Inspection on 04/07/06 for Beaumont House

This inspection was carried out on 4th July 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

Beaumont House 23/02/10

Beaumont House 29/09/09

Beaumont House 16/03/09

Beaumont House 29/09/08

Beaumont House 22/04/08

Beaumont House 05/12/07

Beaumont House 25/06/07

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Beaumont House 26 Church Lane Whitefield Manchester M45 7NF Lead Inspector Lucy Burgess Unannounced Inspection 4th July 2006 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 Beaumont House DS0000008399.V297646.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.V297646.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 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.V297646.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. 12th December 2005 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 £370.00. 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. The home 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.V297646.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 visit to the home. The 1st day was spent split between the office, talking with the Registered Manager and viewing paperwork as well as looking round the environment and speaking with residents, their families and a number of staff. A second visit was made to the home so that staff recruitment files could be examined. As part of the inspection process the Registered Manager/Provider was asked to complete a pre-inspection questionnaire. This was provided and additional feedback was requested from health professionals who visit the home. Four responses were received stating they were happy with the support provided. All the key standards were looked at during this inspection visits. What the service does well: What has improved since the last inspection? Improvements have been made to the management of the home. The Registered Manager and Matron now meet on a weekly basis and write out an action plan of work that needs to be done. This has provided the Manager with more support and a clear plan of work, which she can focus on each week. Some of the communal rooms and bedrooms have been redecorated and fitted with new carpets. This has further improved the appearance of the home and provides a comfortable place for those who live there. Beaumont House DS0000008399.V297646.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. Beaumont House DS0000008399.V297646.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.V297646.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. The manager must ensure that only residents for which the home is registered are admitted to the home and that a detailed assessment is completed ensuring the needs of prospective residents can be met. EVIDENCE: Since the last inspection the home has had several admissions. These have included both respite and permanent placements. Information was examined one resident who privately funds her own placement. This was seen to cover areas in relation to the persons’ social, emotional and physical needs. Records included personal details, legal and financial affairs, medical history, care needs, likes, dislikes and preferences, rising and retiring times, routines, diet, medication, health care, social and emotional needs and life history. It was noted that another resident admitted to the home in March 2006 had previously been assessed as being elderly mentally ill. It had been expressed Beaumont House DS0000008399.V297646.R01.S.doc Version 5.2 Page 9 that the individual’s needs had changed requiring less support. The home had been advised by the inspector in February 2006 to ensure that a full needs assessment was carried out prior to any admission being agreed to ensure that needs could be met by home. Prior to this visit to the home the inspector was contacted by the residents family and informed that they had been requested to seek alternative accommodation, as the home no longer felt they were able to meet the residents needs. The Manager must ensure that assessments documents are completed in full and provide sufficient detail so that an informed decision can be made about whether the persons needs can be met by the home. Where possible residents and/or their representative should be asked to sign the document to evidence that they are in agreement. Once completed this information is then used to develop a care plan. Although the Statement of Purposes was not examined during this visit the inspector was informed that minor amendments are to be made so that the document reflects current arrangements. Once completed a copy is to be forwarded to the CSCI. Standard 6 does not apply to Beaumont House as they do not provide an Intermediate Care Service. Beaumont House DS0000008399.V297646.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 and 10 Quality in this judgement area is poor. This judgement has been made using available evidence including a visit to this service. Whilst care files had improved additional information and monitoring was needed to ensure that records fully reflect the changing needs of residents ensuring their safety and well-being are addressed. EVIDENCE: Three residents were identified. Two of which due to recent changes in their health and well-being and the third who was a new resident to the home. Files were examined for each of them. Discussion was also held with the family members of two of the residents along with observations. One of the residents does not have English as a 1st language Information contained within the files included a referral form, residents admission record, life history, care plan, risk assessments, weight records, record of professional visits and additional correspondence. In the main plans had been reviewed on a monthly basis. The manager also stated that formal Beaumont House DS0000008399.V297646.R01.S.doc Version 5.2 Page 11 reviews had been arranged with families and relevant others for those residents who privately fund their own placement. It was noted that some improvements have been made to care plans however of the file examined several areas still required some development. Issues identified are outstanding requirements from previous inspection. Action must be taken to ensure these are addressed. One file did not have a completed life history, which could have been completed by family members who visit the home regularly. The care plan and risk assessment was not consistent in relation to mobility. The care plan stated that the resident needs assistance with 1 or 2 carers, however recently the resident was unable to transfer and was being hoisted. This had been reflected in the handling assessment and identified that at times 2 or 3 staff were required. The risk assessment regarding falls had not been reviewed since March 06. In the second file identified that the resident had changes in continence and that referral was to be made to the district nurse. No further information was provided to evidence that this had been done or the outcome. Information was also recorded with regards to regular blood tests being carried out but again there was no explanation as to why this was being done or what the results were. The third file had been updated and indicated changes in the resident’s mobility however this had not been risk assessed to show how this was being managed. The handling assessment had been completed stating ‘mobilising not applicable’, however the resident has been moving around independently but unsafely. This too was not reflected on the pressure care assessment. On the nutritional assessment the outcome had been recorded as ‘high need’ and that staff were to monitor, but there was not information held on file or seen within the residents room to evidence that this was taking place. The family of one resident expressed that they were concerned due to changes in their relative level of need, which was impacting on her appearance and the environment. This was discussed with the Manager who agreed to explore a programme of support, which may minimise some of the concerns expressed. The Manager must ensure that all care plans and risk assessments accurately reflect the changing needs of the residents and that staff completing the documents are clear about the level of information to be provided ensuring the residents are safe and well cared for. Risk assessments had been completed and signed by several members of staff. The Manager must ensure that those staff completing the assessments are trained and assessed as being competent to do so. Beaumont House DS0000008399.V297646.R01.S.doc Version 5.2 Page 12 Records are made of all professional visits. Each resident is registered with a local GP. Visits are also made by the district nurses, chiropodist, physiotherapist and CPN etc where necessary. Regular monitoring of weights were also being made. The Manager must ensure that monitoring is still made of those residents who refuse to be weighed or are unable to be weighed. Each of the care plans also stated that families should be involved with the care planning however of the files examined neither the resident nor family members had signed the care plan to evidence their involvement. As family members are actively involved and make regular visits to the home information could easily be made available for them to read and sign. The Manager should explore this. The inspector also observed that residents being transferred by wheelchair did not have footplates in place. Footplates should be used at all times to prevent residents from being injured. A full inspection of the medication system was undertaken by the CSCI pharmacist on the 1 June 2006 due to on-going concerns around the administration and recording of medication. A number of improvements had been made. This area was looked at again. Medication was found to be held securely. Records are made of all items received by the home and returned to the pharmacy. A sample signature list has also been placed on file. A list of residents’ mediation was held with details of when items had been ceased. MARS sheets had been completed in full and hand written entries had been checked and double signed to evidence that they were correct. The inspector was informed that the supplying pharmacist was due to do an audit of the system. A copy of the report has been requested. Residents feel they are treated with respect and their right to privacy is upheld. Staff spoken to gave examples of how privacy and dignity were promoted. Feedback received from visiting GP was that they were always able to see the residents in private and that staff demonstrated a clear understanding of the care needs of residents. Beaumont House DS0000008399.V297646.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this judgement area is good. This judgement has been made using available evidence including a visit to this service. Arrangements regarding activities have improved offering more choice and stimulation. The dietary needs of the residents were also catered offering choice. EVIDENCE: A choice of activities have been provided and included BBQ’s, outside entertainer, bingo and a day trip to Rivington Barn. Some of the activities have involved other residents from Bankfield homes. The home has recently purchased a piano, this is to be set up in one of the lounges and a relative has offered to play. Party arrangements are also to be made for 1 resident who is to celebrate their 100th birthday, it is hoped that the Mayor will attend. The Manager also stated that one of the carers has taken on responsibility for developing the activities within the home. Some fundraising has taken place so that items could be purchased. These have included a large snacks and ladders game and blow up darts. Other new activities have include crafts using beads and baking. Beaumont House DS0000008399.V297646.R01.S.doc Version 5.2 Page 14 Those residents able to pursue their own interests away from the home are encouraged to do so. This includes visiting family, shopping or attending church or local centres. One resident spoken with regularly attends the local community centre taking part in armchair exercise and learning the computer. Visitors are welcome at any time. Relationships with family and friends are encouraged. Relatives spoken with stated that they ‘we’re kept informed of any changes’ and ‘happy with the support provided’. The local clergy and hairdresser also visit residents each week. Dining rooms are provided on each of the floors. Tables are nicely set with napkins and cruets. Menus have been reviewed and detail vegetarian options, diabetic option and additional fibre. Meals for the day were said to be written on the chalkboards in each dining room then residents were aware of the choices available. The meals served during the visits included a lunch of cheese pasties or Cumberland pie with potatoes and vegetable. The evening meal was vegetable quiche, salad, chips and sandwiches. Hot and cold drinks are served with meals and throughout the day. Each of the floors also have a small kitchen where drinks and snacks can be prepared particularly around suppertime. The home has one resident who is Muslim. Through discussion with the manager it was noted that a specific diet is not provided other than omitting pork items. The Manager explained the resident does not specifically follow her culture/religion and that whilst some items are brought in by family members she is happy with the choices made available. It was also noted that as the resident has limited communication skills as she does not have English as a first language therefore choices and requests are made using gestures and signs. Staff have built up a rapport with the resident in understanding her needs. Arrangements are also being made for sky television to be installed in her room then she can watch Arabic television, this has been requested and funded by the family. The inspector was informed that the dietician has recently been involved with the home to review the needs of residents where this had been identified. Individuals were assessed and recommendations made. Beaumont House DS0000008399.V297646.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements are in place in relation to the protection of service users as well as responding to their concerns however outstanding training is still required. EVIDENCE: Information provided within the pre-inspection questionnaire identified that 4 complaints have been received by the home since the last inspection. Action had been taken where possible. The inspector was aware of two issues, one of which is still being addressed. The second issue had initially been received by the CSCI but returned to the Provider to investigate and provide a response. Issues identified were in relation to residents being woken early and the needs of the service user. Following this the inspector carried out a random visit to the home early one morning to establish if the information provided by the home reflected the dayto-day practice. Further action was identified. This has been detailed within a separate report, which is available on request. With regards to adult protection, 7 staff have received the relevant training in this areas with further courses identified for the forthcoming years. The Manager must ensure that training in this area is completed by all staff working within the home. Beaumont House DS0000008399.V297646.R01.S.doc Version 5.2 Page 16 An outstanding requirement remains with regards to the use of bedrails. The Manager must ensure that the is clear policy in place in relation to risk management along with a clear assessment to ensure the safety and protection of the residents. Beaumont House DS0000008399.V297646.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 and 26 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. Beaumont House provides pleasant accommodation. This is being enhanced with the refurbishment and improvements being made within the home so that the residents and safe and comfortable. EVIDENCE: Beaumont House is a large detached property offering pleasant accommodation for the residents. The lounge and dining areas were clean, well decorated and comfortably furnished. Residents make use of all areas. The home also provides an enclosed garden to the rear of the home. The home provides all single private bedrooms each having an en-suite toilet and wash hand-basin. Locks are fitted to the bedroom doors and a lockable space is also provided for the residents’ personal use. Rooms had been nicely personalised with belongings and furniture from home by those residents who wished to. Beaumont House DS0000008399.V297646.R01.S.doc Version 5.2 Page 18 The home have produced a maintenance and refurbishment plan, which is currently being worked through. This includes fire safety equipment being installed, redecorating of bedrooms, new flooring to bathrooms and toilets, recarpeting of bedroom and communal areas, repairs to the bathroom and radiator cover. The Manager explained that as some of the residents prefer to have their doors open arrangements were being made for bedroom door to be fitted with fireguards, which close if the alarm is triggered. However one resident expressed that the one in her room did not work (room 7) and that the guard fitted to the laundry room was triggered by the call bells. The Manager must ensure that the equipment is in good working order and that rooms not fitted with self-closing devise are done so ensuring the safety and protection of the residents. There are also 4 bathrooms within the home two of which are unsuitable for use due to the layout of the room and the physical needs of residents. The Manager explained that additional funding had been allocated to change the rooms with adapted walk-in showers, which would be easily accessible to the residents offering them a choice in bathing facilities. As identified at the last inspection staff hand washing facilities are needed in those rooms were residents are support with personal care to prevent any cross infection. The home was found to be clean and tidy with no malodour. Beaumont House DS0000008399.V297646.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 and 30 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient staffing levels and training are provided. Some improvements are need to staff recruitment files and induction training to ensure the safety and protection of the service users. EVIDENCE: Staffing levels were sufficient to meet the needs of service users. Rotas are clearly maintained showing both day, night and ancillary support. At present the home is recruiting for night and kitchen staff. The Home has recently employed some new staff. One of the staff members was spoken with about how she was settling into the home and what support she was receiving. The staff member expressed that she was ‘quite settled’, that the other staff were ‘friendly and helpful’ and that both staff and managers were ‘very approachable’. It was noted through discussion and whilst examining staff training files that the induction process was not in line with the ‘skills for care’ specification. The Manager should refer to this when developing the system to be used by the home. Staff personnel files were seen for those staff recently recruited. Generally information had been gathered with regards to the application form, written Beaumont House DS0000008399.V297646.R01.S.doc Version 5.2 Page 20 references and criminal record check. However minor shortfalls were found with regards to 1 file having only 1 written reference and another that had gaps in the employment history, which were unexplained and no photograph. The Manager must also ensure that information is clear. One written reference seen had been completed by the Manager following a telephone call to the referee however the Manager had signed the referee’s name. This should not be done and information should clearly show how this has been provided. Training had been undertaken by several members of the team. Courses have included medication, diabetes, 1st aid, health and safety, moving and handling, adult protection, infection control and oral hygiene. Further sessions have also been identified for the forthcoming year, these include moving and handling, dementia, adult protection, bereavement, health and safety, food hygiene and infection control. The Manager must ensure that the training is undertaken by both care and ancillary staff working within the home. With regards to NVQ training this too is provided by the home. Information provided on the pre-inspection questionnaire identified that 10 carers currently hold a certificate in Level 2 or 3 and that a further 10 are to enrol covering Levels 2, 3 and 4. The Manager has recently passed the NVQ Level 4/ Registered Managers Award. Beaumont House DS0000008399.V297646.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this judgement area is adequate. This judgement has been made using available evidence including a visit to this service. The development of effective monitoring systems along with good working relationships will enable the home to achieve its aim in providing a good quality service for the residents. Adequate arrangements continue to be in place to safeguard service user finances. Health and safety issues need to be addressed to ensure the safety of residents and staff. EVIDENCE: The Manager of the home has many years of experience of working with older people. She has recently completed the NVQ Level 4/Registered Managers Award, a copy of the certificate is to be forwarded to CSCI. The Manager is supported in her role by the Martron who also oversees the management of other Bankfiled Care Homes with the local area. The Manager expressed that she feels supported by her manager and has become more informed. Weekly Beaumont House DS0000008399.V297646.R01.S.doc Version 5.2 Page 22 meeting are held and action plans developed offering her more direction and support in carrying out her duties. This has made improvements with the running of the home and will assist in further development. Additional tasks are delegated to the deputy manager and senior staff that support the manager in her role. Formal meetings are also held for both the Managers and Deputy Managers to offer support and share information and ideas. In relation to standard 33 the home has recently sent out questionnaires to residents, relatives and visitors for feedback about the home including the care, environment, activities, food and cleanliness. A sample of four questionnaires returned by relatives scored the home either ‘good’ or ‘excellent’. Comments also included ‘my mother is very settled and comfortable and treated with kindness and respect – I appreciate everything’ and ‘we feel you have an excellent team of carers who show kindness and humour towards the residents in all aspects of their care’. The home is also completing the Investors in People Award, which has involved evaluating the service within the home and implementing improvements and systems where necessary to ensure that this is in the best interests of the residents. The home is also carrying out the Regulation 26 monitoring visits. As outlined within the Regulation this states that the responsibility can be delegated to ‘an employee of the organisation or partnership who is not directly concerned with the conduct of the home’, therefore should not involve the Manager/Deputy Manager auditing his or her own service. This is to offer an objective and impartial view about the care and management provided within the home. Alternative arrangements should be made. With regards to the residents’ finances, the home continues to offer support where necessary with. In the main families take overall responsibility for the residents money particularly for those who lack the capacity to do so themselves. Records and receipts are held for all transactions made. Money is held securely and individual records are maintained. Certificates and records were seen with regards to the health and safety of the environment and equipment. Several areas need to be addressed to ensure that the environment and equipment are safe to use. This includes the annual gas safety certificate, servicing of the hoist and checks to the fireguards fitted to doors. It was also clarified with the Manager her responsibility in relation to Regulation 37. The Manager must ensure that any issues, which may affect the well-being of residents or the running of the home must be reported in writing to the CSCI. The Fire Officer had also visited the home in November 2005 and work had been identified. The Manager expressed that this had been addressed. Beaumont House DS0000008399.V297646.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Beaumont House DS0000008399.V297646.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 OP3 Regulation 14 Requirement That comprehensive assessments are completed on new service users given explicit details of the support required Outstanding requirement That care plans accurately reflect the support needs and how these are to be met. Outstanding requirement That risk assessments are developed for all identified areas and reviewed and updated on a monthly basis. Outstanding requirement There must be evidence of resident/relative involvement when drawing up the care plan. Outstanding requirement That the nutritional needs of service users are fully assessed and monitored. Outstanding requirement That action is taken to address/manage issues related to the identified residents in relation to managing continence. That staff completing the risk assessments are trained and competent to do so. DS0000008399.V297646.R01.S.doc Timescale for action 31/08/06 2. OP7 15 31/08/06 3. OP8 13 31/08/06 4. OP7 15 31/08/06 5. OP8 12 31/08/06 6. OP8 12 31/08/06 7. OP8 13 30/09/06 Beaumont House Version 5.2 Page 25 8. OP18 13 9. 10. OP18 OP26 18 13 11. 12. OP29 OP30 19 18 13. 14. OP30 OP33 18 26 15. OP38 23 16. OP38 13 17. 18. OP38 OP38 13 37 That policies and risk assessments are developed in relation to bed rails and risk management in order to ensure the protection of service users. Outstanding requirement That training in adult protection is delivered to all staff working in the home. To reduce the risk of cross infection staff hand washing facilities must be provided in the residents’ en-suite toilets. Outstanding requirement That staff files include all information as detailed within the report. That the manager ensure that the identified training programme is provided at all staff. That the staff induction reflects information covered within the ‘skills for care’ specification That the completion of the Regulation 26 monthly monitoring reports are delegated to someone other than staff working in the home. That the fireguards fitted to doors are checked to ensure their effectiveness and that they are in good working order. The thermostatic control valves must be serviced in accordance with requirements. Evidence of this must be forwarded to the CSCI. Outstanding requirement That checks are carried out in relation to servicing of the hoists and the gas safety check. That information is forwarded to the CSCI with regards to Regulation 37 30/09/06 30/09/06 31/08/06 31/08/06 30/12/06 30/09/06 31/08/06 31/08/06 31/08/06 31/08/06 31/08/06 Beaumont House DS0000008399.V297646.R01.S.doc Version 5.2 Page 26 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 Consideration needs to be given to devising moving and handling, pressure sore and nutritional risk assessment documents that give clear guidance on how to reach a judgment That a copy of the pharmacy audit is forwarded to the CSCI. That a copy of the Manager certificate in relation to the Level 4/ Registered Managers Award is forwarded to CSCI. 2. 3. OP9 OP31 Beaumont House DS0000008399.V297646.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beaumont House DS0000008399.V297646.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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