Inspection on 29/09/08 for Beaumont House

This inspection was carried out on 29th September 2008.

CSCI found this care home to be providing an Poor service.

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

Beaumont House 23/02/10

Beaumont House 29/09/09

Beaumont House 16/03/09

Beaumont House 22/04/08

Beaumont House 05/12/07

Beaumont House 25/06/07

Beaumont House 04/07/06

Beaumont House 12/12/05

Beaumont House 03/05/05

Beaumont House 08/12/04

Beaumont House 04/08/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 05/12/2008.

CARE HOMES FOR OLDER PEOPLE Beaumont House 26 Church Lane Whitefield Manchester M45 7NF Lead Inspector Julie Bodell Unannounced Inspection 29th September 2008 07:30 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 Beaumont House DS0000008399.V371804.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. Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaumont House Address 26 Church Lane Whitefield Manchester M45 7NF 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) 0161 796 9666 0161 796 7722 glenysgardner@bankfield.org Bankfield Premier Care Ltd Mrs Glenys Enid Gardner Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the maximum of 37 there can be up to 37 OP Old Age. The service should at all times employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 22nd April 2008 Date of last inspection Brief Description of the Service: Beaumont house is a residential care home for up to 37 older people. The home is part of a group of four homes (Bankfield Premier Care) in the Bury/North Manchester area. The current fees are £380.00 per week. Beaumont House is a detached home and set in its own well-maintained grounds. It is situated close to local amenities and accessible for local transport as well as the Metro and major bus routes between Manchester and Bury. The home comprises of four large lounges and a smaller lounge and two dining areas. There are also 37 single bedrooms all with en-suite toilet. They are individually decorated and furnished and include a nurse call. The home is two storeys with an extension to the rear and side. It is divided into two units, one on the ground floor and one on the first floor. Communal areas are found on each floor and access is available via a passenger lift. Respite/short stay care may also be provided if a place is available. Beaumont House DS0000008399.V371804.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 0 star. This means the people who use this service experience poor quality outcomes. Two inspectors and a pharmacist carried out this inspection, which took place over eleven hours. The home did not know that we (the commission) were going to visit. During the inspection time was spent, talking to the head of care, the acting manager, the business manager, a carer, the activities organiser and an acting cook. We also talked to people living at the home, looked at paperwork, parts of the building and watched what was happening. At our last visit we had concerns about how well the home was managed and how people were being cared for. We asked the owner of the home to make improvements to the service and a plan was sent to us telling us what action was to be taken. We took this information into consideration and our findings are that not enough has been achieved to change our view about the quality outcomes for people living at the home, which remain poor. What the service does well: What has improved since the last inspection? Sufficient information is now available to people about the home so that they are clear about what service they will receive. Opportunities for people to become involved in activities to encourage stimulation and interaction with other people have started to increase. A small bathroom has been made into a new assisted shower room and both bathrooms have been repainted. There has been improvement in levels of cleanliness in some parts of the home and better care is being taken in keeping chemicals out of harms way but there is still work to be done in other areas such as the kitchen. Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 7 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 Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 8 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. In the absence of an assessment by a qualified social worker, more detail is needed at the assessment undertaken by the home, before a person moves in, so people can be confident that their needs can be safely met. EVIDENCE: The statement of purpose has been reviewed and revised to reflect recent changes to the service. A service user guide has also been developed within it that gives clear relevant information about what people can expect if they choose to live at the home. We were informed that since our last visit to the home that three people had been admitted to the home, though it was not clear as to whether people were being funded by the local authority or self funding at the point of admission. Two people had been admitted for respite care. Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 9 People are not usually admitted to the home until a community care assessment has been undertaken by a qualified social worker. We checked the files of four new people using the service. Two people had been admitted on a permanent basis and two people for respite. Only one person had a community care assessment on their file. An experienced member of staff also undertakes an assessment on the part of the home. The assessment involves the individual and their family or representative, where appropriate. The assessment format used by the home covers all personal care needs including, physical wellbeing, personal hygiene, breathing, mobilisation, eating and diet, elimination, continence, vision, hearing, dentures, chiropody, history of falls, personal safety and risk, weight, hobbies and orientation. In the absence of a community care assessment there was not always sufficient detail recorded on this assessment to ensure that peoples health needs could be safely met by the home. Beaumont House DS0000008399.V371804.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People using the service were at risk as they were not always properly supervised and supported, did not have accurate risk assessment records in place and did not receive their medication as and when needed. EVIDENCE: From the assessment information a care plan is developed. We looked at the records of four people who had moved into the home recently. Not all care plans had been signed in agreement by the person using the service or as appropriate their relative. We remain concerned that risk assessments lacked detail and were not fully completed. Risk assessments were incomplete in some cases because weight records had not been taken. The nutritional (MUST) assessments had not been completed for the same reason. For one person a pain management assessment had not been completed despite the fact that this person had swollen legs that were leaking and being dressed by a district nurse. Records were confusing with the diary notes stating that the person was self-caring when the plan refers to one carer needed for all tasks. Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 11 We also had concerns about the arrangements for a person who used a catheter. More attention to detail is needed on care plans and risk assessments to ensure consistent practice and that carer’s have all the information to support people safely and effectively. The providers improvement plan states that the head of care, the registered manager, deputy manager and senior care staff would be responsible for ensuring that risk assessments would be accurately completed but this has not happened. We have previously warned the providers that we would be taking action against them if record keeping around risk assessments did not improve. District nurses are involved in treating the pressure sores and other healthcare professionals such as doctors and opticians also supported people. It was still not clear what the arrangements were for chiropodist visits. There appeared to be a lack of a toileting regime, though the acting manager had asked care staff to keep more detailed records so that this could be monitored to ensure peoples needs were being met. At our last visit we observed that people were being moved in wheelchairs without footplates being used. The wheelchairs being used in communal areas had footplates but a number of wheelchairs in bedrooms did not. During the inspection the pharmacist inspector looked at how well medicines were handled to make sure that people were being given their medicines properly. Medicines were stored safely and properly but the floor of the medicines room was dirty and sticky and we found some boxes of medicines had had some medicine spilt over them and they had not been cleaned. It is important that all medicines are kept in hygienic conditions. We found that the record keeping was poor and sometimes confusing. Records could not show that all residents had been given the prescribed doses of medicines nor could they show that all medicines could be accounted for. Some records showed that double doses of medicines had been administered and other records had blank gaps on them so it was not possible to tell if medicines had been given at all. Records also showed that some medicines had been given on days, which were after the date of the inspection or before the person had come to live in the home, clearly these records were inaccurate. The poor standard of record keeping had led to one person not being administered a newly prescribed tablet. When we compared the stock of medicines in the home with the records we found that some medicines could not be accounted for. In some cases there was too much medicine in the home and in other cases there was too little. When records are not accurate and clear peoples health can be placed at risk because they do not receive medicines as prescribed by the doctor or because medicines may be mishandled. Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 12 We found that people were not always given their medicines because staff had failed to make sure there was an adequate supply of medicines in the home. We looked at a sample of medicines for ten people and found that five of them had run out of one or more of their medicines for between three and ten days. When people are not given their medication as prescribed their health may be put at risk. The staff recognised that some people wanted to look after their own medicines, but they were not supported to do this safely. One person wanted to look after some of their own tablets but we found a number of tablets, which had not been taken, scattered in various places in their bedroom. Staff were aware that this person was not taking her medicines properly but had failed to put in any steps to help her and consequently placed her health at risk from harm. Staff also failed to confirm exactly what medicines people should be taking when they came into the home either for short stays of respite care or when coming to live permanently at the home. This is poor practice and could place people’s health at risk. On the day of inspection the training certificates could not be found and so it was not possible to tell if staff had all received up to date medication training. We were told that staff working in the home had not been assessed to make sure they were competent and safe in handling medicines. We were also told that some times there were no staff on duty at night that had been trained to look after medicines. The meant that people could not have certain medicines they may need, such as pain relievers or inhalers, during the night. This could put peoples’ health at risk. Overall we found that many residents heath was placed at risk due to poor medication practices. Although some good practice was observed we remain concerned about the support and supervision people received from the staff team and some of the care practices we observed. People were regularly left without support during our visit, while staff went for breaks under a gazebo at the bottom of the garden. This left people at risk for example the acting cook, (a senior staff member) left the kitchen unattended to go into the garden and left pans of food boiling on the stove and both doors open. The acting cook was reminded not to do this but the same situation arose in the afternoon and a person living at the home was able to access the kitchen and access prepared food. One person said that when they called for assistance they often had to wait sometime or had been told by staff to wait and they will come back, but sometimes they did not return. We observed someone being changed without the door being closed to protect the persons dignity. We also observed the same comb being used to comb three peoples hair in the lounge. Beaumont House DS0000008399.V371804.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. Records of what people have to eat need to be kept to evidence that people are receiving a wholesome, varied and balanced diet. EVIDENCE: Since our last visit but only recently, an activities organiser from within the organisation has started to visit the home two days each week. We observed her spending one-to-one time with people in their bedrooms throughout the day. Her role is also to encourage care staff to become more involved in activities with people. Although we were concerned about the support provided on the ground floor, one period of good practice was noted on the upper floor. Here a carer was seen to be very attentive, reassuring people by holding their hand, reading books and encouraging people to use smelling blocks, but she was on her own for a most of the time. We will look at activities again at future visits to check that they are happening. The activities lounge is still being used as a storage room. Individual records of activities show very little activity. Some people living at the home have there own hobbies and interests and highly personalised rooms that they enjoy spending time in. Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 14 There were many visitors to the home during the day and a catholic priest was visiting one person. Dining rooms are provided on both floors. Tables were nicely set with napkins and cruet sets. People were served a substantial breakfast and dinner. Discussion with some people at our last visit said that these meals were served close together and then it was a small meal or snack supper over a sixteenhour period. It was suggested that it might be better to serve the main meal at teatime. This would balance the intake of meals out over the day and might help some people sleep better. Hot and cold drinks are served with meals and throughout the day. Each of the floors has a small kitchen where drinks and snacks can be prepared, particularly around suppertime. There have been changes in the kitchen staff team and a number of staff have been on sick leave. There was no menu on request in the kitchen to assess what food people had been offered to ensure that they were receiving a wholesome, varied and balanced diet. Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Because of the lack of readily available information we were unable to assess the level of complaints received by the home and what action was taken or how many members of the staff team had received safeguarding training. EVIDENCE: There have been no formal complaints made to CSCI though a number of concerns have been made to us about care practices around arrangements for people including medication practices. We were informed that there have been a number of complaints made directly to the home. As at our last visit information was not readily available. The head of care said that she would forward the details to us but we had not received them at the time of completing this report. There have been no allegations of abuse at the home since the last inspection. The home has a copy of the new local safeguarding procedures. The registered manager and deputy manager attended training in safeguarding procedures at an investigation level in January 2008. There is an internal safeguarding policy and procedure that makes the link to the local authority procedure. A staff training matrix for the home was not available so we were unable to check to see how many staff members had been on the safeguarding awareness course, since our last visit. The head of care said that she would send this information to us. We had not received it by the time of completing Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 16 this report so we were unable to make an assessment as to how much progress had been made. Beaumont House DS0000008399.V371804.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. Beaumont House provides pleasant homely and comfortable accommodation, with all single en-suite bedrooms but attention is still needed around safe practice and levels of cleanliness in some areas to reduce the risk of harm. EVIDENCE: Beaumont House is a large detached property offering very pleasant accommodation for the people who live there. The home also provides an enclosed, attractive and well-maintained private back garden with seating for people. The lounge and dining areas were homely and comfortably and generally furnished to a high standard. People can make use of all communal areas. Unwanted items were found again in the downstairs lounge areas. We continue to be concerned about the condition of both serving areas, but particularly the one downstairs, which needed cleaning, as did the hot trolley. Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 18 We found a large tub of jam that was covered in mould. The upstairs serving area was cleaner but again we found chemicals in accessible cupboards. The home provides all single private bedrooms each having an en-suite toilet and wash hand-basin. A lockable space is provided for peoples’ personal use. We checked a number of beds. One mattress needed to be replaced and some bedding had holes in it. Covers are not used on duvets. Bedrooms had been highly personalised in some cases, with belongings and furniture brought from home by those people who wished to. We checked some bedroom doors, which also act as fire doors. Again, a number did not close to the rebate and would not protect people should there be a fire at the home. This was identified at our last visit and has not been fully addressed. There are a number of toilets and two bathrooms on each floor. The two smaller bathrooms are unused due to the lack of space to support people safely in and out of the bath. Since our last visit one has been refurbished into an assisted shower room and both bathrooms have been repainted to good effect. Improvements in hand-washing facilities for staff in bathrooms has been made. The water temperature to the baths was checked and found to meet the required temperature of 43°C. Incontinence pads were no longer being stored in toilet areas to promote people’s dignity. Malodours persist in toilet areas because the bins being used for the disposal of clinical waste have still not been changed to airtight ones. Toilets are still in need of decorating. There were two new domestics at the home. Generally we felt that there had been an improvement in the levels of cleanliness. The storage of chemicals was better but both the kitchen and the laundry were left opened and unsupervised on occasion throughout the day. We were concerned about the arrangements for cleaning in the kitchen and the conditions of the kitchen fridge. An environmental health officer had also expressed concerns about the condition of the fridge. We were informed that two new fridges were on order. A fly screen had been fitted to the kitchen window. Beaumont House DS0000008399.V371804.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. Because of the lack of readily available information we were unable to assess whether the staff were qualified or have received the training they need to help ensure that a competent staff team supported people. EVIDENCE: There are generally five care staff members on duty in the morning, five in the afternoon and four in the evening, including the acting manager and the deputy. There are three carers on duty at night. Cooks, laundry assistant, domestics and business administration, support care staff members. There has been a high staff turnover at the home since our last visit, particularly on nights and an increase in the use of agency. There are two vacancies on nights. Two senior staff members from the day shift are currently covering nights. We looked at the recruitment files for two people working at the home and found that they were generally in good order. However, we were concerned that a new staff member with only a Povafirst in place spent most of the day working at the home in an unsupervised capacity. The organisation is a member of the local training partnership, which provides training through Skills for Care. We were unable to establish the qualifications and training of the staff team because there were no records available. We Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 20 asked the head of care to forwarded this information to us but we had not received this information by the time we had completed this report. Beaumont House DS0000008399.V371804.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 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The providers must ensure that the staff team is closely managed and supervised to ensure the heath and safety of the people living at the home. EVIDENCE: The registered manager for the home is currently on long-term sick. The head of care for the service is based at the home and as an interim measure a registered manager from another home within the group had come to manage Beaumont House. This person had only been at the home on a part-time basis for two weeks. The head of care and the temporary manager agreed with us that there was still a lot of work to do to bring the home up to standard, particularly around healthcare and personal support, health and safety practices and management. Because the main office was in disarray and was being reorganised by the head of care and the acting manager we requested Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 22 that some information that we needed to view that was unavailable be forwarded to us. Unfortunately this was not received and therefore could not be assessed by us. Although we were able to see some progress, many areas of the improvement plan had not been fully addressed. There are still gaps in the recording in healthcare risk assessment documentation and the handling of medication was a cause of concern. We also continue to be concerned about the lack of interaction between some members of the staff team and people living at the home and that staff members dont appear to be being managed e.g. leaving the building sometimes in large groups for breaks for long periods of time. We were concerned again about the lack of support and supervision provided at times throughout this visit, despite the fact that we were observing carers’ practice. We were concerned about the levels of hygiene and cleanliness in some areas of the home, particularly the kitchen and serving areas. Fire doors still did not close to the rebate to some bedroom doors making them ineffective in a fire. Wheel chair footplates were not always being used. We were concerned about the condition of the fridge in the kitchen, which was leaking and not clean. We were informed that two new fridges were on order. As at our last visit, the providers must ensure that the staff team is closely supervised through formal sessions with individual staff members and through observation of practice. This must be done to ensure that good practice learnt during heath and safety training is adopted as day-to-day practice and utilised in the best interest of the people living there. It was clear from discussions with a member of the staff team that formal supervision had not happened. Given our findings during observation of practice this area must be addressed with some urgency. Certificates and records were seen in relation to the health and safety of the environment and equipment and were found to be in good order. We asked for confirmation that the annual gas safety check had been undertaken. Beaumont House DS0000008399.V371804.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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 1 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 2 17 X 18 2 2 X 3 X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X X X X 1 X 1 Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 24 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 YA3 Regulation 14 Requirement That a community care assessment and/or thorough assessment is completed by the home prior to a person moving in to ensure that their needs can be met. Care plans must be accurately completed to ensure people are being supported consistently and safely. (Outstanding 31/07/08) Risk assessments for nutrition, moving and handling, falls and pressure care must be accurately completed to ensure people are being supported safely. (Outstanding 31.07.08) All records regarding medicines must be clear and accurate in order to show that medicines are given properly and can be accounted for. All medicines must be administered in exact accordance with the prescribers directions in order that residents health is not placed at risk. The registered provider must put in place effective arrangements to make sure that people have DS0000008399.V371804.R01.S.doc Timescale for action 30/10/08 2. OP7 15 30/10/08 3. OP8 13 30/10/08 4. OP9 13(2) 29/09/08 5. OP9 13(2) 29/09/08 6. OP9 13(2) 29/09/08 Beaumont House Version 5.2 Page 25 7. OP9 13(2) 8. OP9 13(2) 9. OP10 12 10. OP15 22(8) 11. OP19 23 12. OP30 18 13. OP31 13 14. OP38 13 an adequate supply of medication to ensure that their treatment is continuous. The registered provider must make sure that people who choose to look after their own medicines are supported to do so safely and the support needed and given is fully recorded. The registered provider must make sure that you have sufficient trained staff on duty to administer medication competently and safely. The registered manager must ensure that people receive appropriate levels of care and supervision at all times. (Outstanding 31/05/08) A record of all internal complaints made to the home needs to be kept and be readily available for inspection. Fire doors must be adjusted to ensure that they fully close to the rebate to offer protection to people should there be a fire. (Outstanding 30/05/08) The registered provider needs to send us an up-to-date training matrix that shows what mandatory health and safety and safeguarding training the staff team have received relevant to their roles and responsibilities. (Outstanding 30/06/08) The registered providers must assure themselves that the registered manager competency in areas of health and safety by training or other means to ensure safe management and monitoring of the service at all times. (Outstanding 31/07/08) That in the interests of health and safety, footplates must be used on wheelchairs unless assessed as not appropriate. DS0000008399.V371804.R01.S.doc 29/09/08 29/09/08 30/10/08 30/10/08 30/10/08 30/10/08 30/10/08 30/10/08 Beaumont House Version 5.2 Page 26 15. OP38 13 (Outstanding 31/05/08) Confirmation is required that a gas safety check has been undertaken by the home. 30/10/08 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 OP15 Good Practice Recommendations Records of what people have eaten should be kept to assess what food people had been offered to ensure that they were receiving a wholesome, varied and balanced diet. Cleaning arrangements for the kitchen should be monitored to ensure standards are being met Clinical waste bins that promote good hygiene practices and prevent malodour need to be provided 2. 3 OP38 OP38 Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Beaumont House DS0000008399.V371804.R01.S.doc Version 5.2 Page 28 - 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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