Inspection on 01/08/05 for Beech House

This inspection was carried out on 1st August 2005.

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

Beech House 14/08/07

Beech House 19/04/06

Beech House 18/02/05

Beech House 14/04/04

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 Beech House, 68 Manchester Road, Heywood, Lancashire, OL10 2AP. Lead Inspector Jenny Andrew Unannounced 1 August 2005 st 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 House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Beech House, Address 68 Manchester Road, Heywood, Lancashire, OL10 2AP. 01706 368710 01706 629435 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) Prylor Properties Limited Mr Gary Prior Care Home Only 27 Category(ies) of Old Age 27 registration, with number of places Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total number of places 27, OP Date of last inspection 18th February 2005 Brief Description of the Service: Beech House is a care home providing personal care and accommodation for up to 27 older people and is owned by Prylor Properties Limioted. No nursing care is provided.The home is situated approximately one mile from Heywood town centre and is on bus routes to and from Rochdale, Middleton and Bury. The M62 motorway network is within easy driving range of the home. Beech House is a traditional Victorian style house, which has been converted and extended to provide accommodation in 27 single rooms, 1 of which has en suite facilities. A variety of lounges are available including a designated smoking area. A garden area is available to the front/side of the home, which service users may access. Ramped access is provided to the front door. A car park is provided for approximately 5 cars and further car parking is available in the lane to the side of the home. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last inspection, the pharmacy inspector had done an inspection at the home on 7 April 2005 to check that the medicines were being given out safely. As she found some unsafe practices taking place, she was doing another visit on this inspection. The inspection took place over two days, five and three quarter hours being spent on the first day with two inspectors. On the second day two and a quarter hours were spent when one inspector went back to the home to speak to the owner/manager. Inspectors looked around parts of the building, checked the records kept on residents, to make sure staff were looking after them properly and other records as well as looking at how the medication was given out. In order to obtain information about the home, the manager, deputy manager, 7 residents, 1 relative, 3 staff, a district nurse, the domestic and cook were spoken with. In addition 6 comment cards were returned by relatives to say in writing what they thought about the home. What the service does well: The home had a group of staff who had worked at the home a long time and residents spoken with liked the present staff team, including the owner/manager. They felt they cared for them well and words used by them were “very good”, “kind”, “caring” and “excellent”. Other comments made were “they look after you well here”, “I’m very satisfied” and “nothing could be better”. Relatives also felt the care was good stating that staff were “caring and considerate”, “patient and understanding” and “cannot praise them highly enough”. The home had a friendly, homely feel and residents’ comments about the building were “it’s nice and homely here”, and “it’s like your own home”. The home was good at making sure residents health was well taken care of by sending for district nurses, and other health care workers whenever they felt they were needed. Residents said they felt happy and cared for. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 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 standard(s) 1 & 3 The Statement of Purpose and Service User Guide were in need of reviewing so that any prospective residents would have up to date accurate information. All residents were being assessed prior to admission, in order to ensure the home could meet their identified needs. EVIDENCE: Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 9 Whilst a Statement of Purpose and Service User Guide were in place, they had not been updated to reflect the present staffing levels and training undertaken by the staff team. In addition, The Service User Guide did not contain all the relevant information as required under Standard 1.2. They must be amended accordingly and copies of the revised documents be forwarded to the Commission for Social Care Inspection (CSCI). Generally service users admitted to the home were care managed therefore had a professional assessment prior to admission. In all 3 examined, care management documentation was in place. One of residents had since had a review with their care manager and as a result request made by her, the owner had had her bedroom re-decorated. and files the of a The manager had produced an assessment form, which included all areas under standard 3.3. This was being used when privately funding people wished to come and live at the home. Those service users spoken to all confirmed they felt their needs were being met at Beech House. Five of the staff who had worked at the home for sometime had received dementia care training. As the home does not provide nursing care, any resident who requires such attention is referred to the District Nursing service. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 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 standard(s) 7, 8, 9 & 10 Care plans were limited as they did not address the identified needs of service users in sufficient detail, which meant that individuals’ personal care needs were not always being met. The home had failed to improve their practices for administering medication, placing residents at potential risk and harm. EVIDENCE: Care plans for 3 permanent and 1 respite stay resident were checked. As the files were not in any structured format, it was difficult to identify exactly what up to date information they contained. There were old review sheets and outdated risk assessments in place. In addition, other personal information such as dates of professional visitors to the home, hospital admissions, bathing records, accident reports etc. were in different places making it a very fragmented system. The manager should review the care planning and reviewing process to ensure it is efficient and effective for staff to use as a working tool. No care plan had been formulated for the resident currently on respite. The information contained in her file was what had been obtained on the preadmission assessment. This information should be utilised to formulate a care plan setting out preferred routines, bathing arrangements and personal care requirements etc. Residents interviewed were unclear about what was in their Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 11 care plan. There was no evidence on the files to show the resident had been involved in the care planning process as they had not signed and agreed their individual care plans. Neither had relatives signed on behalf of those who were not able to sign themselves. Some signatures were however, seen on risk assessments. The care plan files for 3 other residents were examined. One did not contain a detailed moving and handling assessment although a fall risk assessment dated 9 August 2004 was in place and the resident was clearly at high risk when being moved. On another file, there was no risk assessment in place for a resident’s mobility needs. Where risk areas are identified, risk assessments must be undertaken and be reviewed on at least a 6 monthly basis. It was also noted that upon admission, nutritional screening was not routinely carried out although weight was recorded on their file. This should be undertaken as part of the admission procedure. From discussion with residents and evidence seen in the bath book, it was identified that some people were not receiving a weekly bath. For the week commencing 18 July, 2005 6 residents had not received a bath and the week prior to the inspection (25th-31st July), 15 people had not had a bath. On one occasion, a recording was seen that there was no hot water and therefore no baths could be given. It was determined that baths were generally given by the evening staff. Residents should have a choice in when they receive a bath and baths should not be done for staff convenience. Clearly the present system is not working and action must now be taken to ensure that residents receive the number of baths they want at a time which they request. Feedback from the District Nurse, who visited the home twice daily to see to the needs of those suffering from diabetes, indicated she felt the health care needs of residents were being met. She said the staff were very co-operative and acted on her instructions. She stated there were no residents with any pressure sores at the present time. The home had pressure relieving aids in stock should they be required. From checking notes in the daily report book, it was identified that where comments had been made about a resident’s health i.e. encouraging more fluids, this had not been transferred to the individuals care plan. This should be addressed. Visits from health care professionals were arranged as needed and all residents were registered with a General Practitioner. The good practice of staff checking if residents wanted more to drink throughout the day was noted. Also one care assistant was seen removing the spectacles of one resident so that she could clean them. Other good practices observed were staff sensitively dealing with the residents continence needs and assisting residents with their meals on a one to one basis. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 12 The pharmacy inspector had visited the home on 7 April 2005 to check the medication system when several areas of concern were highlighted. This second visit was being done to follow up these concerns in order to sure the home were now following safe practices. Concerns were again raised about various practices in place, resulting in an “Immediate Requirement” notice being served. The medication administration records (MAR) were generally up-to-date but a complete and clear list of current medication could not be confirmed for all residents. A new residents medication was ‘secondary’ dispensed from the pharmacy containers into a dosette box and the contents of the box did not agree with the medication administration record. Records were generally completed at the time of administration but during the round one resident was asked if they needed their paracetamol; the resident replied that they had already been given two that morning, the administration was not recorded on the MAR. The pharmacy inspector will be writing a report on her findings, which will be separate to this report. All assistance with personal care was given in the privacy of service users bedrooms or bathroom. Service users were also able to meet visiting professional visitors and family/friends within the privacy of their own rooms. Evidence of this was seen at the time of inspection when a health care worker and a district nurse visited. Those residents spoken with said that staff treated them with respect and dignity and this was also observed during the inspection. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.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, 13 & 15 Provision of leisure activities was inadequate, resulting in residents becoming bored and feeling unfulfilled. Staffing levels did not enable residents to access community facilities, other than when relatives took them out. The dietary needs of residents were well catered for with a balanced and varied selection of food offered at each meal. EVIDENCE: Two residents spoken to said there were times when they felt bored as there was nothing to keep them occupied. There was no activity programme in place although over the last few days, recordings of activities had been made in a book. An outside activity co-ordinator visited the home on a weekly basis, which residents said they enjoyed and on occasions, entertainers came into the home. An organist had in fact been in to play on the Sunday before the inspection. The manager said he was trying to replace the craft worker who had been off sick for sometime. The manager should consult with the residents as to what they would like organising throughout the week and then produce a programme of activities, which should be implemented by the staff. As there are residents in the home with differing abilities, the programme should take this into account. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 14 Other feedback from residents indicated they were very satisfied with their present lifestyles. They said they could follow their chosen routines and this was apparent on the day of the inspection. Residents were getting up at varying times, eating meals where they chose and using their own bedrooms whenever they wanted. Those who smoked were able to do so in one of the conservatories. This was a facility very much appreciated by these residents. The visitor spoken to said there were no restrictions on visiting and she could come and go as she liked. The feedback on the 6 returned comment cards also indicated that staff made them welcome when they visited. Residents spoken with were generally satisfied with the quality and choice of food served. The menus were run over a 4 week period, with a choice being available each lunch time. Sandwiches or hot snacks were available at tea. The menus did not however, record any desserts although these were being offered. In order to ensure that residents’ nutritional needs are being met, the menus must include a choice of desserts, which should include, milky puddings, custard, fruit etc. The residents spoken with were unaware of what was being served for lunch on the day of the inspection as there were no large print menus or menu board displayed. The inspector sampled the meal, which was shepherds pie, carrots and broccoli, followed by a plain sponge cake and cream. The shepherds pie was tasty and the vegetables were soft but not over cooked. One service user who did not like the main meal was given an alternative of sausages, which he was seen to enjoy. Residents on special diets were being appropriately catered for. On the day of the inspection, an alternative dessert of blancmange (2 flavours), was being offered to the diabetic residents. In addition, a plentiful supply of fresh fruit was seen around the home, which residents could help themselves to. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.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 Satisfactory complaint, whistle blowing and vulnerable adult procedures were in place which staff were familiar with, ensuring that service users were listened to and protected. EVIDENCE: The complaints procedure was included in the introductory pack, which was given out to potential new residents. However, it was not attached to either the statement of purpose or service user guide and this must be rectified. There had been no complaints forwarded to the Commission for Social Care Inspection (CSCI), since the last inspection. Complaints were recorded in a book kept for such purpose and 4 had been recorded over the past few months. The records showed that appropriate action had been taken to address each of the complaints. Relative feedback obtained via 2 returned comment cards, indicated they were unaware of the complaints procedure although it was displayed on the notice board near to the telephone. The Rochdale inter-agency Protection of Vulnerable Adult procedure was in place and the manager said this would be instigated should staff report any concerns. Staff had still not yet received any vulnerable adult training and this must now be addressed as a matter of urgency. Files for 2 recently appointed staff were seen and Protection of Vulnerable Adult (POVA) checks had been obtained. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 16 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, 21 & 26 There had been no change to the décor or furnishings within the home over the last 12 months and whilst this did not pose a risk to service users, the environment was shabby and in need of some refurbishment. In order to control the spread of infection and provide a safe clean environment for residents, some practices were in need of reviewing. EVIDENCE: Whilst a maintenance book was in place, this did not show any renewal of the fabric and decoration of the premises over the last 6 months. It was apparent that there were areas around the home which were in need of re-decoration i.e. paintwork, lounge ceilings etc. Several repairs, which had been recorded in the maintenance book had not been addressed and the manager must now ensure these are actioned. The majority of the bathroom and toilet floors were in need of replacing. The lounge carpets were also in need of cleaning. One of the ground floor toilets was locked with a notice stating “out of order”. This toilet must be repaired as a matter of urgency. It was also observed that in the other two ground floor toilets, there were no toilet rolls, the reason given that a resident was Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 17 repeatedly flushing them down the toilet causing blockages. The inspector was advised that staff provided toilet paper as and when needed. During the inspection, two residents were observed going into these toilets independent of staff without any toilet rolls. In order to ensure the dignity and independence needs of residents are met, the manager must ensure that toilet rolls are available in the toilets at all times. Toilet roll holders, which enclose the toilet roll could be fitted, ensuring they would not be removed. In the daily record book, it was noted that on 20 July 2005, on the evening shift, there was no hot water and therefore staff were not able to bath any residents. Also a resident was having to use an empty bedroom to have a wash as her hot water tap was only producing a trickle of water. Action must be taken to ensure that the plumbing system is working properly. The staff toilet, which was on the second floor of the home, could not be used on the day of the inspection. The owner, who occupied the top floor of the building, kept this area locked when he was not at the home, which meant that staff were having to use a resident toilet. Clearly this is unacceptable practice and action must be taken to resolve this situation. Paper towels were not supplied in all bathrooms and toilets. In order to control the spread of infection, paper towels must be supplied in all communal areas. Good practice was observed of staff using disposable gloves and aprons when assisting residents with personal care. Blue disposable aprons were used when staff were performing kitchen duties and serving food. Upon arrival, it was noted that the lounges were in need of vacuuming as there were particles of food, ash and other bits on the floors. By the end of the inspection, these areas had still not been cleaned. The domestic said the lounge floors were the responsibility of the night staff and she had been instructed not to include these as part of her daily duties. Feedback from 2 relative questionnaires indicated there were sometimes instances when clothes went missing after having been sent to the laundry. Upon checking the laundry, it was identified there were no individual baskets in which to put clean and ironed clothing, nor was there any space on the shelving for this purpose. The manager should address this shortfall in order to try and prevent residents clothing from going missing or being given to the wrong resident. He should also ensure that all clothing is appropriately marked. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 18 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) 27, 29 & 30 Staffing levels and skill mix of staff were insufficient to meet the needs of the resident group. Some shortfalls in the home’s practice of recruiting staff could place residents at risk. Training was limited and did not enable staff to strengthen and develop their skills and knowledge. EVIDENCE: The staff rota, which was located in the office, was inaccurate. It did not contain the name of 3 staff members, who had started work in the home from May onwards of this year. Many changes in staff shifts, seen in the diary, had not been transferred to the rota so that it did not reflect the true staffing position. This is a practice which the owner/manager has been told about before, and to which the CSCI were given assurances it would not happen again. The staff rota is part of the legal records required to be kept within the home and must be an up to date accurate account of staff hours. An immediate requirement notice was left at the home for the rota to be amended as a matter of urgency. As a result of the rota not reflecting the staff hours being worked, the inspector was unable to determine, on the first day of the inspection, whether the staff hours provided were adequate. On the second day of the inspection, the rota had been amended in line with the Immediate Requirement Notice and showed that there was a shortfall of 46 staff hours for the number of residents presently living at the home. Action must now be taken to address this shortfall. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 19 There was a domestic employed to work 5 hours a day from Monday to Friday. Given the size of the building, and the fact that staff were already having to assist in the kitchen at weekends to make teas and perform other kitchen duties, a week-end domestic must also be employed. The home had also been without a laundry assistant since the previous person had left. In order to enable staff to spend more time with residents, a laundry assistant must be appointed or additional hours allocated to a care assistant to undertake such task. The manager agreed to recruit to both these positions. Staff spoken to were enthusiastic and committed to their caring roles but were finding it difficult to spend quality one to one time with the residents. From speaking to one of the more recently recruited care assistants, it was determined that she had not undertaken any formal induction training. She said she had worked alongside another member of staff in order to learn how to do the job as she had no previous experience in this type of work. From checking 2 of the more recently employed staff files, it was determined there were no records of them having undertaken any TOPSS induction or foundation training. In order to ensure that all staff are knowledgeable about their role and how to perform their duties effectively, they must all receive appropriate training. Other files inspected for staff who had worked in the home for a longer period, showed they had not received a minimum of 3 days paid training over the last year. The manager said they were not up to date, but no evidence of training certificates were in their personnel files. Lack of training opportunities for staff had been identified in the last 2 inspection reports. This shortfall must now be addressed. Some shortfalls were identified in the recruitment and selection process. Whilst Protection of Vulnerable Adult (POVA) checks were in place in two of the files inspected, one had been transferred from the staff members previous employer. These checks are not portable and new checks must be undertaken for each new member of staff employed. One new potential care assistant, was working at the home on the first day of the inspection. References had not been obtained, nor was there a POVA check in place. The manager stated she had been working a shift to see if she liked the job, before he undertook the relevant checks. No staff should commence work without the relevant checks having been undertaken. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.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) 33 The systems for service user consultation were in need of improvement to ensure that residents’ views and ideas are sought and acted upon. EVIDENCE: Whilst the home had attained the “Investors in People” award in February 2003, there was no formal and effective quality assurance and monitoring system in place involving residents. Whilst resident meetings used to take place, these had ceased and satisfaction questionnaires had not been circulated to residents, relatives or other visitors to the home since August 2004. The manager said he did spend time with the service users, usually in the evening, when they would discuss any problems with him. He had also checked out with residents, in April of this year, what changes they would like to see on the new menus. Residents spoken to said they liked the manager and found him very easy to talk to. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 21 Feedback from 4 comment cards from relatives, indicated they had no access to a copy of the home’s last inspection report. A copy of this should be displayed within the home and reference made as to where a copy may be found should be recorded in the Service User Guide. In order to ensure that the home is run in the best interests of residents, an effective quality assurance programme should be formulated and implemented. Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.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 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 2 STAFFING Standard No Score 27 1 28 x 29 2 30 1 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 2 x x x x x Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 23 YES Are there any outstanding requirements from the last inspection? 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 1 Regulation 4&5 Requirement The Statement of Purpose and Service User Guide must address all relevant areas and be reviewed and updated to include all relevant information. Each resident, including those on respite stays, must have an up to date care plan, reflecting their health, personal and social care needs. All identified risk areas must be assessed and all risk assessments be reviewed and updated on at least a 6 monthly basis. All residents must be consulted about how frequently and what time of day they require baths, and this information transferred to their individual care plan and implemented accordingly. All requirements in relation to medication, contained in the letter which was sent separate to the report, must be addressed. An activities programme must be formulated and implemented which meets the needs of all abilities of residents currently living at Beech House. The menus must include Timescale for action 30.09.05 2. 7 15 30.09.05 3. 7 13 30.09.05 4. 8 12 31.08.05 5. 9 13 6. 12 16 31.08.05 7. 12 16 31.08.05 Page 24 Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 8. 9. 18 19 18 23 10. 11. 12. 19 21 21 23 23 13 13. 19 23 14. 15. 19 26 13 13 16. 26 23 17. 18. 27 27 17 18 19. 20. 27 30 18 18 desserts in order it can be determined whether residents are receiving a nutritious diet. Care assistants must receive Protection of Vulnerable Adult training. Re-decoration and other refurbishment identified in the body of the report must be undertaken. All outstanding works, as recorded in the maintenance book must be addressed. The bathroom and toilet floors must be replaced with non-slip type floor coverings. The ground floor toilets must be fitted with toilet roll holders and toilet rolls must be supplied at all times and the toilet presently out of commission must be repaired. The hot water system must be checked by a plumber and any necessary works undertaken to ensure that residents and staff have access to hot water at all times. Staff must have access to a staff toilet. All communal toilets and bathrooms must be equipped with paper towels to reduce the spread of infection. The home must be kept clean and appropriate staff identified for all cleaning tasks within the home. The staff rota must accurately reflect staff hours. Staffing levels must be maintained at the ratio of 15 care hours per resident per week between 08.00 - 22.00 hours. A week-end cleaner and laundry assistant must be recruited. All new staff must undertake induction and foundation training F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc 31.10.05 31.10.05 30.09.05 31.10.05 31.08.05 30.09.05 31.08.05 30.09.05 30.08.05 Immediate 30.08.05 30.09.05 30.09.05 Beech House, Version 1.40 Page 25 21. 30 18 22. 28 19 which meets the TOPSS specification. All staff must receive training appropriate to the work they are to perform which must be a minimum of 3 days each year. (This requirement has been made in the last 2 inspection reports with the original timescale of 30.06.04 having originally been set.) Staff must not commence working in the home until all necessary checks have been undertaken. 30.08.05 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. Refer to Standard 19 26 30 Good Practice Recommendations A maintenance and renewal programme should be implemented, outlining the providers intent ,over the next few months, with regard to the refurbishment of the home. The laundry should be equipped with individual baskets for residents clothes or alternatively, the shelving should be utilised. All clothes should be appropriately marked. Staff training should be updated to accurately reflect what training each employee has undertaken and also to identify any future training needs. All copy certificates, should be kept on the staff personnel files. A quality assurance and monitoring programme should be formulated and implemented. Residents, relatives and other visitors to the home should have access to a copy of the most recent inspection report. Nutritional screening should be undertaken upon admission for each new resident. 4. 5. 6. 33 33 8 Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 26 Commission for Social Care Inspection 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 Beech House, F06 F56 S25463 Beech House V230378 01.08.05 Stage4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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