Inspection on 06/01/06 for Beech House

This inspection was carried out on 6th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Beech House 02/07/07

Beech House 13/07/06

Beech House 27/06/05

Beech House 19/10/04

Beech House 23/04/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Beech House Chapel Lane Barton upon Humber North Lincolnshire DN18 5PJ Lead Inspector Beverley Hill Unannounced Inspection 6th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beech House DS0000044474.V276376.R01.S.doc Version 5.1 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 DS0000044474.V276376.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beech House Address Chapel Lane Barton upon Humber North Lincolnshire DN18 5PJ 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) 01652 635049 beech.house@fshc.co.uk www.fshc.co.uk Tamaris Healthcare (England) Ltd (wholly owned subsidiary of Four Seasons Health Care Limited) Position Vacant Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: Beech House is situated in the centre of Barton on Humber, close to local shops and amenities. It is registered to provide support and care for up to thirty older people. The home is a mixture of old and new buildings over two floors, serviced by a passenger lift and stairs. There are twenty-two single bedrooms, sixteen of which are en-suite and four double rooms, one of which is en-suite. The upper floor has a further raised level accessed via five stairs. There are two bedrooms and one unassisted bathroom in this area, which is only accessible to more ambulant service users. There are two assisted bathrooms, one of which has a bath lift and the other a parker bath. A walk in shower room with hairdressing sink is provided on the ground floor. A forth bathroom is now used as a storeroom. There are a further five single toilets throughout the home. The home has two lounges, the larger of the two having two dining tables at one end. There is also a separate dining room. Both lounges have patio doors that have access to a paved area with garden furniture. There is a quiet seating area in the entranceway. The enclosed rear garden is well maintained. Car parking space is available at the front and side of the building. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. The Inspector spoke to the manager, the administrator and five of the care staff members who were on duty at the time of the inspection. Throughout the days the Inspector spoke to six people who lived in Beech House and two relatives who were visiting. The inspector looked at a range of paperwork in relation to the homes statement of purpose and service user guide, staff supervision, rotas, medication, finances, care plans, complaints and adult protection policies and procedures. The Inspector also checked that people who lived in the home had the opportunity to suggest changes and were listened to. The Inspector completed a tour of the building. The home had received a number of complaints last year regarding the management of the home and care practices. These resulted in additional visits from CSCI and requirements were issued. Subsequent visits by the Commission ensured that the requirements were met. It was acknowledged that the home had had several managers over the last eighteen months and this had caused inconsistency and low staff morale. However a new manager, in place for the last two months, was keen to develop the home and improve the quality of care provided. What the service does well: The home appeared clean and tidy and had a welcoming, homely feel. The communal areas and bedrooms had been re-carpeted and staff confirmed that people were able to choose the colour of their bedroom when redecorated. There was a core group of staff that had worked at the home for several years and knew the service users well. People who lived at the home and relatives spoken to were complimentary about the staff. People spoken to stated that the meals were good. They had two choices at lunchtime and had plenty to eat and drink. If they didn’t like the choice on offer they could have an alternative. Catering staff visited each person daily to find out their choice for the next day. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The care that people needed was written down in care plans. Some of these were the new format and addressed all needs but some had a mix of old and new and did not always cover all needs and have clear guidance to staff on how they could meet them. Although staff members were completing personal hygiene records and senior staff members were writing daily progress reports other records were not consistently completed, for example key worker and activity records. Staff spoken to did not have a full understanding of the key worker role. There were a lot of deficiencies in the management of medication and this needed attention straight away to make sure policies and procedures and GP instructions were followed. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 7 The home has a policy and procedure for ensuring that service users are protected from abuse. This needs to state that only the adult protection team are responsible for investigating any allegations. The home is generally well maintained but the inspector noted that one window couldn’t be locked and a towel rail in a bathroom was hot to touch. These were made safe on the day. The home must have the correct staffing complement for the number of service users and their needs. They can adjust the amount of staff required but this has to be based on the dependency needs of the service users and at present these are not monitored. Care staff members were not receiving formal supervision, which means that there was no systematic way of monitoring and recording staff members’ work and development needs. Staff members receive training but not all staff members have received the required training necessary for their roles. Care files used to be locked securely away in cabinets but these had been moved to the top shelf near the seniors’ workstation. Data protection legislation means that confidential information must be held securely so the care files must be locked away when staff members are not using them. The home safe keeps a small amount of personal allowance for service users and this is locked in the safe. Records are maintained and money is held jointly in a computerised account. Some people run out of money and go into deficit with their account. This needs to be managed more effectively. 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 DS0000044474.V276376.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beech House DS0000044474.V276376.R01.S.doc Version 5.1 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 the following standard(s): 1, 2 and 3 The home provided clear information about the services provided in the home that enabled people to make informed decisions, and assessments of need were completed prior to admission. EVIDENCE: The manager had revised the homes statement of purpose and service user guide to give clear and updated in formation to potential and actual service users. The manager and administrator confirmed that since the last inspection all service users had been issued with new terms and conditions, which had been checked by the Office of Fair Trading. They were still awaiting the return of some of these. All new admissions to the home had assessments and care plans completed by care management and the home continued to complete their own in-house assessments prior to admission. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Poor management of medication and inconsistency in the quality of care plans placed service users at risk of inadequate care. EVIDENCE: There had been some improvements noted in the care plans, although one care plan had not been evaluated since July 2005, had not been updated as the service users needs had changed and some identified needs such as communication and social stimulation had not been addressed. The manager had audited some of the care plans and highlighted shortfalls, however these had not been addressed three weeks later. The care plans were a mixture of new and old format. Two of the three care files examined had more than one plan for a particular need, for example one had two care plans for medication needs and two for foot care, and another had three plans for mobility and two for psychological needs. These could be amalgamated onto one care plan for each need to avoid confusion and duplication. Risk assessments were completed but when risks were identified they were not consistently reflected in care plans. One service user had had falls out of bed and required a risk assessment to identify how to manage this. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 11 There was still an issue with recording. Key worker activity was recorded on a separate sheet but when examined this was the form of a diary entry and staff spoken to were not completely sure about their role as a key worker and how to record this activity. There were a number of deficiencies in the management of medication noted during the inspection and these must be improved to ensure the safety of service users. These related to the signing in of medication and some missed signatures after administration, not following policies and procedures regarding administration, poor stock control leading to three service users unable to continue with their prescribed doses, codes used but not defined (it was established this meant out of stock), one service users Temazepam medication was not signed in and there were missed signatures on other Temazepam medication. Temazepam was stored and recorded as a controlled drug for good practice. A number of service users had to take some medication half an hour before breakfast and the staff member interviewed stated this was generally done. However one of the same service users had other medication to be taken at breakfast time with or after food. All the medication for them was dispensed at the same time, which meant that some instructions were not followed correctly and could have implications for their health. The senior care staff needed to ensure they were fully aware of any special instructions regarding times of medication. Discrepancies were noted in two service users’ pain control patches, i.e. these were omitted on two occasions, not signed for correctly when given, the record did not match the actual amount and some were not returned to the pharmacy when no longer needed. An immediate requirement notice was issued to the home to improve the management of medication and to investigate the pain control discrepancy. Six service users were spoken to throughout the day and all confirmed that care was provided in a way that protected their privacy and dignity. Comments were, ‘If I want help I ask the staff and they help me’, ‘the staff are very nice, kind, caring and respectful. They will do anything for you’, ‘the staff work really hard and look after us well’. One service user advised that their mail was always delivered unopened and if they wanted to make a phone call they could use the quiet entrance and they received calls on the office portable phone. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 14 The home provided an environment where service users were able to exercise choice over aspects of their lives and encouraged contact with family and friends. EVIDENCE: Service users and staff spoken to stated that visitors were welcomed at any time and were offered refreshments. Visitors spoken to confirmed this. The inspector witnessed open visiting and it was clear that improvements had been made in the communication with relatives. The manager stated that visitors were positively encouraged and described how one service user’s relative visited daily to have a meal with their loved one. This enabled them to have quality time together and encouraged the service user to eat their meal. Information about maintaining relationships with family and friends was highlighted in the homes statement of purpose and service user guide. The home maintained some community links with local chaplains and the visiting library. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 13 There was evidence that service users made choices about aspects of their lives, for example, management of their finances, choosing the colour scheme of their bedroom and communal areas, personalising their bedrooms, and the routines and activities they wished to participate in. Service users confirmed that routines were flexible with no set times for rising, retiring and visitors. Some service users were able to manage part of their medication and this was risk assessed and detailed in care plans. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home protected service users from abuse but not updating policies and procedures regarding adult protection and a lack of adult protection training for some staff could be detrimental to potential investigations. EVIDENCE: Since the new managers’ start in post there had been a large reduction in the amount of complaints. Service users spoken to on the day did not have any complaints and one relative spoken to confirmed that there had been lots of improvements in the general care and feel of the home, commenting that it was more, ‘upbeat and lively’. The home had comprehensive complaints policies and procedures. The home had an adult protection policy and procedure, however it still needed to link to the local authority multi-agency procedure with regards to referral and investigation. The company policy is dated 2003 and refers to the manager instigating an investigation, interviewing relevant persons and taking statements. There were policies and procedures regarding whistle blowing, restraint and the management of service users distressed or challenging behaviour. Not all staff had received training in adult protection, restraint and challenging behaviour. However via discussions with staff it was clear that they were aware of actions to take should they suspect any abuse has taken place. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 The home provided a clean environment for service users with sufficient communal space and personalised bedrooms. Two areas of the environment compromised service user safety and temporary measures were taken during the inspection. EVIDENCE: The home was generally well maintained inside and out and was suitable for its intended purpose. The home had a rolling redecoration plan and individual bedrooms were redecorated as service users vacated them. The home was noted to be clean and tidy with no malodours. Service users spoken to were happy with the cleanliness of their bedrooms and the home in general. There was an area on the first floor that had four stairs leading to another level, which had two bedrooms and a bathroom. This area was for more ambulant service users and was not currently occupied. The manager advised that there were future plans to make the two rooms into en-suite bedrooms. The bathroom had a heated towel rail that was very hot to touch. Although the room was not used the manager was to adjust the temperature to ensure Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 16 safety. During a tour of the building it was also noted that one upstairs window did not have a lock and could be easily accessed. This was addressed before the inspector left the building. The home had two lounges, one of which had two dining tables at one end. Both had doors that led onto a patio area and a pleasant, well maintained garden. The home also had a dining room and a quiet area in the entrance. Bedrooms were personalised and the majority had privacy locks and lockable facilities. There were still six bedrooms that required a privacy lock and five a lockable facility. It has been agreed that as the current service users do not want these items, as the rooms become vacant they will be fitted as standard. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 The home did not provide sufficient numbers of staff to meet their staffing notice nor did they calculate the dependency levels of service users. This potentially left service users at risk of insufficient care. Not all staff had completed the required mandatory training, which could lead to staff having insufficient knowledge and skills for their role. EVIDENCE: The home was assessed regarding staffing levels in accordance with a staffing notice issued to the home prior to April 2002, which indicated that four staff must be on duty at all times throughout the day. Rotas indicated that four staff members were on duty during the morning with three in the afternoon until 9.30pm. The home had twenty-three service users at the time of the inspection. The manager stated that the home had access to bank staff to provide the home with cover as required. A system of calculating the hours required each week to support the needs of service users was introduced in 2002, however the amount of hours required was based on the dependency levels of service users and the home did not have a tool to calculate this. The home will have to provide staffing in sufficient numbers to meet their notice or monitor the dependency levels of service users in order to calculate the amount of hours required and adjust these as and when needed. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 18 The home appeared to have sufficient catering and domestic staff. Existing staff covered a kitchen assistant vacancy at present. Two staff members were on duty throughout the night and the manager stated they were on call for emergencies. As the manager lived out of town it was required that the home developed an on call system that enabled timely access to the home and that staff were made aware of this. The inspector was unable to see a training plan that indicated the training organised for staff in the next year. The training plan needed to take account of development issues arising from supervision and appraisals, however these had not been completed yet. The home had a central training log and individual training records were maintained. The central log indicated who had completed mandatory training and when, and highlighted other courses such as care plan training, safe handling of medication, customer services, adult protection and bereavement awareness. Since the last inspection on 27th June 2005 the training record indicated that nine staff members had undertaken a health and safety distance learning course and one person had undertaken fire training. There was evidence of staff deficiencies in all areas of mandatory training, for example out of twentyseven staff twenty had completed moving and handling, eight first aid, four basic food hygiene (one was out of date), eleven infection control, twelve health and safety, thirteen fire awareness and eleven adult protection. The inspector was unable to say whether this was due to not updating the training record as courses were completed or whether staff had not completed the training. The new manager stated they were in the process of updating the training information. They were to explore this and develop a training plan to address any deficiencies. Only three staff members had completed NVQ Level 2 although others were progressing through the course. Some staff members were not clear about their role as key workers and documentation of key worker tasks confirmed this. The manager had already become aware of this and was in the process of ensuring that all care staff had an awareness of the key worker role and task. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35, 36 and 37 The home safeguards service users’ money but the current system breached regulations. Documentation was not stored in accordance with data protection legislation. The lack of formal staff supervision means that staff members were not monitored effectively and could place service users at risk of inadequate care. EVIDENCE: The new manager had been in post for two months and had, according to staff, service users and relatives, already made an impact on staff morale and systems within the home. Service users spoken to state the manager was seen around the home and asked them how things were. Staff members reported that the manager was approachable and organised. The manager had been a deputy manager and an assistant manager in other residential homes and had two years nursing experience. The manager explained to the inspector her commitment to providing a quality service for people who lived at the home. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 20 The manager is to apply for registration with the CSCI and for the Registered Managers Award. There had been no change to the monitoring of quality system within the home although the new manager had had a discussion with the local authority quality development scheme assessor for advice. The manager is to put in practice some of the suggestions in order to improve how the home monitors its provision of care for people. The homes administrator maintained comprehensive records of service users finances. Generally the families of service users managed their finances, however one person managed their own money with support from a relative to visit the bank and another had support from a solicitor. The home supported eighteen service users to manage a small amount of personal allowance. Individual computerised logs were maintained regarding deposits and withdrawals and receipts for purchases were kept. The money was kept in the safe and pooled so the whole amount was checked against the records and found to be correct. However, the inspector noted that four service users had a negative balance, whilst awaiting funds from relatives. This amounted to over thirty pounds in total and was a system in which the service users were, in effect, borrowing from other service users without their consent. The home had a bank account to deposit cheques for personal allowance or standing orders and for an overflow of cash from individuals’ personal allowance held in the safe. This account was pooled and not in the individuals’ own names. The administrator advised that this was a non–profit making account. It meant however that service users did not make any interest on savings they may hold. At present the amount in the bank was a small amount. The manager and administrator needed to review the current negative balance system and the depositing of money into pooled accounts instead of individually named accounts and establish whether interest was gained on personal savings. The homes Resident Fund was checked and found to be correct. Care files were stored on shelves in the area used by staff for handovers. This was accessible to all service users and visitors to the home. At the last inspection care files were stored in lockable filing cabinets and although these were available they were not used. As care files contained sensitive information they were subject to data protection legislation and must be stored securely. Supervision of care staff members had been inconsistent since the last inspection. This was an important part of monitoring and developing staff and the manager must start the process. Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 21 Beech House DS0000044474.V276376.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 3 x x x 3 x 3 STAFFING Standard No Score 27 2 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 2 1 2 x Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP18 Regulation 13 Requirement The registered person must revise the adult protection procedures to ensure they link with the local multi-agency procedures. (previous timescale of 31.12.04 not met) The registered person must ensure that the quality assurance questionnaires include the views of staff and other stakeholders. A result of the surveys must be forwarded to the CSCI. (previous timescale of end of QA year April 2005 not met) The registered person must ensure that the updating of old style to new style care plans is completed quickly to contain all assessed needs, clear tasks for staff, are evaluated monthly and reflect changes in need when they occur. The registered person must ensure that risk assessments detail all the measures to be taken to minimise risk and are linked to care plan provision. DS0000044474.V276376.R01.S.doc Timescale for action 28/02/06 2. OP33 12(1)(a), 21&24(2) 31/03/06 3. OP7 15 28/02/06 4. OP8 13(4) 17/02/06 Beech House Version 5.1 Page 24 5 OP9 13(2) 6. OP18 13(6) 7. OP19 13(4) & 23 (2) 8. OP27 18 9. OP30 18(1)(a) 10 11. OP31 OP35 9 20 12. OP36 18(2) The registered person must ensure that the homes management of medication is improved so that policies and procedures and GP instructions are followed. Immediate Requirement notice issued. The registered person must evidence that all staff have completed or are planned to complete adult protection training. The registered person must ensure that the hot towel rail in the upper bathroom and the window in the staff room are made safe and secure. The registered person must ensure that the correct care staffing levels are maintained throughout the day. Dependency levels to be monitored if the home is to use the Residential Staffing Forum on calculating staffing hours required. Immediate Requirement notice issued. The registered person must ensure that all staff members have plans to complete mandatory training with updates as required. The registered person must ensure that the manager applies for registration with the CSCI. The registered person must review the system of service users personal allowance going into deficit and ensure that any service users individual savings held in pooled bank accounts detail the amount of individual interest accrued by them. The registered person must ensure that all staff members receive a minimum of six formal supervision sessions per year and that new staff members DS0000044474.V276376.R01.S.doc 06/01/06 31/03/06 20/01/06 07/01/06 31/03/06 17/02/06 28/02/06 28/02/06 Beech House Version 5.1 Page 25 13. OP37 17 receive their first supervision session. All staff to have had one supervision session by 28/02/06. The registered person must ensure that documents covered by data protection legislation are held securely. 13/01/06 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 OP24 Good Practice Recommendations The registered person should provide lockable facilities in the remaining bedrooms and privacy locks to the remaining doors as standard when the current service users vacate the bedrooms The home should continue to work towards 50 of care staff trained to NVQ Level 2. The manager should ensure that all care staff are aware of their roles as key workers and how to complete the appropriate documentation. The registered manager should apply for registration onto the Registered Managers Award training course. 2 3 4 OP28 OP30 OP31 Beech House DS0000044474.V276376.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 DS0000044474.V276376.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!