CARE HOMES FOR OLDER PEOPLE
Beaumont House 26 Church Lane Whitefield Manchester M45 7NF Lead Inspector
Julie Bodell Unannounced Inspection 5th December 2007 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.V341027.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.V341027.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.V341027.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. 25th June 2007 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. 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.V341027.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second key inspection, which took place over one day and focussed on what improvements had been made to address the shortfalls in standards identified at the previous inspection. The home did not know that the inspector was going to visit. Two days before this visit a CSCI pharmacist inspector examined the medication system. During the inspection, time was spent, talking to the registered manager, the general manager, the business administrator, the deputy manager and two senior care staff, as well as looking at paperwork and parts of the home. The inspector also spoke briefly with the registered providers who were visiting the home. On 5th September 2007 a second meeting took place with the registered providers and we shared are concerns about some care practices and management issues that needed to be addressed by this second key inspection. We made it clear to the registered providers that this situation could not continue. The registered providers accepted our findings and had already taken action to address the issues. As part of the inspection process the registered manager completed a quality review of the service (AQAA) as requested. Feedback surveys were received from two people using the service, with a mixed response. Improvements had been made in many areas of the service but there is more work to be done to continue to raise standards in some areas. What the service does well: What has improved since the last inspection?
Beaumont House DS0000008399.V341027.R01.S.doc Version 5.2 Page 6 There is a clear policy and procedure about what should happen at the point when a person comes to live at the home to ensure that all necessary information to support the person effectively is in place. There is a new recording format for care planning, risk assessment and daily records. Care staff members have received training on how to complete the documents. The deputy manager and two senior carer staff spoken with said that the new documentation had improved the way they think about prevention and support of the health needs of people living at the home. Significant improvements have been made to the accuracy of the medication records to support the safe administration of medication and ensure medicines are administered to people as prescribed. The home has started to improve the opportunities for people to be involved in activities and a new activities organiser has been appointed. The home has been decorated throughout and new carpets have been placed in the hall and in one lounge and six new chairs have been purchased. The kitchen staff members have either received mandatory training or have training planned to improve arrangements in the kitchen. The arrangements for control of infection in the laundry have improved. Items of bedding are being handled safely and washed at temperatures that will ensure that they are thoroughly cleaned and disinfected are now being used. To ensure the protection of people living at the home, safer recruitment practices are now in place with evidence that either a POVA check or a satisfactory CRB check are undertaken prior to staff starting employment. Arrangements are now in place for the registered manager and the deputy manager to receive up-to-date training in local safeguarding procedures to ensure that if an allegation is made about abuse they are clear about what action is to be taken. Arrangements are also in place for all staff members to attend safeguarding awareness training through the Local Training Partnership. Policies and procedures for both complaints and the safeguarding of vulnerable adult procedures have been reviewed and revised. The registered providers continue to take a more active involvement in the running of the home to ensure that all necessary improvements continue to be made for the benefit of people who live there. There is a new pack of policies and procedures and albeit they are from a nursing perspective, they are a significant improvement on the previous pack making clear links to the standards.
Beaumont House DS0000008399.V341027.R01.S.doc Version 5.2 Page 7 To ensure the health and safety of people living at the home and to prevent the risk of scalding thermostatic mixer valves have been fitted to the baths and water temperatures are checked regularly and action taken immediately to rectify problems, if they arise. Paper towel holders and liquid soap dispensers are to be fitted in the bathrooms to improve control of infection measures. 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.V341027.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 Beaumont House DS0000008399.V341027.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Attention is now being paid to obtaining all the correct information about a person before they move into the home to ensure that they can be supported and cared for effectively by the staff team from the point they arrive. EVIDENCE: Beaumont House is a popular home and is usually full with a waiting list for people wanting to come and live there. The registered manager said that the staff put a pack of toiletries and information in the new person’s bedroom, at the time of their arrival, as a welcoming gesture. There is a new policy and procedure in place that gives the staff team more direction about what needs to happen before and during the move into the home to help to ensure a smooth transition.
Beaumont House DS0000008399.V341027.R01.S.doc Version 5.2 Page 10 We talked with the deputy manager and two senior carers whilst examining the admission documentation for one of the three people who had most recently moved into the home. The person was privately funded, and had moved from another care home with no involvement of the local authority. There is much more detail in the new assessment documentation about the person’s needs that transfers easily to develop their care plan. The new assessment format 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. It was noted that there had been some improvement in the health of the person looked at since they had moved into the home. Standard 6 does not apply to Beaumont House, as they do not provide an Intermediate Care Service. Beaumont House DS0000008399.V341027.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments have significantly improved to help ensure the health, safety and protection of people living at the home as well as providing staff with clearer information about the level of support to be provided. More work is needed to develop better recording on risk assessments. The safety of the medication system has also improved with good record keeping and measures that ensure people receive their medication as prescribed, with a small number of outstanding areas to be addressed. EVIDENCE: A new care planning and risk assessment system has been introduced at the home since the last inspection. The system is based on a nursing model. The care staff team have received some training to help them to complete all records in an effective way. However, they had been poorly advised in some areas for example they had been told to keep information in individual daily
Beaumont House DS0000008399.V341027.R01.S.doc Version 5.2 Page 12 records brief. What care staff members were actually recording was good evidence of quality of life outcomes for people living at the home. It was agreed that the staff team would resume previous good practice. The care records of three people were examined and discussed with the deputy and two senior care staff. The first record was for the new person who has come to live at the home, the second was for the person who had the highest level of need and the third was for a person who had recently had a fall that required hospital treatment. Overall the information written in the care plans and risk assessments about these people matched what was discussed. Care plans were signed by a relative and kept under regular review by the staff team. However, it was clear that more work was needed around the scoring on the risk assessments to ensure consistent practice. It was agreed that initially the scoring on risk assessments would be done by the deputy manager and the senior care staff and they would check and challenge each others scoring, in a positive way, to ensure that the risk level was accurate and as a means of developing thinking about a more person centred approach. Unfortunately some of the documentation needed by the home had not been included within the new care records. The most important of these was the Waterlow assessment for the prevention of pressure sores. A number of people had pressure sores that they either had before they came to live at the home or happened during admissions to hospital. District nurses are involved in treating the pressure sores. Monitoring charts for fluid intake, turning charts, pain management and other documents were also missing. It was agreed that the deputy and the senior care staff would consult with the general manager as to what needed to be purchased. The requirement around pressure care risk assessment has been outstanding for a long time and it is unfortunate that the matter was not addressed when the new documentation was put in place. The inspector is in no doubt that the registered manager and the staff team will address this matter. But because of the time factors we will be considering sending out a warning letter that this requirement must now be completed fully by the set date in this report. We also discussed involving more healthcare professionals for support and advise, such as the tissue viability nurse, falls nurse etc. The need for training about person centred planning and end of life plans also needs to be considered. The registered manager said that she would raise these as issues at the local training partnership development day. The pharmacist inspector looked at the medication records together with medication held in the home to make sure that the requirements made at the last inspection had been met and also to make sure people were being given their medicines safely. Beaumont House DS0000008399.V341027.R01.S.doc Version 5.2 Page 13 There were several versions of a medication policy available for staff to read for guidance on the safe administration of medicines. The ‘homely remedies’ policy was still not in use so non-prescribed medicines, like Paracetamol, which can be bought in a chemist shop, were not kept in the home in case a person living at the home should need them. People would be safer if there was just one clear set of medication policies for staff to follow. The records of receipt, administration and disposal of medicines were good and they showed clearly that medicines could be accounted for. The good record keeping also showed that people were given medicines as prescribed and that peoples’ health was safe from harm. Some of the record keeping was very good especially when medication doses were changed; stopped or when new medicines were started. The records could be improved by recording fully why medicines were not given. The manager has made sure that regular checks, audits, were made on medication to make sure that it was being handled safely and peoples’ health was not at risk. Staff recognise that some people want to look after their own medication and help them to do this safely. The people who look after some or all of their medicines have been recently assessed as safe to do so, but it is of concern that there were no regular checks to make sure that they were continuing to look after their medicines safely. Risk assessments need to be reviewed to make sure people always receive the right support when their needs change. Medicines are stored safely including medication, awaiting collection for disposal by the pharmacy. However the medication storage room was very warm and it is recommended that the temperature be monitored to make sure that medicines are not spoilt by poor storage conditions. One person living at the home on a returned survey stated, “The carer’s in the home are excellent and look after my every need.” Improvements in this section must continue to be made and maintained to ensure that the quality rating does not go down again. Beaumont House DS0000008399.V341027.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. There are more opportunities for people to become involved in activities to encourage stimulation and interaction with other people. EVIDENCE: This section of the report was not the main focus of attention at this second key inspection of the home. More information can be gained from the inspection report of June 2007. The registered manager said that there were now more opportunities for people to become involved in activities, with entertainers coming into the home more regularly. A carer has now taken over responsibility for activities three afternoons a week. An exercise ball and jigsaws have been purchased for people to use. Some people were involved in making calendars for family members. This is an area for continued development and will be looked at in more detail at future inspections. Beaumont House DS0000008399.V341027.R01.S.doc Version 5.2 Page 15 Many people living at the home have there own hobbies and interests and have highly personalised rooms that they enjoy spending time in. Dining rooms are provided on both floors. Tables are nicely set with napkins and cruet sets. Menus have been reviewed and detail vegetarian options, diabetic option and additional fibre. We talked to the cook about ways to improve the presentation of food for people on a soft diet. It was thought that the home had received moulds that would make the appearance of soft food more appetising and that these would be found and used in future. The cook had prepared home made scones for tea. 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. The kitchen staff members have received training in basic food hygiene and there are plans for the cooks to attend NVQ Level 2 in Food Processing and Cooking. Beaumont House DS0000008399.V341027.R01.S.doc Version 5.2 Page 16 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Plans are in place for the registered manager and the deputy manager to attend training to ensure that they take appropriate action if an abuse investigation occurs. Policies and procedures for complaints and safeguarding procedures have been reviewed and revised to reflect current legislation. EVIDENCE: There have been no formal complaints made to CSCI, or internally, about the home since the last inspection. The complaints procedure is also in the statement of purpose. The complaints policy and procedure has been reviewed and revised to ensure that it complies with legislation. 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 are booked to attend training in safeguarding procedures at an investigation level in January 2008. Some staff members have not been on the safeguarding awareness course and training is planned on a rolling programme basis. This must be completed. There is a new internal safeguarding policy and procedure that make the link to the local authority procedure. Beaumont House DS0000008399.V341027.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 21 23 and 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Beaumont House provides very pleasant homely and comfortable accommodation, with all single bedrooms en-suite, for people to live in. People are able to bring their own items of furniture and other belongings, which have in some cases been used to good effect to create a home from home atmosphere. EVIDENCE: Beaumont House is a large detached property offering very pleasant accommodation for the people who live there. The lounge and dining areas were clean, homely, comfortably and furnished to a high standard. People can make use of all communal areas. The home also provides an enclosed, wellmaintained and private back garden with seating for people.
Beaumont House DS0000008399.V341027.R01.S.doc Version 5.2 Page 18 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 peoples’ personal use. Rooms had been highly personalised in some cases, with belongings and furniture brought from home by those people who wished to. All bedrooms have recently been re-painted. The home has a maintenance and refurbishment plan. The kitchen, hall, stairs and serving areas have been repainted. New carpets have been placed in the hall and in one lounge and six new chairs have been purchased. 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. Plans are in progress to upgrade the bathrooms, which were generally found to be basic, to improve the experience of having a bath. Improvements in hand-washing facilities for staff in bathrooms have started to be made though some equipment that had been ordered had yet to arrive. The water temperature to the baths was checked and found to meet the required temperature of 43°C and thermometers were available. Thermostatic mixer valves have been fitted to many hot water outlets around the home. Health and safety practices in the laundry were looked at. To ensure good control infection practice, the red bag system of handling soiled items had been introduced and the sluice cycle on the washing machines was now being used, as appropriate. The laundry assistant had recently received control of infection training and protective disposable gloves and aprons are now provided. The home was hygienically clean and tidy throughout. Beaumont House DS0000008399.V341027.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. Mandatory health and safety training is now being undertaken by the staff team to ensure the safety and protection of the people living at the home. If people are to benefit from training then all learning must be adopted as dayto-day practice. EVIDENCE: There are generally six care staff members on duty in the morning, six in the afternoon and four in the evening, including the registered manager and the deputy. There are three carers on duty at night. Cooks, laundry assistant, domestics and business administration, support care staff members. At previous inspections major shortfalls were noted in respect of criminal record checks. This matter has now been addressed by the organisation and a complete list of start dates, Povafirst clearance details and criminal records checks, with disclosure numbers and the issue date was given to the inspector. Two recruitment files were checked and no further issues were raised. We talked to the business administrator who clearly understood her responsibility to ensure confidentiality. We discussed the need to scrutinise information received from potential employees in order to protect people living at the home.
Beaumont House DS0000008399.V341027.R01.S.doc Version 5.2 Page 20 For future reference all employees or volunteers regardless of their position must have a recruitment record that meets legal requirements that can be examined by CSCI, including people in the head of care position or external consultants who might have access to people living at the home. Of the 25 care staff employed at the home we were informed that 5 hold NVQ Level 3 and 12 hold NVQ Level 2 with a further 3 currently undertaking NVQ Level 2. This gives a percentage of over 50 and therefore exceeds the national minimum standards. The organisation is a member of the local training partnership, which provides this type of training through Skills for Care and is now fully utilising this facility. The registered manager is now attending the partnership meetings and was due to attend the partnership development day to look at plans for future training opportunities for the staff team. A training skills audit has been undertaken and information put into a spreadsheet. Arrangements have been made where shortfalls have been identified in mandatory health and safety training. Once this training is completed, what is learnt must be adopted as good day-to-day occupational practice for the benefit of people who live at the home. Beaumont House DS0000008399.V341027.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 adequate. This judgement has been made using available evidence including a visit to this service. The registered providers have become more involved in the operation of the home. They must ensure that there are clear lines of accountability within the home and with any external management so that the home is run smoothly and in the best interest of the people living there. EVIDENCE: The registered manager of the home has many years of experience of working with older people. She has recently completed the Registered Manager’s Award NVQ Level 4. The registered manager is supported by a middle management team, which includes a head of care, a post that is currently vacant, a general manager and business administrator and an external
Beaumont House DS0000008399.V341027.R01.S.doc Version 5.2 Page 22 consultant. Although vital to the operation of the running of the home the middle management group and the external consultant need to be clear about their roles, responsibilities and accountability to ensure that they do not unwittingly compromise the registered providers and the registered manager and their legal responsibilities in respect of their registration, for example not ensuring all the necessary documentation was in the new care record pack. Although we have noted many ongoing improvements in most areas of the service, we are concerned about a number of areas of practice at the home. There were clearly gaps in the risk assessment documentation that should have been identified by the registered manager. Another example was at the last inspection we spent time looking at the kitchen and spoke with the registered manager, one of the two cooks and the kitchen assistant about the Safer Food Better Business documentation. At that time the cook was not aware of the existence of the documentation even when shown a blank copy that was held in the office. We looked at this issue again and found the documentation was this time in a box in the kitchen and still not being used, despite being pointed out by an environmental health officer in the interim period. The registered providers must assure themselves that the registered manager is competent in all areas of practice, by training or other means. Time must be made available to ensure that the manager can monitor tasks delegated to others e.g. the deputy and senior staff to ensure that they have been completed and to a good standard. Care is now being undertaken when completing Regulation 37 notifications. One notification received recently relating to a fall during the night was looked at in more detail. It was clear that the registered manager had taken action to address the matter. Following discussion with other staff members we were satisfied that the incident was an extraordinary occurrence. The registered manager must undertake a review of all health and safety practices carried out during the night to ensure that standards are being consistently maintained through direct observation and supervision. The registered manager completed an AQAA. The form was understated and did not reflect all the areas of improvement that had been carried out. This should be taken into account when completing the next form. It was noted that the registered manager had not completed the National Minimum Data Set for Skills for Care. The outgoing head of care had been undertaking the monthly Regulation 26 monitoring visits and a copy of the report completed was being sent to CSCI. The external consultant is now undertaking this role. The outgoing head of care has purchased a new set of policies and procedures and albeit that they are from a nursing perspective they are a vast improvement on the previous pack. 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. Beaumont House DS0000008399.V341027.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 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X 3 X X 4 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X 2 Beaumont House DS0000008399.V341027.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 OP8 Regulation 13 Requirement Timescale for action 31/01/08 2. OP9 13(2) 3. OP18 18 4. OP30 18 Although significant improvements have been made, risk assessments must continue to be developed for nutrition and pressure care and reviewed and updated on a monthly basis ensuring people are being supported safely. (Outstanding requirement of 31.07.05, 31.01.06, 31.08.06 and 30.04.07 and 31.08.07) Medication risk assessments 31/01/08 must be reviewed and kept upto-date to make sure people always receive the support they need to manage their medicines safely. (Outstanding 31/07/07) 31/03/08 Training in safeguarding awareness and procedures must be provided to all members of the staff team to ensure that they recognise the signs of abuse and what action they must and must not take in the event of an allegation being made. (Outstanding 31/07/07) The registered person must 31/03/08 ensure that the identified gaps in mandatory health and safety
DS0000008399.V341027.R01.S.doc Version 5.2 Beaumont House Page 25 5. OP31 12 6. OP31 13 7. OP38 13 8. OP38 13 training are completed as planned to ensure that all the staff team have receive the necessary training relevant to their roles and responsibilities. To ensure that the home is run smoothly and in the best interest of people living there, the registered providers must ensure that there are clear lines of accountability within the home and with any external management. (Outstanding 31/07/07) 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. To ensure the health and safety of people living at the home the kitchen staff must complete the Safer Food Better Business diary documentation to give a clear record of temperatures to fridges and freezers, meat temperatures when using a probe, what cleaning has been undertaken and a description of the main meal on that day. The registered manager must undertake a review of all health and safety practices carried out during the night to ensure that standards are being consistently maintained through direct observation and supervision. 31/03/08 31/01/08 31/12/07 31/01/08 Beaumont House DS0000008399.V341027.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 OP9 Good Practice Recommendations Policies and procedures must be revised and reviewed and combined into a single comprehensive document to make sure guidance to staff is clear and the health of people living at the home is protected. The temperature of the medication room should be monitored to maintain it at a safe temperature for medicines storage. The provision of activities for people living at the home need to be developed further. To make the meals provided for people on soft diet more appealing and appetising, food should be arranged separately using the moulds available. 2. 3. 4. OP9 OP12 OP15 Beaumont House DS0000008399.V341027.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
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