Inspection on 10/06/08 for Beech House

This inspection was carried out on 10th June 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beech House 06/04/09

Beech House 16/07/07

Beech House 01/06/06

Beech House 11/12/05

Beech House 11/08/05

Beech House 04/12/04

Beech House 08/07/04

Beech House 08/01/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Beech House Yew Tree Lane Northenden Manchester M23 0EA Lead Inspector Geraldine Blow Unannounced Inspection 10th June 2008 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 Beech House DS0000053654.V364579.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. Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech House Address Yew Tree Lane Northenden Manchester M23 0EA 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 945 2083 S J Care Homes Ltd Manager post vacant Care Home 43 Category(ies) of Learning disability (1), Old age, not falling registration, with number within any other category (42) of places Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. The service should, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. A copy of the Residential Forum Guidance on Staffing in Care Homes for Older people must be available. Staffing levels for service users who require personal care only must comply with minimum requirements of the Residential Forum guidance. Staffing levels for service users who require nursing care must comply with the minimum requirements of the staffing notice, served on 15 July 2004, under Section 13 of the Care Standards Act. A maximum of 43 service users can be accommodated at any one time. Of this number a maximum of 28 service users will require nursing care and a maximum of 15 service users will require personal care only. One service user is currently accommodated who is under 65 years of age and requires nursing care and also care by reason of learning disability (LD). Should this place no longer be required then the category will revert to old age (OP). 16 July 2007 6. Date of last inspection Brief Description of the Service: Beech House is located in the Northenden area of South Manchester, close to local amenities. The home is registered with the Commission for Social Care Inspection to accommodate 43 residents over the age of 65. The large extended detached house is set in its own grounds and has some car parking spaces. Residents living accommodation is available on the ground and first floor, access to which is facilitated by a passenger lift. The building is accessible to wheelchair users via a ramp and the home is wheelchair accessible. Shops and access to public transport is nearby and the home is within 1 mile of the M56. There are several lounge areas, a conservatory, and a separate dining room. The current fees for the home are £373.54 to £599 a week. Extra charges are made for personal items, hairdressing and newspapers. Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1star. This means the people who use this service experience adequate quality outcomes. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 16 July 2007 and supporting information received in the Annual Quality Assurance Assessment (AQAA) submitted by the managing director prior to this visit. Residents, staff and relatives were sent comment cards. At the time of this visit 1 resident comment card, 2 staff comment cards and 4 relative comment cards were received by CSCI. Some of their comments are included in the body of the report. This visit was unannounced, which means that the manager and staff were not told that we would be visiting. This visit forms part of the overall inspection process and took place on Tuesday 10 June 2008. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This report is an overview of what the inspector found during the inspection. As part of the visit we (the commission) spent time examining relevant documents and files. We also spent time talking with the manager, the general manager, several people living at the home, members of staff and a tour of the building was undertaken. Feedback was given to the manager’s during the course of this visit. What the service does well: Visitors are welcome in the home at any time and can visit in the residents’ own rooms or in any of the communal areas of the home. All of the comment cards received from relatives indicated that they are always kept up to date with important issues affecting their relative. One resident spoken to said that the “food was gorgeous and the staff are very kind”. Another comment in a returned relative comment cards was “the food is varied and wholesome”. Beech House DS0000053654.V364579.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Not all prospective residents needs are thoroughly assessed prior to being admitted to the home. EVIDENCE: A selection of people’s care files was looked at. In all of the files examined no evidence was seen that a full assessment of their needs had been undertaken to ensure that the home could meet their assessed needs. The manager confirmed that it was her intention to ensure, in the future, that for all the people placed by the local authority a care manager’s assessment of needs or a funded nurse assessment would be obtained and the home would also undertake their own pre admission assessment of needs prior to any admissions taking place. An intermediate care service is not provided at Beech House. Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 9 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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some shortfalls were identified in ensuring that the health care needs of residents were being met. EVIDENCE: The manager had been in post for 4 weeks and she confirmed that she had identified shortfalls in the care planning process and it was her intention to review all of the care plans and implement new documentation. A sample of care plans were seen and 3 residents were case tracked. The care files examined all contained a plan of care, although shortfalls were identified. Not all of the residents identified care needs had been incorporated into the care plan. For example, one care file identified that the resident had shortterm memory loss and some confusion yet there was no plan of care for this identified need. In addition it was documented that the resident was “verbally aggressive” and the manager confirmed that the resident often gets frustrated and then can be verbally aggressive. This had not been included in the plan of Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 10 care and there were no details of how staff should best manage the aggressive behaviour. Some parts of the plans were vague and did not clearly set out the actions that needed to be taken by staff to ensure that resident’s health and personal care needs are met. For example ‘offer what she likes” to eat and ‘apply cavilon cream to affected area” and “give psychological support”. There was no description of exactly what the resident likes to eat, where the affected area was or what psychological support was needed. In addition some entries did not preserve the dignity of residents or promote choice. This was discussed with the manager during the course of this visit. There was no evidence that resident’s religious or cultural needs had been assessed or were being met. It is recommended that that all residents’ care plans are developed using a person centred approach and contain sufficient detail for staff to meet all resident’s identified needs and personal preferences. In order to promote the dignity of residents it is also recommended that some of the terminology used in the care plans is reviewed. It was documented that the plans of care had been reviewed on a monthly basis. However they were seen to contain contradictory information and in some instances they had not been updated to reflect the evaluation. For example one care plan documented that the resident required hoisting for transfers, then there was an entry that they were mobilising with a Zimmer frame. It was unclear exactly how this resident could transfer. In addition another care plan identified that the resident had a urinary catheter, yet the monthly evaluation documented that the catheter had been removed. To ensure that residents’ needs are fully met it is recommended that the plans of care are updated to reflect any changes in care needs identified in the monthly evaluation. There was no evidence of any continence or nutritional assessments. To ensure that the health and welfare of residents are fully met a thorough assessment of needs must be undertaken on admission and a care plan developed in response to the assessment. Some risk assessments were seen in the care files examined. However it was noted that there was not a falls risk assessment, a risk assessment for the use of wheelchair lap belts or the use of an electric scooter. In addition the risk assessment for the use of bed rails did not assess the risk of using the bed rail, just the risk of falling out of bed. To ensure that residents are not placed at any unnecessary risk appropriate risk assessments must be undertaken. A daily report was completed for each resident. However from discussions with the manager it was clear that the reports did not accurately reflect the care given over a 24 hour period. A recommendation has been made. Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 11 There was no evidence that residents or their representative had been consulted regarding the plans of care. It is recommended that any consultations with residents and/or their representatives be recorded. Evidence was seen that residents were registered with a local General Practitioner (GP) and evidence of GP visits. There were arrangements in place to access other health care professionals if needed. The records regarding medication were examined. It was day 2 of week 1 of the recording. One medication record sheet examined identified that the resident had been prescribed a drink thickener, which is used to thicken drinks and soups for residents with a swallowing impairment. This had not been signed for on the record sheet and there were no details in the care plan as to the required consistency of the drinks. The RGN spoken to confirmed that they were not recording any drinks given to that particular resident. To ensure that residents are not being placed at risk and their needs are being appropriately met it is recommended that the medication record sheet should clearly cross reference to where there is a signed accurate recording of thickened fluids given to residents and that the Speech and Language Therapists (SALT) instructions, with regard to the thickness of fluids and the consistency of diet, are readily available to all staff. It was noted that one particular medication was prescribed as “follow directions given to you by the doctor”. To ensure that residents are not placed at risk and receive medication as intended by the General Practitioner (GP) confirmation of the prescribers’ intentions must be sought and documented. Surplus, unwanted or expired medicines were documented in a returns book, although it is recommended that 2 staff witness and sign for the disposal of waste medication. The RGN spoken to said that the dispensing pharmacy order the monthly repeat prescriptions and the GP sends the prescriptions directly to the chemist for dispensing. The routine ordering of repeat prescriptions must be undertaken by the care service and must not be delegated to the dispensing pharmacy. In addition it is recommended that the GP’s original prescriptions come directly to the home so that the manager can sign the exemption declaration on behalf of the resident before they are sent to the pharmacy for dispensing and that there is a copy of the GP’s original prescription so that the medication received into the home can be checked against medication prescribed. The manager confirmed that there was no system of auditing medication and only boxed and bottled medication were being signed as received. To ensure that residents are receiving medication as prescribed by the GP medication Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 12 should be accounted for at all times by means of an audit trail. In addition all medication received into the home should be signed for and not just boxed or bottled medication. It was noted that a medication with a limited life e.g. eye drops had the date of opening documented to ensure out of date medication is not given to residents. As already identified in this report some of the written terminology did not fully promote the dignity or encourage choice. However residents and staff spoken to confirmed that privacy and dignity was respected during day-to-day interactions and residents are encouraged to exercise choice in their daily lives. Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Some activities were provided and residents were able to maintain contact with family and friends. EVIDENCE: Since the last inspection visit the activity coordinator had left and the post was currently being advertised. From the files inspected evidence could not be provided that residents had been consulted regarding their social interests, hobbies, or as already referenced in this report their religious or cultural needs. The general manager confirmed that once the activity coordinator has been appointed it is their intention to have consultations with the residents regarding their interest and to implement a system to record the activities provided and who attends them. One comment received in the resident comment card was “there are never activities arranged by the home”. However evidence was seen that there was a May bank holiday musical entertainer. Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 14 Copies of the menus were seen and there was a daily menu on display in the dining room. The menus seen and the menu on display did not evidence that alternatives were available at lunchtime, which is the main meal of the day, although staff spoken to and one resident confirmed that if people did not want what was on the menu an alternative could be provided if requested. The general manager stated that the kitchen staff ask the residents each morning what they would like for their meal that day, although no evidence could be provided to support that statement. One resident spoken to said that you can have a drink whenever you ask for one. Residents and staff spoken to confirmed that there is open visiting and visitors are made welcome. The care plans examined did not evidence that choice was promoted in everyday life but staff spoken to stated that residents can exercise choice over their daily lives and the returned resident comment card indicated that staff do listen and act on what is said. Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable people to raise concerns. EVIDENCE: The complaint procedure was on display in the main reception area and the general manger said that it was also on display on the back of resident’s bedroom doors. However it was noted that it contained the name and address of the previous registering body. The complaint procedure must be updated to include all the information detailed in Regulation 22 of The Care Homes Regulations 2001. There was a complaint book. The last recorded complaint was 1/1/07. The manager was aware of the need to record any complaints made, and that the record should include details of the complaint, any staff statements, copies of any correspondence and an outcome of the investigation. She stated that she has an open door policy and will be encouraging people to raise any concerns or complaints they may have. There was a copy of the Manchester ‘No Secrets’ guidance that the manager stated will be used as the safeguarding adults procedure. She was able to clearly describe the events to be taken in the event of an allegation of abuse being made. Safeguarding adults training was being provided the day after this visit by an independent company. It is recommended that following Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 16 safeguarding adults training a competency assessment is undertaken to ensure that staff have fully understood the training and know what to do in the event of an allegation of abuse being made. Beech House DS0000053654.V364579.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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements have been made to the homes décor but there is a risk of cross infection. EVIDENCE: During this visit a tour of the building was undertaken which included the communal areas and some resident’s bedrooms. Generally it was clean and tidy and residents spoken to and comments received in the comment cards confirmed that that was usually the case. As already stated in this report since the last inspection visit there has been some ongoing improvements to the décor and furnishings of the home. However the previous inspection report identified that the glass in the conservatory door was cracked and was in need of replacement. This had not been replaced and poses a possible risk to Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 18 residents. The need for this to be replaced as a matter of some urgency was discussed with the manager and the general manager during this visit. It was noted that there were no protective gloves or wipes stored close to the toilets or bathrooms and all the bathrooms and toilets seen had bars of soap rather than wall mounted or pump operated soap dispensers. In addition the bathrooms and toilets seen did not have any paper towels for people to wipe their hands on. In an attempt to minimise the risk of cross infection and inline with infection control guidelines all staff must be able to access the necessary facilities to help reduce the risk of cross infection. The manager stated that it was her intention to have a small stock of personal protective equipment (PPE) such as gloves, aprons, wipes and disposable bags in resident’s rooms. This would be seen as good practice. During a tour of the building it was noted that many of the wheelchairs were dirty and contained encrusted food. These must be thoroughly cleaned. Beech House DS0000053654.V364579.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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all staff had received appropriate training and the recruitment procedure did not full protect people. EVIDENCE: At the time of the site visit 32 residents were accommodated and the staff rota showed that during the day there was always 2 nurses and 4 care staff on duty in the morning and 3 care staff on duty in the afternoon. During the night there was 1 nurse and 3 care staff. The completed AQAA stated that 14 care staff are employed. Seven care staff have successfully completed NVQ Level 2 or above and 5 members of staff are currently working towards NVQ Level 2. A sample of staff files were seen to see whether the required documentation was in place and the necessary checks had been made. The staff files looked at did not contain a photograph of the person and it was of concern that only Protection of Vulnerable Adults (POVA) firsts had been obtained for those staff. The general manager explained that they had recently applied for all staff to have a Criminal Records Bureau (CRB) check, as this previously had not been done even though some staff had worked there for some years. Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 20 It was discussed with the general manager that when the original CRB’s are destroyed, inline with the Date Protection Act, it is recommended that a record of the certificate number, type and date be kept on record. The files looked at contained photocopied documents and there was no evidence that the original documents had been seen. It is recommended that all photocopied documents are signed and dated to indicate that the original has been seen. In addition, in the files looked there was no evidence that a set interview format had been used or that notes were taken. It is recommended that a set interview format is used and notes are taken during the interview process. There was no system in place to check the registration details of the nurses employed at the home to make sure their details were up-to-date and they were not suspended or excluded from the register. The manager and general manager confirmed that there were gaps in staff training and they were in the process of auditing training and producing a training matrix. Evidence was seen that training relating to Moving and Handling and Safeguarding Adults had been arranged and Infection Control and Health and Safety training were in the process of being organised. The manager confirmed that she was in the process of reviewing the basic induction. It is recommended that the manager seek advice about registering with Skills for Care and then update the induction accordingly. All the staff team must have the knowledge, skills and values to support vulnerable people with high levels of need in a dignified and respectful way. Beech House DS0000053654.V364579.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, 35 & 38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Improvements are needed to management procedures to ensure the home is run in the best interests of residents. EVIDENCE: The new manager had been in post for 4 weeks. To ensure the home is managed in the best interests of the people living there, an application for registration must be submitted as soon as possible. As detailed in the previous inspection report there was no evidence that the home were seeking the views of the people using the service or the relatives or visiting professionals. However the manager did describe what she intended to do to quality review the service being delivered. Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 22 Policies and procedures were seen. However they were not dated so it was not clear when they were last reviewed and as already stated in this report the complaint procedure had not been updated as it contained out of date information. The AQAA indicated, as did the manager, that the polices and procedures were to be reviewed. Evidence was seen that the systems in place safeguarded resident’s financial interests, although there were no polices or procedures in relation to finances. It is recommended that these are developed and implemented. The information provided in the AQAA demonstrated that the home’s maintenance certificates and records were up to date. Beech House DS0000053654.V364579.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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement Timescale for action 18/07/08 2. OP7 12(1) (a) To ensure that all prospective residents needs can be met a full assessment of needs must be undertaken by a suitably qualified or suitably trained person prior to accommodation being offered 1. To ensure that the health and 18/07/08 welfare of residents is fully met a thorough assessment of needs must undertaken on admission with particular reference to continence and nutritional assessments 2. To ensure that the health and welfare of residents is fully met a detailed plan of care must be implemented for each identified care need. 3. OP7 13 (4) (c) To ensure that residents are not placed at unnecessary risk appropriate risk assessments must be undertaken with particular reference to falls, the use of bed rails, the use of electric scooters and the use of wheelchair lap belts. DS0000053654.V364579.R01.S.doc 18/07/08 Beech House Version 5.2 Page 25 4. OP9 13 1. To ensure that residents are not placed at risk there must be sufficient information to enable nurses to administer medication as intended by the General Practitioner (GP) and therefore the doctors’ instructions must be recorded. 2.The routine ordering of repeat prescriptions must be undertaken by the care service and must not be delegated to the dispensing pharmacy. 18/07/08 5. OP16 22 6. OP19 23(2)(b) 7. OP26 13(3) The complaint procedure must 18/07/08 be updated to include all the information detailed in Regulation 22 of The Care Homes Regulations 2001. To prevent possible injury to 18/07/08 residents the cracked glass in the conservatory door must be replaced. 1. Staff must be able to access 18/07/08 the necessary facilities to help reduce the risk of cross infection. 2. All the dirty wheelchairs must be thoroughly cleaned. All staff files must include all the details listed in Schedule 2, including a CRB check. All the staff team must have the knowledge, skills and values to support vulnerable people with high levels of need in a dignified and respectful way. To ensure that Beech House is managed in the best interests of the residents living there an application for the manager to register with CSCI must be submitted. DS0000053654.V364579.R01.S.doc 8. OP29 19 and schedule 2 18(1)(a) 18/07/08 9. OP30 18/07/08 10. OP31 9(1)(2) 18/07/08 Beech House 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 OP3 Good Practice Recommendations It is recommended that any pre assessment of prospective residents needs include an assessment of social interests, hobbies, religious and cultural needs. 1. It is recommended that the residents individual plans of care be more person centred and contain more details of the specific action which needs to be taken by staff to ensure that all individual aspects of residents health, personal, social, cultural and spiritual needs are met. 2. It is recommended that any consultations with residents and/or their representatives be recorded. 3. In order to promote the dignity of residents it is also recommended that some of the terminology used in the care plans is reviewed. 4. It is recommended that the plans of care are updated to reflect any changes in care needs identified in the monthly evaluation. 5. It is recommend that the monthly care plan audits are undertaken, formally recorded and contain evidence of any actions taken for the shortfalls identified. 6. It is recommended that the daily reports are written in sufficient detail to accurately reflect the care given over a 24 hour period. 1. It is recommended that the medication record sheet should clearly cross reference to where there is a signed accurate recording of thickened fluids given to residents and that the SALT instructions, with regard to the thickness of fluids, are readily available to all staff. 2. It is recommended that 2 staff witness and sign for the disposal of waste medication. Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 27 2. OP7 3. OP9 3. It is recommended that there is a copy of the GP’s original prescription so that the medication received can be checked against medication prescribed. 4. Original prescriptions should come directly to the home so that the manager can sign the exemption declaration on behalf of the resident before they are sent to the pharmacy for dispensing. 5. To ensure residents are receiving medication as prescribed by the GP medication should be accounted for at all times by means of an audit trail. 6. All medication received into the home should be signed for. It is recommended that people are consulted about the social and leisure activities that they enjoy and want to participate in and clearly record this through their care plan. It is recommended that following safeguarding adults training a competency assessment is undertaken to ensure that staff have fully understood the training and know what to do in the event of an allegation of abuse being made. 1. It is recommended, that inline with the Data Protection Act, when the original CRB is destroyed the certificate number, type and date be kept on record. 2. It is recommended that written evidence be maintained that the original documentation had been seen, the date and by whom. 3. It is recommended that a set interview format is used and notes are taken during the interview process. 1. It is recommended that a complete audit of training be undertaken, as stated by the manager, to establish what training staff have received and to establish what further and/or refresher training staff require. 2. It is recommended that staff must be assessed as competent to be able to provide the support that residents require to meet their needs and maintain their health and safety. 3. It is recommended that the manager seek advice about registering with Skills for Care and update the induction accordingly. Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 28 4. OP12 5. OP18 6. OP29 7. OP30 8. OP33 It is recommended that evidence be provided that the policies and procedures are regularly reviewed in light of changing legislation and of good practice advice for the Department of Health. It is recommended that policies and procedures are developed and implemented with regards to residents finances. To ensure service users and staff benefit from a consistently applied health and safety regime, written procedures and policies should be developed to cover all potentially vulnerable areas. 9. OP35 10. OP38 Beech House DS0000053654.V364579.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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