living away, dominoes league, strawberries and cream tea while watching Wimbledon. There are also church services of all denominations held regularly in the home and a variety of local clubs attended. People confirmed that a planned activities programme is in place within the home, but that they also have the opportunity to go out into the town and local community, on day trips, attend church and coffee mornings. A number of fundraising events are also held in the home the proceeds of which are used for further activities. The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 & 18 People who use this service experience good quality outcomes in this area. Complaints are listened to and acted upon, and people feel safe and protected. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The home takes all complaints seriously. There had been seven complaints in the last year and each had been dealt with appropriately and within the agreed timescale. There has also been three safeguarding referrals made, each of these were considered to have been unfounded on investigation. By the Social services Department. A copy of the home’s complaint procedure is displayed in the home. Service users and their relatives are made aware of the complaints procedure on admission and this was confirmed during discussion. Staff members were aware of the procedure and the documentation used to record complaints. Two people using the service spoken with confirmed that they felt safe in the home. One stated, ‘I have never had any cause to make a complaint, but if I did I’m sure that the staff would take action. They would definitely sort it out.’ They also said that they would feel confident about approaching staff with a complaint. There is a Whistle blowing policy in place and a clear adult abuse policy. The home has a copy of local authority guidelines for reference and staff have
The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 16 received Adult Protection training and spoke knowledgeably about abusive practices and what action they would take if this came to their attention. People living in the home are registered on the electoral role. Details of external advocacy agencies are displayed within the home. The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23 24 25 &26 People who use this service experience good quality outcomes in this area. The clean and well-maintained environment has a positive impact on the quality of life for people. The judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been an extensive programme of refurbishment in the home, which has been completed to a high standard, providing people with a homely, comfortable, well maintained environment. All the bedrooms are now single and all have en suite facilities. There is a selection of lounges, sitting and dining areas for people to use as well as a new conservatory. There is also accessible seating areas in the garden where people living in the home were growing tomato plants in pots. The home has forty single rooms with en-suite toilet and washbasin facilities over three floors and all are furnished to a good standard. There are five bathrooms, four of which have hoists. There are also four toilets available. All
The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 18 areas are equipped with handrails; grab rails and adapted equipment to promote service users independence. There is a lift to all three floors of the home and a call system. Each call bell is situated within easy reach for service user’s use. Rooms were individual and personalised with photographs and other memorabilia and people had the opportunity to bring some of their own furnishings into the home if they wished. All bedrooms had lockable facilities and privacy locks to the doors. People living in the home were happy with their rooms and relatives commented that rooms were always fresh and clean. The laundry was well organised and equipped with industrial type washing machines and driers. Relatives and people living in the home commented on the high standard of laundry service provided. The home was clean and free from odour throughout. The Acting Manager has recently been successful in obtaining a grant, which the home has decided to use to landscape the garden at the front of the home, for the service users use and enjoyment. Work on this is due to start imminently. During the visit a wedge was seen being used to hold the medication door open for short intervals of time. When this was raised the proprietor was keen to take advice from the fire department as to what suitable alternatives could be used. The door to the medication room is not a fire door. The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, &30 People who use this service experience good quality outcomes in this area. People using the service have their needs fully met by a competent and trained staff group, who are recruited appropriately. The judgement has been made using available evidence including a visit to this service. EVIDENCE: All staff are subject to an induction and statutory training, which includes, fire safety, food handling, health & safety, manual handling and first aid. The organisation has a training manager whose role includes ensuring that staff have the necessary skills and knowledge for their roles. Training is provided through a mix of in-house, external facilitators, distance learning, local colleges and visiting professionals. The home records all training undertaken by care staff and a training plan is in place for 2007. Regular staff meetings are held and staff receive regular supervision and appraisals, which are recorded. Staff spoken with said that they felt well supported in their roles. Appropriate checks for all new workers are completed before they commence work at this home. Two new staff files were examined and both had application forms, two references, POVA first checks, prior to the start of their employment and Criminal Record Bureau Checks. 41 of the staff team have achieved a National Vocational Qualification at level two or three in care. A further seven staff members are working towards this award. The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 20 The duty rota showed that four staff numbers plus the manager were available to meet the needs of twenty seven service users during the day and three staff during the night in this home. There was also a cook, kitchen assistant, laundry assistant, handyman and domestic on duty. Staff said that the numbers of staff on duty even at the busiest times are able to accommodate the numbers of people living in the home. The staffing levels are reviewed regularly and altered when the need arises, for example, additional staff have been recruited and trained before any further admissions to the home were made after the completion of the extension. The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33,35 & 38 People who use this service experience good quality outcomes in this area. People using the service benefit from a safe and well managed home. The judgement has been made using available evidence including a visit to this service. EVIDENCE: The Acting Manager has worked in the home during the last year, during which time she has been supported by the proprietors and a mentor. She is competent through her experience and has extensive experience of working with older people. The Acting Manager has applied to become the Registered Manager and is close to completing NVQ level 4 and the Registered Managers Award. Staff said they are well supported and they are confident to approach the manager with concerns or ideas. Staff, relatives and people living in the home commented; ‘The Acting Manager is excellent, she is always there and available to talk’.
The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 22 The minutes from the recent residents’ meeting show that residents contribute and raise issues, and that action is taken to address these. The home has a robust quality assurance system in place that is based on seeking information from the manager, staff, residents, relatives and other visitors to the home. It is obtained through discussion, interviews and comment cards, depending on the individual needs of the person. A detailed report is completed from the information collated and areas, in which the home excels or identified areas that need to be improved, are included. A current summary of all quality progress and staff training is displayed on the home’s notice board.’ Records in the compliments log stated ‘The staff are a credit to The Beeches there is a warm welcome and the atmosphere is excellent’ The home also has the local authority gold Quality Development Scheme award. Staff are regularly supervised both formally and during every day observation. Annual appraisals also take place. Assessments are documented in relation to health and safety issues that may arise from the environment of the home. Maintenance records are also kept. Records within the home are stored securely and service users said they were aware that they can see them if they wish. Policies and procedures were found to correspond to the information made available by the home in the Annual Quality Assurance Assessment document. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was also evidence that fire alarm, fire drills and emergency lighting checks have been undertaken. Care staff also receive fire training as part of the homes initial training. Certificates were available showing that the shaft lift and bath hoists had been serviced six monthly. Electrical equipment had also been serviced. Wheelchairs seen on the day of the inspection had footplates, which were in use. The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 18 3 3 3 X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X X 3 The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 YA23 Good Practice Recommendations The registered person should seek advice from the fire department as to what alternative suitable devices can be used to open the medication room door. The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Beeches DS0000062843.V346324.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
