Inspection on 27/02/08 for Beamish Residential Care Home Ltd

This inspection was carried out on 27th February 2008.

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

Other inspections for this house

Beamish Residential Care Home Ltd 27/02/07

Beamish Residential Care Home Ltd 06/02/06

Beamish Residential Care Home Ltd 07/09/05

Beamish Residential Care Home Ltd 08/03/05

Beamish Residential Care Home Ltd 30/07/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Beamish Residential Care Home Ltd Old Vicarage West Pelton Stanley Durham DH9 6RT Lead Inspector Elaine Charlton Key Unannounced Inspection 27th February 2008 09:30 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 Beamish Residential Care Home Ltd DS0000041569.V359630.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. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beamish Residential Care Home Ltd Address Old Vicarage West Pelton Stanley Durham DH9 6RT 0191 3701763 0191 3701763 No e-mail 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) Beamish Residential Care Home Limited Mrs Marie Theresa Murray Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2007 Brief Description of the Service: Beamish Residential Care Home is on the outskirts of West Pelton, next to the church and close to local shops and other village amenities. The bus stop is a five-minute walk away from the home. The home, which was previously the vicarage, has been extended and modernised to provide accommodation for 21 older people. Bedrooms are located on both the ground and first floor. There are 17 single bedrooms and two double rooms. None of the bedrooms have en-suite facilities. floor. Nursing care is not provided. The weekly charge for this home is £382.50, no additional fees are charged for privately funded residents. Copies of the Commission for Social Care Inspection (CSCI) reports can be seen in the home. There is also a service user guide that gives information to help people decide if the home can meet their needs. There is a stair lift to the first Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star, this means that the people who use this service experience adequate quality outcomes. An unannounced visit was made on the 27 February 2008. The proprietor who is also the registered manager was present throughout the inspection. Before the visit we looked at: Information we have received since the last visit on 27 February 2007; Annual Quality Assurance Assessment (AQAA). The AQAA gives CSCI evidence to support what the agency says it does well, and gives them an opportunity to say what they feel they could do better and what their future plans are; How the service dealt with any complaints and concerns since the last visit; Any changes to how the home is run; The provider’s view of how well they care for people; The views of people who use the service, their relatives, staff and other professionals who visit the service. During the visit we: Talked with people who use the service, staff, the manager and visitors; Looked at information about the people who use the service and how well their needs are met; Looked at other records which must be kept; Checked that staff had the knowledge, skills and training to meet the needs of the people they care for; Looked around the building/parts of the building to make sure it was clean, safe and comfortable; Checked what improvements had been made since the last visit; Before the inspection we sent out “Have your say” questionnaires for residents to complete. We told the manager what we found. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A new, spacious, shower room has been provided on the first floor for the comfort and enjoyment of people who live in the home. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 7 New carpets have been fitted in communal areas and were being fitted to the ground floor corridor on the day of the inspection. This has made the areas warm and comfortable for people living in the home. What they could do better: A full range of care plans covering individual residents needs must be completed so that staff know what care and support is needed. Care plans must be evaluated on a regular basis so that the changing needs of people who live in the home are identified and the appropriate care and support is provided. Recordings in care plans and all other documents must be made in a consistent way and be dated and signed. They must also promote privacy, dignity and respect of people who live in the home. Individual risk assessments must be in place to support any areas of risk that affect the health, safety and welfare of a person living in the home. Policies, procedures and good routines must be followed at all times to support the safe ordering, recording, dispensing and disposing of medication. This will keep people who live in the home safe. Activities and social opportunities for people who live in the home must be promoted and records kept supporting the choices that people have made. Personal items must be removed from communal bathroom and toilet areas. Paper towels and soap dispensers must be regularly checked and filled to promote the control of infection within the home. The number of staff on duty must be reviewed to make sure that there are sufficient people around to meet the needs of people living in the home and carry out all the domestic/laundry routines. Records of staff training must be available so that it is easy to see mandatory training is up to date and when it needs to be renewed. This will promote the ability of staff to do their job and keep people safe. Bedroom temperatures must be monitored so that people can sit comfortably in their bedroom when they choose. Quality assurance systems in the home must be reviewed so that the views of residents, visitors and health care professionals are gathered and reported on. Proper procedures for dealing with residents finances must be followed and good records kept to protect people living in the home and staff. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 8 Staff working in the home must receive supervision to meet the National Minimum Standard of six times per year. Records of supervision must be kept so that performance and training needs can be monitored. The follow up action taken in the event of a resident having an accident must be recorded together with any timescales for action. This will help to keep people who live in the home safe. 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. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 9 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 Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 10 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): Standards 3 and 6. People who use the service experience good quality outcomes in this area. People who wish to live in the home have their needs assessed and can visit the home to make sure that the care and support they need can be given. The home does not provide intermediate care. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Each person living in the home has a copy of the service user guide. People who wish to see if the home can provide the care and support they need, can also have a copy of the guide to help them decide if they wish to move in. Respite care is offered when there are vacant bedrooms and no one is ready to move in permanently. “Have your say” questionnaires were sent to the home for residents to fill in. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 11 Five people living in the home sent the questionnaires back. All five said they had a contract and were given enough information before moving into the home. Copies of the single assessment documents provided by Durham County Council, setting out a prospective residents needs, are obtained. We were told that the home does not provide intermediate care. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 12 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): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. People living in the home are asked how they wish their personal care to be provided, and by whom, but their needs are not clearly recorded. Medication routines and records were poor and this could place people living in the home at risk. Health care professionals visit the home and see the people living there as their health needs dictate. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Five residents sent back “Have your say” questionnaires. Three people said they always got the care and support they needed. All five residents said that staff listened to what they said and act upon it. They said staff were always available when they needed them. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 13 Four people said they always got the medical support they needed. People living in the home also said: “I appreciate everything that is done for me”. “Staff are very caring and supportive”. “Staff couldn’t be more helpful”. We saw no evidence of proper, comprehensive care plans, risk assessments or moving and handling plans. Care plans were contradictory, incomplete, not dated or signed. On a later visit to the home the manager showed us some earlier examples of care plans that were previously used in the home. These identified a person’s needs and recorded the actions staff needed to take to look after the person concerned. The manager identified a care plan format and evaluation sheet that she is comfortable with. She told us that she is going to introduce these files for everyone living in the home, bringing together in one place all the information that must be kept to meet the National Minimum Standards and Care Home Regulations. One said that a person could mobilise and was independent in self-care. Further on it was recorded that the same person “uses a stick/needs support and carers to assess daily whether two or one needed to carry out transfers”. Another care plan recorded that a person “can toilet herself”. The next recording said “needs help to bath/shower/dress/toilet”. We saw no evidence of what had been done to check the possible causes of a resident’s weight loss. Staff are not completing records for bathing and bed changing regularly. If these are to be of value they should be consistently completed. The manager told us that when someone was admitted to hospital the family were given the opportunity to go with him or her. We carried out a random check of medication held for four people who live in the home. The following issues were identified: • A member of staff was seen dispensing medication into a pot and giving it to another member of staff to take to a resident. When they returned with the empty pot the first member of staff signed the Medication Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 14 • • • • • • • • Administration Record (MAR). This is poor practice and contrary to procedures promoting the safe handling of medication. Handwritten entries on the MAR were not double signed and instructions were not fully recorded. One medication being administered was not entered on the MAR. Eye drops had not been dated when opened. Differences were seen between the instructions for dispensing written on the pharmacists label and those on the MAR. Medication had been signed as given but was still in the blister pack. Medication that had not been returned to the pharmacist at the end of the month was not carried forward onto the new MAR so that the number of tablets held could be audited. Senna tablets were being kept loose in a pot in the top of the medication trolley. Money for the “book man” was being kept in the medication trolley. After the random check was completed the manager locked the medication trolley and removed key. Controlled drugs are kept separately in a secure cupboard. A register is kept to record the use of any controlled medication. These records were seen to be in order. The latest copy of the Royal Pharmaceutical Society of Great Britain document “The safe handling of medicines in social care” was available. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 15 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): Standards 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. People living in the home are encouraged to be as independent as they wish and to have regular contact with their families who are welcome in the home. The social opportunities within the home and the wider community are limited. People can choose what they want to eat and when. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Three people who sent back questionnaires said there were always activities they could take part in and two people said there usually were. One person said “There are tapes to listen to and plenty of books to read”. We saw records of activities taking place. These included ball games, reminiscence, DVDs, dominoes, and a sing-a-long to Max Bygraves. A couple that live in the home told us how they spent their time. The gentleman told us about a holiday in Rothbury. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 16 Visitors were seen coming into and leaving the home throughout the day of the inspection. Five relatives were spoken to. All were complimentary about the care and support their relative received. Two relatives said they visited most days and were always made welcome. The dining room is warm, homely, spacious and adjacent to the kitchen. Cold and hot menu choices are available at breakfast, lunch and teatime. The four weekly menus are displayed on the dining room wall. Separate daily menus were placed on the dining tables. Cold juice is available at all times in a refrigerator in the dining room. Residents were seen being offered hot drinks throughout the day. Residents and their relatives told us about the home cooked meals, cakes and pastries that they are offered. On the day of the inspection banana loaf and chocolate cake had been made for afternoon tea. Fridges, freezers and dry stores were well stocked and there were lots of things residents could choose as an alternative to the daily menu. Staff have access to the kitchen during the evening and through the night if someone wants something to eat. Visitors were seen being offered a drink and piece of cake whilst visiting their relative. Advice and guidance was available in the kitchen to support a resident who has problems with swallowing. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 17 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): Standards 16 and 18. People who use the service experience adequate quality outcomes in this area. The views of people who live in the home are listened to. They are protected from harm through policies, procedures and staff training. Not all procedures and checks are up to date which may place people who live in the home at risk. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Everyone who sent back a questionnaire said they that always knew who to speak to if they were unhappy and how to make a complaint. One person said “I have nothing to complain about”. The complaints form states all complaints will be responded to in 48 hours. The procedure does not clearly set out the stages of complaint and the maximum period it may take to carry out an investigation. There were no notes available to support an interview with a member of staff following a complaint being expressed about this person. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 18 The complaints procedure we saw displayed in the hallway still referred to the National Care Standards Commission. This was removed immediately and updated. We saw records that showed that all staff had done safeguarding training in January this year. We were not able to see evidence of Criminal Record Bureau (CRB) checks being renewed. The staff contract we saw did not include a statement that staff need to report any new cautions or convictions they may receive following their employment to the manager. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 19 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): Standards 19, 25 and 26. People who use the service experience adequate quality outcomes in this area. People live in a homely environment that promotes their independence and the chance to spend time privately. Everywhere is clean and tidy and hygiene routines are generally good. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Everyone who sent back a questionnaire said the home was always fresh and clean. One person said “the home is always clean and fresh smelling and the rooms are always spotless”. The manager showed us around the home. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 20 There are two lounges on the ground floor where people can spend their time and see visitors. Seats are also set out in the hallway/reception area. The laundry is on the ground floor and was seen to be clean, tidy and well organised. The washing machine can be set to carry out different programmes, including sluicing and hot washes. During the tour of the premises the following issues were identified: • • • • • • • • A lockable facility was not available in bedrooms 2 or 3. The hinge on the wardrobe in bedroom two was damaged. The door closure device for bedroom 2 was in need of adjustment. Pull cords in toilets and bathrooms were dirty and unhygienic. Personal toiletries were left out in the communal bathrooms. Some bedrooms were noted to be quite cool and may have been uncomfortable if a resident had wished to spend time there. Paper towel and soap dispensers were not all full. Staff provided cotton hand towels but these do not promote good infection control. A urine bottle had been left on the window sill in one toilet. A locked Control of Substances Hazardous to Health (COSHH) was seen in a down stairs bathroom. All bedrooms are homely and people who come to live in the home are encouraged to bring personal items with them to personalise their bedrooms. We saw a new, spacious, wet room that has been provided on the first floor. We checked the temperature of water in the bathrooms. These were between the recommended safe temperatures of 37 and 43 degrees centigrade. Alarm mats are fitted outside bedrooms on the first floor landing and let staff know that people are up and about during the night. The use of these mats for everyone is not documented or risk assessed. The home is surrounded by garden, and there are ramped walkways for people to use. All areas of the home were seen to be clean, tidy and odour free. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 21 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): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. People living in the home are protected by recruitment and selection procedures but these are not always properly followed. Staff are supported through training to provide care to people in a way that meets their individual needs but supervision is limited. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A senior carer told us that she had just completed her NVQ3 and medication training. There are 12 permanent members on the staff team. Nine have achieved a qualification at a minimum of National Vocational Qualification (NVQ) 2. This is above minimum standard of 50 the National Training Organisation (NTO) requires. Another member of staff is working towards this qualification. We were able to see staff rotas for the last year. The manager and two care staff are on duty throughout the day. Two care staff are on duty at night. Some entries were made in pencil, which is not good practice. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 22 Domestic staff are employed between 9.00 and 12.00 noon, Monday to Friday. We were told that care staff on duty during the day share the laundry duties and night staff do ironing. We saw four staff files. They were very disorganised. One contained no application form, no references, and no dates of employment. The Criminal Records Bureau (CRB) check had not been renewed since 2002. We saw no evidence of induction or supervision in these files. Staff had been issued with contracts of employment. The contract does not include a statement that staff need to advise the manager of any new cautions or convictions they receive. We saw evidence that staff training between 2002 and 2008 had included risk assessment, infection control, dementia, no secrets, fire safety, medication, basic life support, and moving and handling. It was not easy to see which staff had completed what training. We were shown the latest application form. It requests an employment history back to school days and includes a health questionnaire. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 23 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): Standards 31, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. The home is run in a way that benefits the people who live there. There is limited evidence that people are consulted about what goes on in the home through surveys and meetings. Both people living in the home and staff are protected through good health and safety procedures, systems and training. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The owner of the home is also the registered manager. She is qualified and experienced to run the home. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 24 The AQAA was submitted to us when we asked but this was not fully completed. The homes certificate of registration and an up to date certificate of insurance were displayed in the reception area. We saw a resident’s survey questionnaire. This gives people a limited opportunity to comment. Responses are asked for in a yes/no or good/fair/poor format. The manager has a book where visitors can recorded their comments about the home and the care their relatives receive. This started in October 2007, and people had said: “Mum continues to be happy and content.” “Mum settled well as a result of friendly staff.” “The atmosphere in the home is very warm and friendly.” “I cannot thank the staff enough for their patience, kindness and good nature.” We saw no care plans to say how people living in the home wish to be supported with their finances. We carried out a random check on monies held on behalf of people living in the home. Changes on residents finance sheets had been made but were not initialled by the person making the change. Residents had not been asked to sign entries on their individual finance sheets. Entries had been made in the wrong columns on the finance sheets. Staff were initialling entries instead of signing. Throughout the inspection we saw that attention was not being paid to completing documentation. We were not able to see a schedule of supervision or supporting documents to show that people were being supervised in line with the National Minimum Standard of six times each year. All checks had been carried out and evidence was available to support this for the maintenance of electrical, gas and water systems within the home. All electrical appliances had been checked in September 2007. We saw the accident recording books for both residents and staff. Accidents and injuries to residents were recorded but follow up action was not always recorded. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 25 The fire risk assessment for the home carried out by a Safety Service Company in May 2006, had been reviewed in May 2007. We saw the fire log that gave evidence of regular checks being carried out on fire equipment, lights and alarms as required by the Fire Authority. There is a health a safety file that includes generic risk assessments covering issues like COSSH, control of MRSA, moving and transferring, and use of the stair lift. Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 26 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 1 X 2 Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 Requirement A full range of care plans must be prepared covering a individual residents needs. This will mean that staff know what care and support is needed. (Previous timescale of 30/06/07 not met.) Care plans must be evaluated on a regular basis. This will mean that the changing needs of people who live in the home are identified. Recordings in care plans and other documents must be made in a consistent way and be dated and signed. They must promote the privacy, dignity and respect of people who live in the home. This will show that people who live in the home are respected and valued. Risk assessments must be in place to support any areas of risk that affect the health, safety and welfare of a person living in the home. This will mean that people are kept safe. DS0000041569.V359630.R01.S.doc Timescale for action 30/05/08 2. OP7 15 30/05/08 3. OP7 15 30/05/08 4. OP7 13 30/05/08 Beamish Residential Care Home Ltd Version 5.2 Page 28 5. OP9 13 Policies, procedures and good routines must be followed at all times to promote the safe ordering, recording, dispensing and disposing of medication. This will mean that people who live in the home are kept safe. 27/02/08 6. OP12 16 (The manager was made aware of this requirement on the day of the inspection.) Activities and social opportunities 30/06/08 must be promoted and records kept supporting the choices people have made. This will mean that people who live in the home have the chance to do things they like. (Previous timescale of 30/06/07 not met.) Personal items must be removed 27/02/08 from all communal bathroom and toilet areas. Paper towel and soap dispensers must be regularly checked and kept filled. This will promote the control of infection in the home. (The manager was made aware of this requirement on the day of the inspection.) Bedroom temperatures must be 30/03/08 monitored. This will mean that people can sit comfortably in their bedrooms when they wish. The number of staff on duty 30/05/08 must be reviewed against the needs of people living in the home. This will mean that sufficient staff are in the home to meet people’s needs and carry out all practical and domestic tasks. Records of staff training must be 30/08/08 available. This will promote the safety of people in the home and the ability of staff to do their job. DS0000041569.V359630.R01.S.doc Version 5.2 Page 29 7. OP19 13 8. OP25 23 9. OP27 18 10. OP27 19 Beamish Residential Care Home Ltd 11. OP33 24 12. OP35 17 13. OP36 18 14. OP38 17 15. OP38 13 Quality assurance systems in the home must be reviewed so that the views of people who live in the home, their visitors and health care professionals are gathered and reported on. This will mean that people know they are listened to. Proper procedures for dealing with the finances of people who live in the home must be followed and good records kept. This will mean that people living in the home and staff are kept safe. Staff must receive supervision to meet the National Minimum Standard of six times per year. Records of supervision and training must be kept. This will mean that people in the home are kept safe and staff are supported to do their job. Follow up action taken in the event of a resident having an accident must be recorded together with any timescales for action. This will help keep people who live in the home safe. The use of denture cleaning tablets must be risk assessed. This will help people who live in the home to be safe. 30/12/08 30/03/08 27/02/09 30/03/08 30/03/08 Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 30 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 OP18 Good Practice Recommendations Criminal Records Bureau checks should be renewed and staff should report any new cautions or convictions they receive to the manager. This will mean that people who live in the home are kept safe. Entries in pencil should not be made in any records required to be kept in the home. This will prevent changes being made that cannot be audited. All documents should be dated to support the auditing of health and safety within the home. This will promote the safety of staff and people who live in the home. 2. 3. OP27 OP38 Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Beamish Residential Care Home Ltd DS0000041569.V359630.R01.S.doc Version 5.2 Page 32 - 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. 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