CARE HOMES FOR OLDER PEOPLE
Beech Court 52 Church Lane Selston Nottingham NG16 6EW Lead Inspector
Jayne Hilton Unannounced 22 September 2005 at 9:00 am
nd 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 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. Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Beech Court Address 52 Church Lane Selston Nottingham NG16 6EW 01623 752512 01773 581445 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Alan Peter Pearce Mr Alan Peter Pearce Care Home 23 (Twenty Three) Category(ies) of Old Age (OP) - 23 (Twenty Three) registration, with number Dementia Over 65 (DE(E)) - 23 (Twenty Three) of places Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: NONE Date of last inspection 22/9/05 Brief Description of the Service: Beech Court, 52 Church Lane Selston, Nottinghamshire is a 23 bedded, care home offering personal care for older people with dementia. The building is a converted rectory with a purpose built extension and is on two floors. There is a passenger lift to the first floor. The home has an easy accessed garden and is located in a quiet corner of the village opposite the church. The home was sold in September 2004 and now has new proprietors. The new providers have been re-furbishing parts of the home and has implemented many changes. The change process has presented the providers with many challenges amongst a busy time. Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Inspection took place on 22nd September 2005 at 9.15am and concluded at 1.50pm. The unannounced inspection was carried out by, Regulation Inspector Jayne Hilton. The focus of the inspection was to assess the requirements and recommendations set at the last visit and to assess the four requirements and five recommendations set after a pharmacist inspection, which was carried out by Neveeda Knopp, Pharmacist Inspector CSCI on 9th August 2005. The home received a letter outlining the outcome of the pharmacy inspection, however the letter is not published but can be made available on request to members of the public or other enquirers. The registered provider, the care manager, one relative and five service users contributed to the inspection. Three staff were also spoken with briefly. A part tour of the building took place and various records and policies were examined. Three service users plans were examined. What the service does well:
All service users spoken with reported that they were happy with the care provided and service users were observed to be relaxed and comfortable throughout the inspection. One service user commented, “everything is fine thank you, I’m quite satisfied”. A relative commented that staff were very kind respectful to service users at all times. A relative also stated that the sign outside of the home says ‘Care Home’ but it should state ‘A home that cares’. A relative reported that the shared responsibility now in place for her relative has improved the quality time spent with each other and has been conducive in improved health for herself. The Providers have many years experience in care provision and state that they have cared for service users with dementia type illness in their other care home, however Beech Court is more specialised provision and the provider is developing staff to meet the varied needs of the service users. Staff members have undertaken training in dementia care and activities for people with dementia. Service users are treated with respect and their privacy upheld and they maintain contact with family/friends/representatives and the local community as they wish. There were good records kept regarding outside professional input such as GP and district nurse visits. Observations made of staff, the providers and care manager interacting with service users provided evidence of mutual respect and kindness. Service users were noted to wander into the office and not excluded in any way. The providers are keen to provide a good service and speak fondly of service users. . Service users and relatives were clear about making a complaint should they need to. Service users live in a clean, well - maintained environment that is currently being re-furbished to improve the quality of facilities for service users.
Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 6 Bedrooms meet standards and are personalised. The home was found to be clean and free from mal odour. The health and safety of service users is generally safeguarded. The meals provided are overall on the whole nutritious and adequate. Service users have a contract in place their needs are being met and the overall outcomes, for service users is positive. What has improved since the last inspection? What they could do better:
The providers are still not currently providing clear information materials of what the home offers and this must be rectified to establish the foundation for setting out its aims and objectives, range of facilities and for fully informing prospective service users/representatives to enable choice about whether the home is suitable and able to meet the individual’s particular needs. It is recommended that more detail be kept in the individual service users care plan for falls regarding time of fall and treatment sought etc for quality monitoring purpose etc. There were minor areas to address in relation to financial procedures at the previous inspection, which were not assessed at this inspection. The inspector advised that there was an obvious lack of visual cues for service users with dementia and suggested that the care manager look at implementing pictures and symbols throughout the home.
Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 7 The provision of stimulation and activities in the home, particularly for those service users with dementia appears to have declined somewhat and a requirement has been set for this to be formally re-instated with evidence of social and recreational needs of service users and how these are being met. Although the meals provided are overall on the whole nutritious and adequate there are still issue to address regarding the promotion of choice options. The complaints procedure needs to include good practice action of follow up to complaints made and action taken. Several policies and procedures required further development The policies for dealing with service users who are dying examined in the home require consolidation. There are some areas, which require attention temporarily until the ground floor bathroom is fully re-furbished. Recruitment procedures require some improvement to ensure that all of the regulatory documentation is in place. The health and safety of service users is generally safeguarded, however it may be compromised regarding evidence of a breach in practice for COSHH [Control of substances hazardous to Health] 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. Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1-4 The providers are still not currently providing clear information materials of what the home offers and this must be rectified to establish the foundation for setting out its aims and objectives, range of facilities and for fully informing prospective service users/representatives to enable choice about whether the home is suitable and able to meet the individual’s particular needs. Service users have a contract in place their needs are being met and the overall outcome for service users is positive. EVIDENCE: The statement of purpose and service user guide inspected in the home was inspected. The Statement of Purpose was found to still have shortfalls, although produced and submitted to CSCI for the new registration, the copy in the home on the day of the inspection, was not sufficient to meet the regulations and NMS. The manager was advised to revisit the document and provide CSCI with a revised copy as soon as possible. Evidence was provided that copies of the service user guide are issued to prospective and existing service users.
Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 10 The terms and conditions document has been prepared and there was evidence that this is now in use. The document examined was comprehensive. All service users should be issued with the terms and conditions and a copy held on their individual file. It was observed during the inspection that a change of rooms that was had involved the relative and service user in the decision of the room change had been documented and once terms and conditions have been issued further room changes should induce issue of new terms and conditions for the relevant room number and clearly indicate the room number. The provider/manager has introduced a new care plan format and has been in the process of transferring existing service users information into the new format. All were now transferred. Three, service user’s files examined had relevant assessment detail, and these had been reviewed to reflect the service users changing needs. The provider is now using assessment tools for nutrition and tissue viability. A newly admitted service users assessment was completed well and covered the required needs as specified in Standard 3.3 of NMS. The service users social needs, likes and preferences were also well covered. The assessment however was dated when completed and was endorsed by the service user or representative. All service users spoken with reported that they were happy with the care provided and service users were observed to be relaxed and comfortable throughout the inspection. One service user commented, “everything is fine thank you, I’m quite satisfied”. A relative commented that staff were very kind respectful to service users at all times. A relative also stated that the sign outside of the home says ‘Care Home’ but it should state ‘A home that cares’ and the relative reported that the shared responsibility now in place for her relative has improved the quality time spent with each other and has been conducive in improved health for herself. The Providers have many years experience in care provision and state that they have cared for service users with dementia type illness in their other care home, however Beech Court is more specialised provision and the provider is developing staff to meet the varied needs of the service users. Staff members have undertaken training in dementia care and activities for people with dementia. The inspector advised that there was an obvious lack of visual cues for service users with dementia and suggested that the care manager look at implementing pictures and symbols throughout the home. Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7-11 Specific care plans direct staff of how they should meet service users needs. Service users health care needs and personal needs are being fully addressed and met. The system in place for the management of medicines is much improved. Service users are treated with respect and their privacy upheld. The policies for dealing with service users who are dying examined in the home require consolidation. EVIDENCE: Three care plan files were examined and there was evidence that clear direction as to how to meet the needs of service users is detailed and is in the form of identified risks and care planning. There was overall improvement in the writing of daily care notes, cross- referencing and inclusion of relevant information, dates etc. Service users and a relative spoken with were generally aware of their care plans. There were signed agreements within care plans also.
Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 12 There were good records kept regarding outside professional input such as GP and district nurse visits. Observations made of staff, the providers and care manager interacting with service users provided evidence of mutual respect and kindness. Service users were noted to wander into the office and not excluded in any way. The providers are keen to provide a good service and speak fondly of service users. Nutritional assessments and tissue viability tools were now in place. Service users mental health needs and any challenging behaviour appears to be identified. There were no service users identified with concerns for nutritional input other that one person who had been prescribed supplements, which were signed as taken on the medication record. There was evidence of bowel health monitoring and weight records. Copies of accident records are kept however it is recommended that more detail be kept in the individual service users care plan for falls regarding time of fall and treatment sought etc for quality monitoring purpose etc. The providers had installed a new medication system, which was examined at the previous inspection and the pharmacist inspection. The requirements set at both inspections were assessed. Policies and procedures for medicines management are in place. The home is registered with a local pharmacy and a blister pack system is in use. The systems for management of the medication are now much improved providing a more robust and safer service for residents in the home. The British National Formulary has been replaced with an up to date version and records for receipt and return were in place and detailed fully. There was evidence that the temperature of the medication storage room, has been taken. The care manager reported that there are, no service users currently able to self medicate and that a new system is being worked on currently to address this within the care plans. Staff members who are authorised to administer medication have attended medicines management training and the audit system is to include competency assessments. The practice for potting out has ceased. Staff confirmed they have received a copy of the medicines handling policy and had signed for this. Signatures were evident on the medication folder. The fridge had only appropriate items stored in it. The medication charts examined all appeared satisfactory Service users spoken with confirmed that staff were, respectful and polite. Staff were observed respecting service users privacy and knocked before entering their rooms. There are policies and procedures in place for dealing with dying and death, however these were duplicated and need consolidating into one policy. The homes policy for Physical Care of the dying which states care charts will be implemented to record nutritional intake, turns, oral care etc. Service users files now contain the wishes of individuals at the end of life. Although spiritual needs are covered within the assessment documentation. The inspector gave advice regarding documenting the wishes of service users who do not wish to e resuscitated.
Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 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 standard(s) 12-15 The provision of stimulation and activities in the home, particularly for those service users with dementia appears to have declined somewhat. Service users maintain contact with family/friends/representatives and the local community as they wish. Although the meals provided are overall on the whole nutritious and adequate there are still issue to address regarding the promotion of choice options. EVIDENCE: There was little evidence of activities provision in the home, which was very different from the evidence found at the previous inspection, which suggests that the activities provision has declined somewhat. There was no evidence of any structured activities and service users stated that they had not participated in any recently. There was evidence of some pictures and cards, which had been made by service users on the walls around the home. A relative spoken with confirmed that she had seen dominoes being played and that there had been a summer trip to a safari park, which was most enjoyable. There was no evidence of the Service users social activities record, which was evident at the previous inspection, which detailed service users choice of whether to participate. The social and recreational needs of service users must be obtained fully and included as a care plan for each person. Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 14 Service users were observed to move freely around the home and the care manager stated that service users could now access their rooms in the daytime, which was not usual practice previously. Rooms were observed to be personalised and contain service users own personal possessions that had been brought with them to the home. Service users confirmed they went to bed when they chose to. A relative confirmed that she had a key to her husband’s room, which was important to them both. Information on advocacy is available and there was a notice on the notice board informing visitors that service users will be asked if they wish to receive visitors and if not this will be respected. The menu was set over a four- week cycle and detailed two options, however service users reported that they did not have a choice or knew what was on offer for lunch. There was no pictorial format of the menu, so service users who cannot read would not benefit from the menu information on the notice board. There was no other evidence to support the menu options being offered, no record kept of service users choosing the options on offer and staff confirmed that there was only one choice on offer at lunchtime, despite the menu stating otherwise. Care plans did identify whether service users had eaten a full or part meal. A complaint had been received by the home regarding the fish served being greasy, chips being cold and sandwiches being served that were not freshly made and lacking in variety. The manager reported that this had been addressed, but the person who made the complaint was spoken with and it was reported that there was a little improvement in the variety of sandwich fillings offered and that hot snack meals such as beans on toast, hash brown and sausage had been introduced and welcomed. It was reported that at times large portions were served, rather than smaller portions and seconds as required. The menu should be developed with service user preferences and offer at least two options which service users can be offered and make an informed choice, which must be recorded. Service users were observed to be relaxed and happy at lunchtime. Service users are helped to make choices and take control over most aspects of their lives apart from meal options, which is a basic fundamental right and is outstanding from the previous two inspection requirements. Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 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 standard(s) 16, 18 The complaints procedure needs to include good practice action of follow up to complaints made and action taken. Service users and relatives were clear about making a complaint should they need to. The provider is more aware of local adult protection protocols. Referrals have been made and CSCI notified. Several policies and procedures required further development. EVIDENCE: The complaints procedure is issued with the service user guide and was displayed although would be better viewed if cited close to the visitor’s book. But it does meet the standard and informs the reader that all complaints will be responded to within 28 days. There was one, recorded complaint since the previous inspection, this was in relation to the standard of meals served. Service users and relatives all confirmed they would make a complaint through staff if they were unhappy about anything. It is recommended that follow ups are made regarding complaints to ensure issues are resolved satisfactorily. Staff have attended training in adult protection. A policy for adult protection and whistle blowing is in place and needs further development, as it is brief. Three service users reported that they felt safe in the home. At the previous inspection the following were identified, however the inspector did not check these at this visit and will carry this task over to the next visit.
Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 16 There is a policy for restraint, this needs to be expanded to include use of bedrails, lap belts etc. The confidentiality policy needs to address when information must be passed on/reported and that the service user or other individual making a disclosure is informed of this. The policy for staff benefiting from wills or accepting gifts should inform staff that this is not acceptable practice rather than just recommend they do not accept gifts etc. Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 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 standard(s) 19-26 Service users live in a clean, well - maintained environment that is currently being re-furbished to improve the quality of facilities for service users. There are accessible, safe indoor and outdoor communal areas, where service users are free to wander. Bedrooms meet standards and are personalised. There are some areas, which require attention temporarily until the ground floor bathroom is fully re-furbished. EVIDENCE: The new provider has commenced a programme of refurbishment of the home and is keen to improve the standard of accommodation and facilities of the home. New chairs and carpets have already been purchased to improve the comfort and appearance of the home for service users. The small lounge has been fully refurbished and creates a homely and quiet sitting area, which overlooks extensive gardens. The garden area is pleasant and spacious and this is to be made more accessible for service users and extended to provide safe and secure outdoor space for service users who wish to spend time in the garden. The provider reported that there are plans to extend the car park and build a new patio area.
Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 18 The kitchen is currently being re-furbished and the owner has planned this with care to ensure minimum disruption to the service users. Call alarms in bathrooms must be in reach of the service user and staff member and not tied up out of reach as observed on the day of the inspection. This issue has been raised on several occasions previously. The bath on the ground floor has a patch of missing enamel caused by the bath hoist and the rail around the toilet should be painted and this should be addressed. The provider/manager reported that the bathroom is to be refurbished fully around Christmas time. Service users bedrooms examined were clean, personalised and equipped to meet service users needs. Lockable facilities were seen in the bedrooms examined but files did not address whether service users have been offered keys to their rooms or whether ‘risk assessed’, as not able. A relative had been issued with a key however. The water system has been problematic for the new owner, which is being assessed currently by plumbing contractors. Temperature of water outlets, are taken but it is recommended that, all rooms be tested monthly. Records of these temperatures are kept with any action taken. The temperature of the home was warm and lighting sufficient and domestic in type. The home was found to be clean and free from mal odour. Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 29 Recruitment procedures require some improvement to ensure that all of the regulatory documentation is in place. EVIDENCE: A sample of staff files was examined and although most were completed satisfactory there was one file that was outstanding of completion from the previous inspection. The individual staff member has been off work, which has prevented the provider from obtaining this information. The provider is fully aware of current regulation regarding CRB and POVA first checks. Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35,38 There were minor areas to address in relation to financial procedures at the previous inspection, which were not assessed at this inspection. The health and safety of service users is generally safeguarded, however it may be compromised regarding evidence of a breach in practice for COSHH [Control of substances hazardous to Health] EVIDENCE: A sample of service users financial records was examined at the previous inspection and found to be satisfactory apart from not always having two signatures for transactions. It is recommended that procedures for safeguarding staff and service users are amended to include a checking system for when staff do any shopping for service users. This standard was not reassessed at this inspection due to time constraints and therefore recommendations carried over to the next inspection.
Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 21 Observations made at the inspection was that staff practices were appropriate of health and safety policies, staff were observed to wear protective clothing for attending to service users personal care and when serving food. Health and safety policies were in place. The provision of training is good and the maintenance of equipment seen to be satisfactory. Magnetic door closures, which release when the alarm is triggered, have been fitted to enable doors to be held open during the day. A cleaning product was found in the bathroom and a mop bucket left with water standing. This practice poses risk factors for service users in the home. Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x 2 x x 2 Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 23 Are there any outstanding requirements from the last inspection? Yes, St 1, St 15, St29 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. 2. Standard OP1 OP12,14 Regulation OP4 Requirement Timescale for action 22nd December 2005 22nd December 2005 3. 4. OP15 OP29 5. OP38 The Statement of Purpose must be completed as specified in Schedule 1 of the Regulations 14, 25 Service users must be consulted regarding their social and recreational needs and a formal activities programme devised from this. Evidence of activities provision and service users participation needs to be reinstated. 14, 25 Service users must be consulted regarding their choice of meal options 7, 9, 19 Ensure that the outstanding information required at the last inspection, pertaining to one staff member is finalised 12, 13, 16 Ensure staff practices follow COSHH [control of substances hazardous to health] at all times. 22nd December 2005 22nd December 2005 22nd October 2005 Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 24 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. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. Refer to Standard OP4 OP8 OP9 OP11 OP16 OP18 OP18 OP18 OP18 OP22 OP22 OP24 OP35 OP35 Good Practice Recommendations Provide visual cues around the home for assistance to service users with dementia Incidents of falls should be monitored. Include the option for service users to self medicate within the assessment documntation or a risk assessment stating thay are not able. Consolidate the many policies and procedures for dealing with dying and death Site the complaints procedure with the visitors book Further develop the adult protection and whistleblowing policies so staff are clear about actions to follow Expand the ploicy for restraint to include use of bedrails and lap belts etc Expand the policy on confidentiality as stated within the report Review the policy for staff benefiting from wills and gifts as stated in the report Call alarms should be in reach of srevice users and staff when placed over bath Attend to the worn enamel patch on the bath and repaint the rail around the toilet in the ground floor bathroom Ensure that keys are provided to those who want them unless a risk assessment identifies this is not possible [this should be documented within the care plan] Financial procedures should include a checking system when staff carry out shopping on service users behalf Two signatures should be in place for all transactions on service users personal allowance records Beech Court C53 C03 S62132 Beech Court V246065 220905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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