Inspection on 27/07/06 for Ascot House

This inspection was carried out on 27th July 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ascot House 23/07/07

Ascot House 11/01/06

Ascot House 20/05/05

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE The Beeches 88-90 Oswald Road Scunthorpe North Lincolnshire DN15 7PA Lead Inspector Beverly Hill Key Unannounced Inspection 28th July 2006 09:00 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.V295683.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.V295683.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 Statepalm Ltd Position Vacant Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 2006 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 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 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 nicely decorated and is well maintained. According to information received from the home on 30.05.06 their weekly fees are £327 to £379. Items not included in the fee are toiletries, chiropody, hairdressing, newspapers and magazines, various taxis and non-emergency escorts to appointments. Information about the services the home provides is kept in each of the service users bedrooms. The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day. Throughout the day the inspector spoke to nine service users and a relative to gain a picture of what life was like for people who lived at The Beeches. The inspector also had discussions with the manager, the proprietor and care staff members. The inspector looked at assessments of need made before people were admitted to the home, and the home’s care plans to see how those needs were met while they were living there. Also examined were medication practices, activities provided, nutrition, complaints management, staffing levels, staff training, induction and supervision, how the home monitored the quality of the service it provided and how the home was managed overall. 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. Prior to the visit to the home the inspector had sent out a selection of surveys to service users, family members, a selection of staff members and professional visitors to the home. The return rate was quite good and they were checked and comments used throughout the report. In surveys service users and relatives were complimentary about the care provided with comments such as, ‘I am very happy and satisfied with the care given to me’, ‘I’m looked after very well’, ‘the staff are very helpful’, ‘ my relatives room has always looked extremely clean’, ‘meals are very good with a good variety’, ‘overall the care she receives is of a good standard and she is happy there’. Staff members indicated they enjoyed their jobs, received lots of training and felt well supported, although some commented on the times that the home was short staffed due to holidays and sickness and the lack of back up for ancillary staff such as cleaners, cooks and laundry assistants which then impacted on care staff as they filled in. This had also been noted in three surveys returned by relatives and sometimes by service users when four out of seven ticked the box on the survey that indicated staff members were available when needed ‘usually’ instead of the choice of ‘always’. Professional visitors to the home commented that service users appeared happy with their care and one person stated, ‘I undertook two reviews recently and both residents were extremely happy with the care provided and both commented about the staff being brilliant’. Another commented that an issue The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 6 of the unavailability of staff to escort to non-emergency appointments had been taken up with the home and this was something the proprietor was dealing with. Professionals ticked the boxes that stated they were satisfied with the overall care, communication was good and there was always a senior to talk to. What the service does well: What has improved since the last inspection? The assessments of peoples’ needs that the home completed prior to admission had been improved. This meant that they had full information about the person and this made it easier to decide if the home could meet the needs properly. They had also improved the care plans that they wrote and made sure that they were easy for staff to follow and were updated when the service users needs changed. People signed their care plans to show they agreed with them. The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 7 Some parts of how medication was managed had improved but there were still some areas to address. See below. The manager had enrolled on the Registered Managers Award and had completed two units so far. They had also just completed gathering the information they required to begin the application of registration with the Commission for Social Care Inspection, which was a requirement for all managers of care homes. 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 DS0000062843.V295683.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.V295683.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed prior to admission which enables the home to be sure they can meet their needs. EVIDENCE: Three case files were examined, one of which was a new admission and they showed that service users had assessments of need completed prior to admission. These included assessments completed by care management. The assessment stated what the service user was able to do for themselves and what they required assistance with. It was more comprehensive than the assessments examined at the last inspection and covered the full range of health and social care needs. Case files in general had a range of information in which to assist the care planning stage and there was evidence that the home formally wrote to service users or their representatives following assessment stating their capasity to meet their needs. The information the home provided to prospective service users had been updated and makes clear the assessment process for planned admissions and The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 10 for emergencies as well as providing full information about the services provided. Inspection reports were held in the managers office and the manager was advised to make these more accessible by placing them on the main notice board. The home did however provide a service user guide in all bedrooms and this does state were the inspection report can be located but in light of two relatives comments stating they had not accessed the report they need to be more prominently sited. Service users spoken to stated that they had trial visits. One person said they had respite stays and these gave them a chance to see what the home was like. The home had a separate en-suite respite bedroom on the upper floor that had a sitting room attached to it. The manager stated the first four to six weeks of admission were seen as a trial period before the service user made up their mind about permanent residency but this could always be extended if necessary. The Beeches DS0000062843.V295683.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans produced for service users set out their care needs in a very comprehensive way, reflecting individual needs and the promotion of independence, privacy and dignity. More care was required in the management of one persons medication to ensure they received the medication they were prescribed for. EVIDENCE: Three care plans were examined in detail. Care plans were very comprehensive and had clear tasks for staff. They related to needs identified in assessments, referred to cultural differences and individual preferences and highlighted and encouraged areas of independence and respect for privacy and dignity. They were evaluated monthly and there was evidence of changes made when needs changed. The care plans were an improvement on the last inspection and it was clear that satff had worked hard on them. There was also evidence cf family members contribution to the service users care. Care plans were signed by the service user or their representative. The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 12 Daily records gave a good picture of the care provided and there was evidence of follow on to the next shift of issues identified that needed attention. There was evidence that service users health care needs were met and people spoken to stated they felt well looked after. Records were kept of visits by GPs, district nurses, occupational therapists, chiropodists, dentists, opticians and out patient department appointments. There was evidence of professional advice for risk situations and assessments were made and specialist equipment obtained. There was also evidence of service users wishes being respected regarding risk situations and management of these. Service users spoken felt that staff respected their privacy and dignity, and all bedrooms doors had signs on them stating, private, please knock before entering as a reminder to staff and other visitors. There were some good comments in surveys from relatives and service users, I am very happy and satisfied with the care given to me’, ‘I’m looked after very well’, ‘the staff are very helpful’, ‘overall the care she receives is of a good standard and she is happy there’. Some issues with the management of medication required attention. One persons’ medication, which had been dispensed from the pharmacy, wasn’t quite what was written on their medication record in the home. The dosage wasn’t correct and another had, ‘as directed’ on the packet. The staff members were not fully sure how often this was to be given. Neither of these discrepancies had been checked out with the GP. The transcribing of some medication didn’t have the full instruction written down. It was really important to get the management of medication right to ensure people received the medication they were prescribed for. The home had a very limited supply of medicine pots, an out of date British National Formulary, and did not dispense medication from a trolley but from the medication room, service user by service user, which some staff thought was time consuming. This latter point needs to be reviewed and discussed with staff for the best way forward. The Beeches DS0000062843.V295683.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally the home ensured that service users were able to make choices about aspects of their lives and the provision of flexible routines, nutritional meals and social stimulation enhanced the quality of their lives. EVIDENCE: Information about activities on offer and those actually completed was displayed as part of the quality assurance process in the entrance so visitors to the home could see what had been provided. This showed a good selection of 1-1 and group activities and the home employed an activity coordinator for the three homes. The home also completed lists of who attended and whether they enjoyed the activity. Evidence that service users had participated in some inhouse training events had been reported in the local newspaper. One visitor stated that the home had made their relatives’ birthday special for her. Service users spoken to felt there was sufficent activities on offer and their participation depended on choice. The home actively encouraged visitors. Service users spoken to stated that visitors can come at any tiome and the homes statement of purpose and service user guide referred to how links with families could be maintained. The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 14 Clergy visit for Holy Communion and religious services for some service users and the proprietor advised that the home had just started to sponser a local under 8s football team with the plan that the children and the manager would visit the home to keep the service users up to date on their progress in the local league. The home also arranged coffee mornings with their two other homes on a monthly basis and rotated the venue at each of the homes. Approximately 3-4 service users from each home visited the host home and had a get together. As most of the service users were from the Scunthorpe area it meant that some met up with old aquaintances. One service user continued to access a local social group monthly. Generally the home ensured that service users were able to make choices about aspects of their lives although, in discussions with them, it appeared that on two occasions, what a staff member thought best for the service user overode personal choice. This was discussed with the manager and proprietor to discuss with the staff member in particular. However in all other areas service users stated they could make choices and suggestions and would be listened to. One service user showed the inspector their particular seating area in the lounge, which they had made their own special corner and decorated the wall with pictures. Another described how they preferred to remain in their own room as they liked peace and quiet and the option of watching just what they liked on TV when they liked. Staff said routines were flexible and service users confirmed there were no set times for rising or retiring, visitors etc. Good support was observed at meal times. Staff sat next to service users to assist them to eat, offered protective clothing, assisted to cut up food where required, were attentive and friendly. Menus were on display and offered variety and choice. The meal sampled on the day was well cooked and presented. Comments were, the meals are very good with good variety, diabetics seem to be catered for very well, my aunt really enjoys the food. Service users liked the availability of fresh fruit in bowls in the sitting room for them to help themselves to. The Beeches DS0000062843.V295683.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 inspected at least once during a 12 month period. 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. Service users are able to complain about services and are protected from abuse by the general openness within the home, staff members’ knowledge of policies and procedures and adult protection training. EVIDENCE: The home had a complaints procedure that was displayed in the home. Staff members were aware of the procedure and the documentation used to record complaints. Service users spoken to knew who to speak to if they had any complaints and most named the manager in person. One relative survey reported that they were unaware of the complaints process but they hadn’t needed to use it. Complaints that the home had received were minor and dealt with appropriately. The complaints records indicated that people felt able to complain in the knowledge that they would be addressed. The home had a policy and procedure on the protection of vulnerable adults from abuse and all staff had completed training. Staff members were aware of how to respond if they suspect abuse has occurred and the manager was aware of how and to whom a referral had to be made. Service users spoken to stated they felt well looked after and surveys received from relatives and visiting professionals confirmed these statements. The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 16 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a clean and well maintained environment for service users and they have the opportunity to personalise their own space. EVIDENCE: During an environment check it was noted that the home was spotlessly clean, a credit to domestic staff. Only one bedroom had a slight odour but the manager confirmed the carpet was being cleaned regularly to address the problem. Surveys revealed that service users and relatives were happy with the cleanliness of the home. One relative stated, My relatives room has always looked extremely clean and tidy and the sitting room is always clean and fresh although the decoration is now looking a little tired. The home was light and airy and had three separate lounge areas, a dining area and a quiet seating area in the foyer. One service user spoken to stated they were very pleased with the laundry and said, ‘it’s homely, a lovely clean place’ and The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 17 another, when asked about the cleanliness of their bedroom said, ‘yes very much so, it’s cleaned to a high standard’. Bedrooms were personalised to varying degrees and some people had their own telephones and items of furniture and ornaments. All bedrooms had lockable facilities and privacy locks to the doors. Each bedroom had a ‘tidy checklist’ that staff had to complete when they supported service users with tasks. The proprietor discussed plans to extend the building to incorpoarte sixteen new en-suite bedrooms, a lounge and conservatory, a new kitchen and a walk– in shower room on the upper floor. Three of the en-suite bedrooms have curtained en-suite areas and these will be walled in to make proper en-suite rooms. As the extension is to be built on the back of the home in two stories it will have minimum disruption for the current service users. The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides robustly recruited and well trained staff to care for service users. However fluctuations in staffing numbers have left some shifts short and this could place service users at risk. EVIDENCE: Staffing rotas were examined and showed that usually three staff members were on duty throughout the day with two staff at night. On closer examination it was found that only two staff had been rostered for the coming weekend. The manager seemed completely unaware of this and had not planned any cover. This confirmed some of the staff points in surveys about being short staffed at times. An Immediate Requirement notice was issued for the days to be covered and for correct staffing at all times. Some staff surveys also indicated that laundry, domestic and catering staff, did not always have back up cover for sickness and holidays so care staff members filled in detracting from their caring duties. Comments about staff attitude were good apart from one staff member where it was stated by two service users that the person had made decisions for them that they would not have made at that particular time. However, general comments about the staff were, they are brilliant, the staff are very nice, staff are very helpful, Im looked after very well. However out of the seven surveys received from service users four of them stated the staff were The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 19 available, usually rather than the choice of, always, three out of seven relatives felt that there was not sufficient staff all the time and some staff commented that at times there was insufficent staff, which meant for them that only the basic care could be given and they wanted to spend more time giving quality time to service users. Staff were observed giving support in a friendly way, they spoke to people appropriately and there seemed a genuine warmth between them. One service user told the inspector one staff member was like a ‘daughter’ to her. Some staff spoke to service users, whose first language was not English, in their own language. This could be built on and a repetoire of words, greetings etc could be written down for all staff to use. The company had a training manager and a good track record with ensuring that staff had the required skills and knowledge for their roles. Training covered madatory and some service specific training and induction covered skills for care induction standards. Staff were positive about the training they received. One stated, Ive never had so much before in any job Ive had. The company has built a training room at one of their homes and training was a mixture of in-house, external facilitators, visiting professionals, distance learning and local colleges. Ten care staff have either completed NVQ level 2 and 3 or were progresing through the courses. Recruitment was robust. Four staff files were examined, three of them new and all these had application forms, two references, povafirst checks prior to the start of employment and criminal record bureau checks. The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the way the home was managed promoted the health, welfare and safety of service users who lived there and staff who worked there. However the management of the staffing rota must be given more attention to ensure sufficient staff at all times. EVIDENCE: The manager was a qualified nurse and was progressing through the Registered Managers Award. The company had a supportive network for the manager in the form of a training manager, monthly management meetings and the proprietors themselves who played an active role in the home. Staff spoken to, staff surveys received and records examined indicated that the manager was approachable and supportive and supervision was completed in accordance with national minimum standards. Some surveys had commented The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 21 on fluctuations in staffing levels and the difficulties in covering sickness and holidays. Although the manager was aware of this they were not aware that the immediate rota had not been covered and the home was due to have shortages at the weekend. The manager must be aware of staffing shortages and develop strategies to address them. The company advocated an inclusive style of management with views of service users, relatives and staff welcomed. Service users views were obtained via quality circle meetings, monthly service user meetings and the annual quality assurance questionnaires about the service provided. Lists of dates of the meetings and past minutes were displayed on notice boards and minutes evidenced that service users views were listened to and actioned. One person told the inspector, ‘we used to have large cups but I suggested smaller ones and we got them’. A number of service users had also taken part in a training session, which was reported in the local press, on fire prevention, keeping medication safe and the importance of the signing-in/out book. Each service user was awarded a certificate of attendance. The home had a very good system for monitoring the quality of the service provided and this consisted of a range of regular internal audits and questionnaires. The questionnaires were sent to service users, relatives, staff and professional visitors to the home and action plans produced of any shortfalls highlighted. The results were displayed on the notice boards and an annual service review completed. The home had been awarded the Gold Standard Award for quality monitoring from the local authority. Service users finances were appropriately managed and bedrooms had lockable facilities in which to store valuables. Some people spoken to managed their own finances with support from their families. The manager and staff team ensured that the home was a safe environment by maintaining and servicing equipment, ensuring staff were well trained in areas such as health and safety and fire, complying with environmental health recommendations and the management of identified risks. The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 22 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 X 3 X 3 X 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 4 X 3 3 X 3 The Beeches DS0000062843.V295683.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES 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 OP9 Regulation 13(2) Requirement The registered person must ensure that full instructions are written when transcribing medication onto record sheets (previous timescale of 11/01/06 not met) The registered person must ensure that the correct numbers of staff members are on duty during the day to support the needs of the service users (previous timescale of 11/01/06 not met) Immediate Requirement issued. 3. OP31 9 The registered person must ensure that the manager applies for registration with the CSCI (previous timescale of 17/02/06 not met) The registered person must ensure that any medicines that are administered are those prescribed by the GP. The registered person must ensure that all staff consistently DS0000062843.V295683.R01.S.doc Timescale for action 31/08/06 2. OP27 18 28/07/06 30/09/06 4. OP9 13 31/08/06 5. OP14 12 31/08/06 The Beeches Version 5.2 Page 24 6. OP31 18 supports service users to make their own decisions and choices about aspects of their lives. The registered person must ensure that the manager is aware of the rota situation and takes the appropriate steps to address shortfalls. 31/08/06 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 OP9 Good Practice Recommendations The manager should review the current working arrangement for the administration of medication individually without a medication trolley and discuss with the staff team to find the most appropriate way forward. The home should continue to work towards 50 of care staff trained to NVQ level 2. The manager should continue working towards the Registered managers Award. 2. 3. OP28 OP31 The Beeches DS0000062843.V295683.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: 0845 015 0120 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.V295683.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!