Inspection on 07/06/06 for Beaufort House Care Home

This inspection was carried out on 7th June 2006.

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

Beaufort House Care Home 22/09/07

Beaufort House Care Home 11/01/07

Beaufort House Care Home 31/01/06

Beaufort House Care Home 17/08/05

Beaufort House Care Home 15/03/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Beaufort House Care Home High Street Hawkesbury Upton South Glos GL9 1AU Lead Inspector Grace Agu Key Unannounced Inspection 7th June 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 Beaufort House Care Home DS0000061734.V296691.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. Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaufort House Care Home Address High Street Hawkesbury Upton South Glos GL9 1AU 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) 01454 238589 01454 238589 Beaufort Care Ltd Ms Glenda Elizabeth Graham Care Home 28 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (21) Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st January 2006 Brief Description of the Service: Beaufort House is situated in an attractive village location where there are shops, community facilities and a bus service. The home is situated approximately 4 miles from Wooton-Under-Edge and 8 miles from Chipping Sodbury. Bristol and Bath are within easy commuting distance. The property is a large mature house that has been extended. Accommodation is arranged on three floors. There is a passenger lift. Rooms consist of 26 single bedrooms and one double room. 17 bedrooms have en-suite toilet facilities. The home is set in attractive, well maintained gardens with lawns and a patio area. The gardens are accessible to all service users and have been made safe. The categories of registration change will be noted in future inspection reports as: DE(E) Dementia - over 65 for 6 and OP Old age for 22. Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which was undertaken over fourteen hours to review the requirements made at the last inspection and also to review the care practice to ensure that it is in line with the legislation and that best practice is followed at the home. The inspection also followed up seven Regulation 37 notifications of accidents to residents sent to the Commission for Social Care Inspection by the home. Full details can be found in the body of the report. At the last inspection five requirements were made in relation to different areas of service provision at the home. Three of the five requirements have been met. There was evidence to show that the home is making efforts to ensure that all staff received training on Protection of Vulnerable Adults from abuse in order to meet this requirement. It was also noted that the three recommendations made have also been met. However, It was disappointing to note that the requirement made in relation to medication administration had not been met and a further requirement was made. Further requirements were made in relation to ensuring that a satisfactory recruitment procedure is followed before a staff member commences employment and that all staff attended fire drills to ensure that the residents are adequately protected. An explanation including action plan on how the home has met the above requirements were received at the Commission within the timescale set. A tour of the building was undertaken and a number of records were viewed. Thirteen residents, and five staff members were spoken with on the day. No relatives or visitors were available on the day; however, their comments received before and after the inspection are included in this report. What the service does well: The manager stated at a discussion the home provides a homely environment for the residents. Staff know the residents very well and provide them with good care, this is evidenced through comments received from the relatives. The manager also stated that she always made herself available to meet the residents and relatives. The manager believes that there is a good relationship between the home, doctors and the district nurses and that this had resulted in Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 6 the latest approach to the home by the Ambulance Service to commence a “rapid response training” for the home and the village. What has improved since the last inspection? What they could do better: At the last inspection, five requirements were made. It was noted that one requirement has not been met. This requirement included; ensuring that staff adhere to medication policy and procedures when administering medication. The manager must ensure that this requirement is met in line with the legislation. The requirement remains in place. At this inspection it was agreed that the residents would be better protected if all satisfactory documentation were in place before a staff member commenced employment. All medication administered must be signed for, all medication not administered must be properly recorded to prevent drug errors and to protect the residents. Further more all hand written medication must be signed and dated. To ensure that staff are aware of measures and procedures to follow in fire emergency, regular fire drills must be provided for all staff. Residents would be better protected if the care plan of an identified resident’s need is regularly reviewed to ensure that this need is adequately met. To ensure that the nutritional needs of the residents are met at the Home it would better if residents were consulted when the menu is changed. Adequate numbers of staff mix must be working at all times to ensure that residents’ needs are adequately met. A resident would enjoy a better hygienic and odour free environment if the room is kept clean at all times. Further more the resident would enjoy a comfortable environment if appropriate flooring is provided and the hole identified on the wall is repaired. Whilst reviewing the care files, it was noted that the daily record sheets were inconsistent. It was recommended that this practice be reviewed to maintain a more consistent report on the residents to ensure that important information about residents is not missed out. Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 7 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. Beaufort House Care Home DS0000061734.V296691.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 Beaufort House Care Home DS0000061734.V296691.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): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are assessed before admission to the home. EVIDENCE: The residents care files reviewed contained detailed assessment of physical, mental and social needs before admission to the home. Residents spoken with made positive comments about the home and staff. One example of comment made included “we like it here staff are very good and kind to us.” Staff spoken with demonstrated understanding of the needs of the resident. Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 10 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, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are not protected through medication administration mal-practices EVIDENCE: Nine care files were reviewed following high numbers of falls at the home. All the care files but one contained detailed assessment of their needs and care plans were in place to support staff in meeting those needs. Evidence of detailed risk assessment and care plan was seen in the care file of one resident with challenging needs. However, it was noted that the last care plan for this particular need was last reviewed on 24/11/05 and no review was carried out following an entry on 5/04/06 (aggressive, kicking and biting). A requirement was made to remedy this situation. Other care files reviewed contained required information to include weight monitoring and were reviewed monthly to reflect the residents changing needs. Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 11 Whilst it was noted that daily record was maintained for each resident, this was not consistent. One example was entry on a resident’s daily record sheet on 24/4/06. No other entry was made until 7/06/06. The registered manager stated at a discussion that the home does not make entries on a daily basis unless there were specific incidents. It was recommended that this practice be reviewed to maintain a more consistent report on the residents to ensure that important information about residents is not missed out. There was a record of when each resident had seen a doctor, the reason for referral and the treatment. Records of visits from other health professional including chiropodists and district nurses were also seen. One resident spoken with stated “doctor comes to see me when I want him to” The procedure for the administration storage and disposal of medication was reviewed and was noted to be unsatisfactory. The Medication Administration Record Sheets (MARS) for almost all the residents had missing signatures for medication administered and some medication was noted to be left in the blister packs without any explanation why these were not administered. One example of this was noted on 23/05/06 all medication for a resident was not signed for other unsigned medications were noted on 27/05/06. It was also noted that on the day of inspection one resident was not given all the morning medication, no reason was given and the manager was not made aware. At a discussion with the manager, the inspector expressed concern about these unsafe practices and immediate requirements were made for these to be remedied to ensure that the residents are adequately protected. A requirement was also made for staff that administer medication to the residents to attend updates on medication administration. Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 12 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): 12,13,14,15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are provided with meaningful activities, however are not consulted in relation to choice of meals. EVIDENCE: On the day of inspection residents were noted relaxing in the lounge and enjoying the company of each other, some residents were noted sitting in their bedrooms other residents were also observed accessing different areas of the home without restriction. At a discussion with some of the residents met in the lounge, both stated that they are happy at the home; they get up when they wanted to and retire to bed when they wanted to and that staff treated them with respect. One resident met in the bedroom stated that staff were not always there when he wanted them however he was satisfied with the care provided at the home. The home had a range of activities provided for the residents to include music for health, Piano and organ player, Massage, Quizzes, ball games, exercise videos, card making for special occasions. At the last Easter celebration Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 13 residents made cards and Easter nests, which was later, sent to their relatives and their representatives. To strengthen the relationship between the home and the community and to support the residents who practice their faith, the local vicar visits once a month to offer full church service to the residents. On the day of this inspection, residents were noted taken outside in the garden before lunch and after lunch to enjoy the good weather. One resident stated, “ it is a wonderful day and it is nice to sit out in the garden”. The activities book reviewed, identified residents who participated in activities and those who declined but preferred to watch. Two residents met in their rooms stated that they chose to be in their rooms. The manager stated that some residents are taken out for walks in the village when the weather permits, this was confirmed in the entries in the activities book and comment card received from a relative which states “ Also great care is taken to make sure everyday needs are met, little things like being taken for a walk if required or encouraged if needed.” The manager also stated that there are plans to take the residents to visit Leyhill prison, to watch cricket this summer. A garden party is also being planned. Whilst the menu looked balanced and nutritious, the lunch on the day was different from the menu. On the board outside the kitchen the menu advertised for lunch was roast lamb with chicken as an alternative; however, the residents were given Gammon. Two residents were noted eating corned beef. The cook stated that the residents were given Gammon because there was no lamb and the second cook who was on duty the previous day made the decision. There was no evidence that the residents were consulted before this decision was made. Three residents interviewed were not aware of what they were having for lunch. Staff were noted wearing aprons and interacting with them in a respectful manner whilst assisting them with their lunches. At a discussion with the manager, it was acknowledged that although, the residents may be unable to make everyday decisions due to their medical condition the home must show evidence of consultation with the residents based on individual capabilities to ensure that their right to choice is not compromised. A requirement was made to remedy this situation. The kitchen was found clean; there was evidence of regular recording of fridge, freezer and food probing temperatures. The dry food store was clean however three opened tins with expired dates were noted in the cupboard and were disposed of immediately by the cook. Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 14 The certificates for Basic food hygiene updates for the kitchen staff were noted displayed in the kitchen Beaufort House Care Home DS0000061734.V296691.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): 16,17,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are enabled to complain and are protected from abuse through appropriate policies and procedure EVIDENCE: The complaint procedure was noted in all the care files reviewed. This document contained relevant information to enable the residents or their relatives to make a complaint if they were not satisfied with the services provided at the home. The complaint procedure was also noted displayed at the entrance of the building. The complaint book had no recorded complaint since the last inspection, however the concern received at the Commission in relation to how a staff member spoke to a resident was reviewed and was found to be satisfactorily resolved. The staff member who was involved stated that the relationship with the resident is very much improved. Evidence of action taken to prevent a repeat of the incident was noted in the concerns book. One staff member spoken with stated that they would enable the residents to complain by building strong relationships that would enable the residents to develop confidence and trust to talk to staff about their concerns. One relative’s comment card stated, “ I am able to discuss fully my worries/ concerns and have received a great deal of kindness and support”. Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 16 Evidence from speaking to staff and review of staff records showed that the home has made efforts to ensure that staff receive training in the subject area in order to protect the residents. The manager stated the home is making arrangements for the eight staff members identified to attend training on Protection of Vulnerable Adults from abuse as soon as the South Gloucestershire Council offers them places. The home has a policy and guidance on the Prevention of abuse as well as the South Gloucestershire Council policy on reporting incidences of suspected abuse. Residents spoken with stated that they felt safe at the home Beaufort House Care Home DS0000061734.V296691.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,23,26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is suitable for its purpose however it fails to protect the residents through lack of maintenance and cleanliness. EVIDENCE: A comment card received from a health professional states “ General cleanliness of the home occasionally gives cause for concern. Hot water and towels are not available at all times in the rooms”. Also a comment card from a relative expressed concern about bedroom hygiene. In order to review above concerns a tour of the premises was undertaken. The bedrooms seen were of reasonable sizes, however these were not measured on the day. The corridors and bathrooms/toilets had hand-rails and grab-rails respectively to assist with resident’ mobility. Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 18 Whilst some bedrooms, bathrooms and toilets were found clean, one resident’s bedroom flooring was noted with unpleasant odour, one bathroom and one toilet/shower had no soap and no hot water from the taps. It was also noted that one resident, prone to falls, had unsuitable flooring in the bedroom and a big hole in the wall and another resident’s room was noted with offensive odour The manager stated at a discussion that there are plans to install a new heating and plumbing system to remedy the problem of lack of hot water on the top floor. A requirement was made for the flooring in the resident’s room to be deep cleaned or replaced and the hole noted in the resident’s room to be repaired. One cleaner was noted carrying out their responsibility. There is a separate laundry facility, which is located in the basement. This included washing machines with a separate sluicing facility programme. The area was found clean and had hand-towels aprons and soap. The laundry person stated that staff inform her when there is any infection and that all infected clothing is washed separately Beaufort House Care Home DS0000061734.V296691.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents enjoy good relationships. With staff however the home fails to protect them by unsatisfactory recruitment practice and inadequate staffing levels. EVIDENCE: On the day of inspection, evidence from the rota showed that there were three care staff from 8.30 to 13.30 one-care staff from 8.30 to 18.00 one-care staff from 9.15 to 13.15. Also three care staff from 13.30 to 18.00, one care staff from 16.00 to 22.00 and one waking and one sleep-in from 22.00 to 08.00. The manager stated that the staffing level was adequate and was maintained on a regular basis. However, review of the staffing level on the weekend of the 3/06/06 and 4/6/06 showed that the home was one staff short between 08.30 and 13.30 on both days. The manager stated that the laundry staff helped out on those days. The laundry person or staff on the floors did not confirm this. Two comment cards received from relatives raised concern about the staffing level at the home, one comment card stated “In my opinion staffing levels appear low at weekends, the staff on duty work hard and are attentive, kind and caring. But there are insufficient numbers for the demands of the residents” Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 20 Another comment card felt that there was not sufficient staff at the home. In view of the numbers of recorded accidents to residents the home must review its staffing levels to ensure that residents are adequately supervised in line with their level of needs. Review of the training matrix sent to the commission before the inspection showed that six staff members have achieved National Vocational Qualification (NVQ) at level 2. Four staff members are undertaking NVQ level 2, four need to be trained and two have achieved NVQ level 3. Other training attended included medication competency (seven staff); Infection control (eleven staff); fire safety (twenty staff); First Aid (sixteen staff); Dementia training (five staff). In relation to health and safety training nine staff members have attended training updates, six staff have been booked to attend on 14/07/06. Protection of Vulnerable Adults from Abuse training has been discussed in standard 18. The manager showed the inspector a booklet named “ An insight into Dementia” This document contains detailed information on dementia and how it affects people. The manager stated that staff would be trained in groups of four using the booklet to make it more effective. Each staff member will then be issued with a booklet after the training session. The manager also stated that the home has issued every staff member with a Personal Development folder for easy auditing of all training attended. Two Staff files of those most recently recruited to work at the home were reviewed. The staff member recruited on 13/02/06 had appropriate documentation and induction before and after commencement of employment respectively. However one staff member that commenced work a week before the inspection had no details in the file to be reviewed. The manager stated that the individual’s papers were in the post to the Home Office for registration as a non United Kingdom citizen. A Criminal Record Bureau (CRB) form had been competed and sent but no disclosure had been received. Two references were being awaited from the individual’s home country. Whilst it was acknowledged that this was necessary, the individual must not start work until all checks are completed and satisfactory references obtained. An immediate requirement was issued for the individual to cease from working until all relevant and satisfactory documentation had been obtained. Two satisfactory references for the staff member were forwarded to the Commission For Social Care Inspection with a covering letter from the manager stating that the references were received on 9/06/06. The manager has agreed to inform the Commission when the CRB disclosure is received. Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 21 Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 22 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, 32, 33,35,36,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well managed, staff are supervised regularly’ however the residents are protected through satisfactory health and safety practices EVIDENCE: Glenda Graham was recently registered as manager of Beaufort Care Home after a successful “Fit Person’s interview at the Commission for Social Care Inspection. Glenda had completed the required National Vocational Qualification at Level 4 in Care, May.02 and Registered Managers Award, December 02. The manager stated that she is well supported by the providers; this has enabled her to empower staff to provide good care to the residents. Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 23 On the day of inspection, there was a friendly and interactive atmosphere in the home. Residents looked well cared for and were noted talking to staff in an informal way. Staff spoken with made complementary remarks about the manager and would approach her if there was any problem. Staff work as a team and that this is due to the manager’s openness and leadership style. However, it was disappointing to note that the manager was not informed that one resident was not given all the morning medication before the staff member went off duty in the afternoon on the day of inspection. Furthermore, the manager was not aware of the change in the residents’ menu on the day of the inspection. Some residents were not able to engage in conversation due to their level of concentration and understanding. However, some of the relatives comment cards were positive, for example, one comment card states “ the staff at Beaufort House have overall created a climate where my father is happier, healthier and more mobile than previously. I do not regret choosing them”. Evidence from staff records and staff discussion showed that staff is receiving regular supervision to enable them to discuss areas of concern in relation to residents care. The fire logbook was noted to be well maintained and up to date and staff have attended fire lectures. However it was noted that the last fire drill was on 10/10/05 and 19/04/06 to ensure that staff are aware of their responsibility in terms of actual fire emergency. The home has an up to date generic risk assessment covering most areas of the home. Other health and safety checks were satisfactory. Methods used by the home to review its quality of service were reviewed. The manager stated that questionnaires were sent to families to provide a feedback on the home’s performance in terms of staffing, environment, food and group activities and that the outcome was satisfactory. There are also regular social services care plan reviews. Part of the inspection was in response to the number of reported accidents to residents since the last inspection. Whilst most of the accidents were recorded and reviewed, one accident to a resident on 11/04/06 was not recorded and an accident to a resident on 15/02/06 was not reviewed following a fall. A requirement was made to remedy this situation. The manager stated in the response to the immediate requirement that the accident to the resident on 11/04/06 and review of accident on 15/02/06 were recorded in the files achieved in the manager’s office. The requirement has been withdrawn. Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 24 The home has policies and procedures to include whistle Blowing, Medication, Protection of Vulnerable Adults from Abuse and Manual handling and Confidentiality. All residents’ records were noted to be securely locked away Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 25 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 X 3 3 3 2 3 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 26 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. 5 Standard OP29 Regulation 19 Requirement Satisfactory recruitment procedures must be followed before a staff member commences employment. Staffing level appropriate to the needs of the residents must be maintained at the home at all times. Deep clean/replace the flooring to eliminate offensive odour in a resident’s room. Ensure that residents are consulted before the menu is changed. Review a residents care plan following the entry on 5/04/06. The home must ensure that medication administered must be properly recorded. All medication given must be signed for. All medication hand written on the MARS must be signed and dated. Timescale for action 07/06/06 4 OP27 18 08/06/06 3 2 6 7 OP24 OP15 OP9 OP9 23 16 15 13 07/07/06 15/06/06 08/06/06 08/06/06 Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 27 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 OP8 Good Practice Recommendations It was recommended that the home maintain a more consistent report on the residents to ensure that important information about residents is not missed out. Beaufort House Care Home DS0000061734.V296691.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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. 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