Inspection on 04/12/07 for Asheborough House

This inspection was carried out on 4th December 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Asheborough House 12/07/10

Asheborough House 17/05/10

Asheborough House 23/03/10

Asheborough House 05/02/10

Asheborough House 04/12/09

Asheborough House 25/08/09

Asheborough House 27/11/08

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Beech House Care Centre St Stephens Saltash Cornwall PL12 4AP Lead Inspector Elaine Bruce Unannounced Inspection 4th December 2007 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 Beech House Care Centre DS0000070450.V355216.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. Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech House Care Centre Address St Stephens Saltash Cornwall PL12 4AP 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) 01752 845206 Sheval Limited Mrs Sharon Anne Reif Care Home 31 Category(ies) of Dementia (31), Mental disorder, excluding registration, with number learning disability or dementia (31), Old age, of places not falling within any other category (31) Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with Nursing - Code N to service users of either gender whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (Code OP) Dementia (Code DE) Mental disorder, excluding learning disability or dementia (Code MD) The maximum number of service users who can be accommodated is 31. 2. Date of last inspection Brief Description of the Service: Beech House is a detached property set in it’s own grounds with a lawned area to the side and rear. Car parking is available in the grounds of the home. Saltash is approximately five minutes away by car and has all the usual facilities of a small town. Accommodation and care to include nursing is offered at the home in the category of dementia or mental disorder. The home is entered via secured garden gates into an entrance with communal areas off to include a lounge and a dining room. A communal quiet area is available to people (and their visitors) on the first floor of the home. Bedrooms are available on all levels of the home. A shaft lift is available to all the bedrooms in the home on the first and second floor. The laundry and kitchen are on the lower ground floor area of the home. Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection at Beech House took place on the 4th December 2007 between the hours of 0900 and 1630. This is the first inspection following the change of ownership of the home. The owner and the responsible individual for the Company were present during the course of the day. Prior to the inspection a completed Annual Quality Assurance Assessment Document was received as well as four survey forms completed by relatives of people in the home. The survey forms indicate a general level of satisfaction with the care being delivered at the home with some suggestions for improvements in particular areas. Due to the very high dependency levels of the people in the home conversations are limited, therefore observations of the people during their daily routines were observed. A total of four people in the home were case tracked to include inspection of their care plans and associated documentation. It is noted that some of the people in the home have complicated needs that can include challenging behaviour at times. In addition to observations of daily life in the home time was spent inspecting care plans and associated records, staff files, policies and procedures, medication arrangements and the standard of meals in the home as well as an inspection of the environment for two key standards. Considerable work is presently taking place which will enhance the environment considerably when completed. At this time this includes replacing the kitchen, laundry and updating the lower ground area of the home. Due to the changes that are taking place in the environment admission levels are limited to an occupancy of 20 at this time. Ultimately the home plan to run at full occupancy when the work is completed and the staffing levels increased. The weekly cost of care is £550. What the service does well: Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 6 The home is caring for people with very complicated care needs and in some cases challenging behaviour. Staff in the main were observed to be attentive to diverse needs and able in the majority of cases to meeting them. The home has worked well to establish good working relationships with health care professionals who attend the home. Consideration has been given to addressing the quality of the meals and the time spent to feed people in the home to ensure that there is a stability of weight and not a loss. The responsible person for the Company is presently involved in the running of the home at this time to ensure that progress is being made in important areas as required. What has improved since the last inspection? What they could do better: Staff must ensure that they are attentive to meeting the basic needs of the people in the home, for example ensuring that people are warm with the correct clothing on ie their tights and stockings. Two surveys suggested (and one relative spoken to) more stimulation could take place in the home to include spending time with people to allow them to be mobile around the home. On the day of the inspection the beds in the home did not look welcoming with worn sheets and badly ironed counter pains. Management advised that new sheets have been purchased and this would be dealt with as a priority. The administration arrangements for medication were found to be unsatisfactory on the day of the inspection. Two systems appear to be being used with no consistency in how they are being used. It is essential that all nurses receive training to improve their practice as a priority. Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 7 Care planning documentation is good but a fluid and food chart had not been implemented for one person identified at risk. Staff in charge must ensure that care planning requirements are addressed to meet needs at all times. In addition it was apparent that one to one staffing for a person with complicated needs was not in place as required due to a communication problem between staff in arranging the cover. This placed additional pressure on the staff during the course of the day. Safeguarding policies and procedures should be updated and all staff should receive external training on a rolling programme. 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. Beech House Care Centre DS0000070450.V355216.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 Beech House Care Centre DS0000070450.V355216.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 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use this service (and their representatives) have information about the home in order to make a decision about whether the service is right for them. The pre admission needs assessment that is undertaken means that the diverse needs of the people are identified and planned for before they move into the home. EVIDENCE: Documentation to include the service user guide and statement of purpose were put in place by the new organisation for the change of ownership requirements. These documents are available in the home and have been provided to the people in the home and their representatives. Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 10 A number of new admissions to the home have recently taken place, the majority of these being from local hospital wards. Prior to the admission the deputy manager has carried out a pre admission assessment to ensure that the home will be able to meet the needs of the person coming into the home. The home is registered to care for people with a dementia and or mental disorder and a number of the people in the home have complicated care needs and in some cases challenging behaviour. It is therefore very important that the assessment process is very thorough. There are plans ultimately for this to take place with two senior members of staff involved in the assessment to ensure that the process is as good as it can be. A relative of one person recently admitted to the home was spoken to. Through the discussions it was apparent some attention to basic comfort had been overlooked which the home agreed to address as a priority. The home is able to offer a respite facility when there is a vacancy. The home is running at an occupancy level of 20 at this time until further improvements to the environment have taken place. Beech House Care Centre DS0000070450.V355216.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The planning and delivering of care is generally in place to meet health and personal care needs. Attention needs to be given to ensure that basic needs of comfort are being met at all times. The people in the home could be at risk from poor medication administration which must be addressed as a priority. EVIDENCE: Each person in the home has a care plan in place based on the activities of daily living. The care plans are detailed and include information on personal hygiene, communication, continence, mental health, social and spiritual needs, sleeping, end of life and wounds for example. Monthly reviews are taking place but there appears to be no evidence of the representative of the person in the home being involved in the planning and reviewing of the care. Daily records that support the care plans are good and include important Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 12 information to evidence that care needs are being met. The care staff who have key worker responsibilities are involved in the records that are kept on bathing and toileting and the weighing of the people in the home. Generally consideration has been given to ensuring that people are maintaining their weight and that there is stability rather than weight loss. It was though noted that one person who was at risk of malnutrition did not have a fluid and intake record in place as required by the care plan. It was also noted and discussed that due to a problem with agency staff availability one person who required one to one staffing support was not in receipt of this at the time of the inspection. Inspection of the care plan records evidences that the home is involving a number of health and social care professionals in meeting planned care needs and in some cases very complicated care needs. This is good practice and is a credit to the home that these working relationships are established and being maintained. General observations of people in the home indicated that a number of people are mentally very frail and in some cases very mobile and confused. Staff were attentive to a number of situations and needs during the course of the day. Observation of two ladies in the lounge indicated that they had not been provided with stockings/tights to aid their comfort and warmth. The storage of the medication is in a treatment room with a medication trolley being used for ease around the home. The home is using the Boots monitored dosage system which is usually very straightforward to administer with little room for error. It was though apparent that at this time two systems of medication would appear to be running and within the two systems it was concerning that there was no consistency on administration. The inspection indicated that some people in the home may have not received their medication which is very unsatisfactory, for example medication administration records were signed but the medication was still in the packet. All qualified nurses have responsibility for medication administration and the inspection has highlighted the need for immediate training in this area. Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a range of opportunities for people to participate in stimulating and motivating exercises. Due to dependency levels there are times when it is difficult to meet needs in this area. Staff are attentive to the nutritional needs of the people in the home, a large number of whom require assistance with feeding. EVIDENCE: Care planning identifies the social and recreational needs of the people in the home. On the day of the inspection entertainment was provided by a singer for one hour in the later part of the afternoon. This appeared to be a positive occasion for the people in the home. On the notice board a social event programme is displayed with an activity every day of the week sometimes by external people and sometimes by the staff in the home. A sample of the activities for the month included: reminiscence, musical movement and ball games, afternoon film and massage. Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 14 A number of staff have been trained to deliver an activity for people specifically with a dementia. This is a small group activity known as “Sonas” which involves music and exercises and a shoulder and hand massage, instruments are sometimes played. When a person has taken part in an activity and received any visitors a record is made of this. Visitors are welcomed and encouraged into the home. One relative survey form stated: “I am always welcomed when I visit”. All visitors to the home are asked to sign in the visitors’ book when they visit the home. One visitor was spoken to during the course of the inspection. A couple of suggestions that she made were fed back to management which they agreed to deal with immediately. Two survey forms were received from relatives about the home, both the forms indicate satisfaction with the standards at the home. Two suggested that more mobile stimulation could be considered to encourage and maintain mobility. Some of the people in the home do not have an advocate and the home is looking at this to arrange where they can a representative for that person. The religious and spiritual needs of the people in the home are identified in care planning. The local vicar is a regular visitor to the home and sometimes some of the parishioners visit the home. The arrangements for the main meal of the day were observed at 1230. People are brought to the dining room from 1200 onwards or tables are brought to them in the lounge. It was noted to be a very busy time with all staff being involved in feeding a number of people in the home. The main meal on the day of the inspection was liver, onions and bacon with mashed potatoes, carrots and peas followed by treacle sponge and custard. An alternative choice to the main meal of the day and tea is always available and on the day of the inspection this was pastie, chips and beans. For tea there was to be sausage rolls, egg sandwiches, corned beef sandwiches and crisps followed by rice pudding and or fresh fruit. The meals for the day are displayed on the door to the dining room for visitors and people to read. The menu rotates over a three week period and is mainly traditional in what is being provided. The cook is a long standing employee and works a lot of hours in the home which is a credit to her. The home are advertising for another part time cook. The cook is supported in her duties by a long standing kitchen assistant. The cook prepares the meals for tea and the staff who heat the meals up in the evening have received training to the basic food hygiene certificate level. The cook has received training in food safety provided by the District Council Environmental Health Officer. A number of staff have undertaken training in Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 15 nutrition. Daily home made cakes are provided to the people in the home and all special diets are catered for. The new owner is presently in the process of fully updating the kitchen, this involves new units and a large amount of money has been spent already on a new fridge, freezer, microwave and dishwasher. The people in the home are monitored for any weight loss and records indicate that they are generally gaining weight. Considerable attention is given to ensuring that the meals at the home are adequate and that the people in the home are receiving their nutritional requirements. Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints policy and procedure in place. Formal processes need to be further developed so that the home’s safeguarding procedures are available, understood and consistently applied. EVIDENCE: The home has in place a satisfactory complaints policy and procedure on display in the entrance hall of the home. This information is also provided to the people in the home and their representatives in the service user guide. One relative comment card indicated that they were fully aware of the complaints policy and procedure. Adult protection policy and procedures are in place although it is recommended that more information be included in the document on the procedures for working with the Local Authority when an alert is raised. In addition to the internal training that the home is providing it is important that all staff attend external training provided by the Local Authority to ensure that people are safeguarded at all times. Beech House Care Centre DS0000070450.V355216.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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Considerably improvements are presently taking place to the home to the benefit of the people in the home and the staff. EVIDENCE: The main access to Beech House is via steps to the front door although there is a level/ramped access also provided. A small amount of parking is available in the grounds of the home and additional parking in the road. The main door of the home is locked to ensure the safety of the people in the home at all times. It was though noted at the time of the inspection that improvements to the security of the home should be addressed as a priority. Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 18 Since the change of ownership of the home considerable improvements are being made to the premises with a large refurbishment programme having commenced. This includes at this time a replacement of the old kitchen, new equipment has also been purchased to include a fridge, freezer, microwave and dishwasher. The laundry is being moved to a new more spacious area and major decoration is taking place to the lower ground area of the home. Lighting in the home has been considerably improved. The owner has further plans to improve the toilet and bathing facilities in the home and attention is also being given to the call bell system and heating at this time. On the day of the inspection the grounds were being improved with lighting for the safety of the staff and visitors to the home. The inspector was informed that a large amount of new bedding had been purchased for the home but this was not on the beds on the day of the inspection. The responsible individual agreed to address this immediately. Some attention is required to deep cleaning of carpets at this time in communal areas. Beech House Care Centre DS0000070450.V355216.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 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 is aiming to deliver a good standard of care to people who have complicated care needs. There are times when the staff require more support to enable this to be met. EVIDENCE: On the day of the inspection there were 20 people in the home to include a number of recent admissions. The staffing levels for the home at this time include four carers in the morning with an additional staff member to assist with breakfast and teas. In the afternoon there are also four carers and a qualified Registered Mental Nurse is on duty 24 hours, seven days a week. In addition there is an activities person employed for two afternoons in the week and cleaning, maintenance and laundry staff are also employed. Staff on duty were spoken to during the course of the inspection. They showed a good understanding of their roles and responsibilities. The people in the home have very complicated needs and one person who required one to one assistance was not in receipt of this on the day of the inspection causing additional pressure on the staff. It is understood that this was a Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 20 communication error between staff that agency cover had unfortunately been cancelled. Staff files are well organised into training evidence and recruitment evidence which allows an audit of these areas to take place with ease. Statutory training to include moving and handling, fire drill training and first aid training is up to date. The deputy manager has responsibility for training staff in moving and handling and fire drill training and has attended training in these areas to allow him then to train the staff. As discussed and agreed at the time of the inspection the priority training for staff is medication training (nurses) and external adult protection training (all staff). New staff members are receiving induction training that is based on “Skills for Care” standards. Recruitment procedures for employing new staff were found to be satisfactory to include a completed application form, two written references and a criminal records bureau check. Beech House Care Centre DS0000070450.V355216.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): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The new owner is committed to achieving good outcomes to people at the home and it is noted that a considerable number of improvements are planned over the course of the next few months EVIDENCE: The home has recently changed ownership and the registered manager who had been working at the home over that period has now left the home. On the day of the inspection an interview was taking place with a potential candidate Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 22 and it is anticipated that an appointment is imminent. The deputy manager has responsibility for undertaking a large amount of staff training at the home. The responsible individual for the Company is very involved in the running of the home and is presently at the home most days of the week. She is fulfilling the responsibilities of law in completing a monthly Regulation 26 report and providing that to the CSCI. The owner is also very involved with the home and at this time is actively involved in overseeing the improvements to the environment. The responsible individual is fully aware of where progress is to be made in meeting outcomes of standards. This information is included in the monthly reports that are received by the CSCI. There are plans for a full quality monitoring/assurance to take place with the people in the home and their representatives and health and social care professionals. The home is holding money on behalf of a number of people in the home. Records were in place and evidence that an audit of incoming and outgoing expenditure can be made. All money is held securely in the home. A number of staff have received infection control training and health and safety training. To support the training the home has in place policies and procedures which are being updated to ensure that full risk assessments are in place for any health and safety requirements. Beech House Care Centre DS0000070450.V355216.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 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 2 Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 Arrangements must be put in place for the safe administration of medication in the home. Timescale for action 04/12/07 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. 3. 4. 5. 6. Refer to Standard OP7 OP10 OP12 OP18 OP19 OP26 Good Practice Recommendations To ensure that at all times the care plans are followed to include where required ensuring that someone identified at risk has their fluid/food records in place. To ensure that people are dressed appropriately to include wearing tights/stockings for example. To ensure that stimulation is provided to people in the home which should include at times mobile stimulation. To update the adult protection policy and procedure and provide external safeguarding training to all the staff in the home. To ensure the safety of the home at all times by improving the security in the home. To deep clean carpets in communal areas where required. DS0000070450.V355216.R01.S.doc Version 5.2 Page 25 Beech House Care Centre 7. 8. 9. 10. OP27 OP30 OP31 OP38 To ensure that staffing levels are satisfactory to meet the needs of the people in the home at all times. To ensure that staff receive appropriate training as required to enable them to undertake their jobs. For a manager to be registered as soon as is possible. To ensure that at all times the home is safe. Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Beech House Care Centre DS0000070450.V355216.R01.S.doc Version 5.2 Page 27 - 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. 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