Inspection on 07/08/07 for Beech House

This inspection was carried out on 7th August 2007.

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 15/10/08

Beech House 06/12/07

Beech House 30/10/06

Beech House 30/01/06

Beech House 22/06/05

Beech House 27/09/04

Beech House 02/08/04

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

CARE HOMES FOR OLDER PEOPLE Beech House 29 Great Bowden Road Market Harborough Leicestershire LE16 7DE Lead Inspector Keith Charlton Unannounced Inspection 7th August 2007 09:35 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 DS0000001806.V340876.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 DS0000001806.V340876.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech House Address 29 Great Bowden Road Market Harborough Leicestershire LE16 7DE 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) 01858 464289 beech_house@harborough.uk.com Mr Keith Burrows Mrs Lesley Burrows Mrs Lesley Burrows Care Home 13 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (5), Old age, not falling within any other category (13) Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers. No one falling within categories DE(E) and MD(E) may be admitted into the home when there are 5 persons of categories/combined categories DE(E) and MD(E) already accommodated within the home. Date of last inspection 30th October 2006 Brief Description of the Service: Beech House is a residential home, which is registered to accommodate up to thirteen older people, including five within the category of mental disorder and dementia. Beech House is situated in a residential area, close to the Market Harborough town centre. The home is accessible by car or public transport. Parking is available to the front of the home. The home provides a large lounge to the front of the property and a dining room to the rear. There is a patio area to the rear of the home, which is accessible to residents using wheelchairs and walking aids. Bedrooms are located on the ground and first floor that is accessible by the stair lift or the passenger lift. Bath/shower and toilet facilities are located close to the bedrooms. The weekly fees range from £390 to £410 - the Registered Manager provided this information on the day of the inspection. There are additional costs for individual expenditure such as hairdressing, dentist, optician and private chiropody. The home provides information to residents and prospective residents in the form of a Statement of Purpose and service users guide that describes the services it offers, and a copy of the last Inspection Report. They can be provided to enquirers upon request to give a view as to the quality of life for residents. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for resident and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting two residents and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection, conducted with the Registered Manager. Planning for the Inspection included reading the Annual Quality Assurance Assessment completed by the Registered Manager prior to the inspection, checking on the notifications of significant events sent to the Commission for Social Care Inspection and reading the last Inspection Report. There have been no complaints made to the Commission for Social Care Inspection since the last inspection. The Inspection took place between 9.35 and 14.50 and included a selected tour of the home, inspection of records and indirect observation of care practices. The Inspector spoke with seven residents (though this was limited for some owing to the difficulty with communicating with a number of with a high level of mental frailty) two staff members, one visitor and the Registered Manager. Four surveys have been sent to the Commission for Social Care Inspection from relatives, who all testified to the high standard of care their relatives receive. One relative stated that Mrs. Burrows looks after residents ‘’with kindness and love just like one big happy family’’. What the service does well: Residents said that staff were always very friendly and helpful towards them, that they were encouraged to retain their independence as much as possible, and reported that staff welcome visitors. Staff were observed to be friendly and positive towards residents. The inspector observed a relaxed and friendly atmosphere in the home. Residents said they would feel confident to raise concerns if they ever had any and were satisfied that these would be listened to and acted on by staff and management. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 6 Residents said they liked staff spending time with them when they were able to do so. Relatives are told when their relative in care is not very well and are consulted over the support that is given. The home is clean, homely and comfortable for residents. Staff thought they were valued and supported in the performance of their jobs by the Registered Manager and that National Vocational Qualification training is encouraged in order to equip them to meet residents needs. Residents liked the food and said the portion sizes were good. The main meal included three vegetables plus potatoes, thereby offering healthy food choices. What has improved since the last inspection? What they could do better: The Registered Provider needs to ensure that the welfare of residents is further assured by – staff must not commence employment until the return of a statutory check on file, keeping full Care Plans regarding residents needs including comprehensive Risk Assessments to ensure that residents are protected from falling, staff being asked to read all Care Plans and having Plans agreed with residents/their representatives. It is recommended that residents personal choices of daily living are included in residents Care Plans. A review of staffing practices is needed to ensure that staffing levels always meet the needs of residents, staff receive full training on all essential care issues, they receive on going supervision to ensure they receive support to provide a consistent service, and have a full understanding of essential procedures, e.g. the Vulnerable Adults procedure. It is recommended that there is a review of the menus so that two choices are offered each day, that residents are protected from burning by ensuring all radiators do not pose a risk to residents, that all fire systems are tested at Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 7 proscribed intervals, so as to ensure full fire safety, that all staff receive training in essential issues, that the level of care staff on duty for weekend periods must be reviewed to meet all residents needs, and specialist equipment is regularly serviced. . Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 8 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 DS0000001806.V340876.R01.S.doc Version 5.2 Page 9 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 DS0000001806.V340876.R01.S.doc Version 5.2 Page 10 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 good. This judgement has been made using available evidence including a visit to this service. The admission process is good and the pre-admission process ensures that most of residents needs are met. EVIDENCE: Residents said they had been provided with a service users guide to the services the home offers and they have received contracts from the Registered Manager. There were contracts on file to evidence this. It was recommended that the Statement of Purpose and copy of the last Inspection Report be displayed to be easily noticed and accessible to current residents and their representatives. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 11 Residents said that they could visit the home if possible prior to their admission usually by way of a trial period, to give them a good idea of what services the home offers. There was evidence of assessments undertaken by the Registered Manager available on the residents files examined by the inspector, which covered their needs, medical conditions etc. It covers important issues though not all National Minimum Standard issues are covered so the Registered Manager was recommended to use the list of issues contained in the Standards to ensure that all relevant issues were included. The home does not offer intermediate care facilities. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 12 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. Care plans describe identified care needs to ensure proper care is supplied by staff though they need to include all relevant medical information and Risk Assessments. Medication systems are good in general. EVIDENCE: No residents asked knew they had a Care Plan and no Plan seen by the inspector had a signature of a resident/representative agreeing to its contents – this needs to be followed up. Care plans and risk assessments continue to be generally satisfactory. There continue to be some gaps, for example when health checks took place – dental, optical, hearing tests etc that is needs to be recorded so that these can be arranged at regular intervals. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 13 The inspector observed that when a resident was assisted to walk by staff she was at risk of falling. The Registered Manager was asked to carry out a Risk Assessment to ensure this risk was minimised. There was reference to the continence needs of a resident in a Care Plan, but this did not contain a referral to the continence nurse to see if any action could be taken to help with this need or to establish what the need was as to at what frequency the resident needed to go to the toilet. The Registered Manager said this issue would be followed up. Care plans are reviewed six monthly and this was seen as recorded in the Plans. This needs to be carried out on a monthly basis as per the National Minimum Standard. It is recommended that there is a record of residents normal routines, capabilities/requirements, getting up and going to bed routines etc., and that all residents have full personal histories compiled so that they can be seen as individuals with a valued history (some but not all residents have these histories on file). A staff member said that she had not read all the residents Care Plans. This is recommended so that there is full awareness of residents needs. The inspector observed that a staff used a wheelchair without footplates, which is a health and safety concern. The Registered Manager said that she would follow this up. Both the residents and the relative spoken with said that staff were very kind and caring and that the standard of care was always of a high standard. The inspector noted that staff always addressed residents in a friendly manner. The relative said that he was always made welcome. The inspector viewed accident records. The Registered Manager calls medical services if there has been a potentially serious injury, e.g. a head injury. Care notes for one recent incident supported this. The medication system was inspected. The Registered Manager and staff confirmed that only senior staff issue medication and all had received training. The inspector saw a certificate of medication training. Medication recording was nearly complete with only eye drops for one resident not recorded. The Registered Manager said this issue would be followed up. Medication is kept locked away. Return of medication records were viewed and found to be satisfactory. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 14 Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to lead full lifestyle and can exercise choice. Menu planning is thorough and residents are appreciative of the food though providing a choice of main meal needs to be reviewed. EVIDENCE: Residents again said that there were some activities but this was kept to their preferred low level of activity and they again said they were glad that the TV was not on all day. Regarding outings they said they liked going out sometimes but were not interested in having too many outings. The Registered Manager said she was getting round to providing memory boxes for residents, containing valued items, particularly for residents with dementia, so as to provide valuable reminiscence material. The inspector Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 16 noticed that residents were given staff support in small groups or on a one to one basis to carry out activities. The inspector recommended that the Registered Manager arrange training for a designated staff member on the provision of activities for residents with dementia, so as to offer more relevant activities. Residents again said that there were no rules that they knew of, e.g. no one reported that there were set going to bed and rising times, and everyone thought the atmosphere of the home was friendly and relaxed. Inspection of residents accommodation again demonstrated that they were able to bring in to the home their personal possessions. Both residents and the relative spoken to said that visitors are always welcomed to the home and no one reported any restrictions. The visitor spoken with said that there were no problems with the care the staff provided and that any health concerns were reported to relatives when they arose. There were again positive views regarding the food. Menus were inspected and found to have choice though it is recommended that residents have a clear choice of food for the main meal each day – at present if a resident does not want to have the set meal then they can request a salad, omelette etc. There is now a recorded breakfast choice for a cooked breakfast and teas offer a choice of cooked snack. The food was tasted and was found to have flavour with three vegetables served with mashed potato, thereby offering a healthy choice of diet. This is commended. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 17 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 poor. This judgement has been made using available evidence including a visit to this service. Residents are confident in the system of managing complaints. Staff have a generally good level of understanding regarding the prevention of abuse. However residents are not properly protected from unsuitable staff as proper employment checks were not in place. EVIDENCE: Residents said that they thought that if there was a problem then they were confident that the Manager would sort it out. The Complaints Procedure is generally satisfactory and now gives the complainant the opportunity to contact the Commission for Social Care Inspection at the initial stage, as per the National Minimum Standard. The Registered Manager is to add that the local Social Service Department is now the Lead Agency for complaints investigations. Complaint records were inspected and no complaints were recorded in the file. There have been no complaints regarding the service since the Commission for Social Care Inspection was set up. This situation is commended. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 18 Policies and procedures for are in place for protecting Vulnerable Adults. A staff member spoken with was aware of most of the full procedure but did not know all the agencies to contact if the in house arrangement failed. The Registered Manager said this would be followed up. It is again recommended that a short procedure be set up to remind staff of which agencies to contact. It was found that staff commencing employment this year had not had statutory Criminal Records Bureau / Protection of Vulnerable Adults first checks in place. This is a serious issue and an Immediate Requirements Notice was served at the time of the inspection to direct the Registered Providers to rectify this, and a legal Notice will be served to ensure residents are fully protected from unsuitable staff. In the 2006 inspection it was discussed, and stated in the Inspection Report, with the Registered Manager that statutory checks need to be in place prior to employment commencing, as detailed in Schedule 2 of the Care Homes Regulations 2001. This must occur in future or the Commission for Social Care Inspection will seriously consider taking further legal action. The Registered Providers sent a letter to the Commission apologising for this matter and stated that it will not be repeated. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. Residents see facilities as homely and clean. Odour control is of a very good standard. Maintenance needs to be swiftly carried out when necessary. EVIDENCE: Residents said that they liked the facilities of the home and they could organise their bedrooms in the way they wanted. The inspector observed that bedrooms had been personalised and accommodated residents personal possessions. It was observed that all areas were generally well decorated and furnished, clean and tidy and well maintained, though plans to redecorate where paintwork had been damaged in skirting/doorways etc has not yet been carried Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 20 out. The Registered Manager agreed this would be completed by December 2007. There was one suggestion in that someone said that it would be nice to be able to have a shower. The Registered Manager said that this would be considered. It is again recommended that the Registered Manager investigate a signing system for residents with dementia, e.g. colour coding wc/bathroom doors, having pictures on bedroom doors (one bedroom has a resident’s name on it), having a board to indicate date, weather etc, so as to provide more clarity for residents. It was indicated in the Annual Quality Assurance Assessment that the Registered Manager was looking into providing this. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 21 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. Staffing levels may not fully meet residents needs. Recruitment processes need to be strengthened to ensure the protection of residents from unsuitable staff. A staff training system needs to be extended to cover training on all essential issues. EVIDENCE: The rota and the Registered Manager confirmed that there was normally a minimum of three care staff on duty during the morning and two on duty for the afternoon/evening period and there is a staff member on duty during the night. This reduces to two staff on duty at weekends. The Registered Manager was asked to review this reduction, as staff have to cover all duties, including cleaning and kitchen tasks in addition to covering the needs of residents, the majority with dementia/mental health conditions, and the majority needing assistance with physical care. Residents were again very happy with the staff team and said they are very helpful. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 22 Three staff files were inspected and contained information required – references, identification etc, though, as previously outlined, did not contain statutory Criminal Records Bureau checks. Staff files contained evidence of training though not all staff had received training on essential care practices – food hygiene, health and safety, challenging behaviour, fire, moving and handling, first aid, infection control, mental heath issues, dementia, training on residents health conditions – stroke, parkinsons disease etc. The Registered Manager said in 2006 that she would ensure that all staff were suitably trained and would compile a Training Matrix so that this would indicate at a glance what training needed to be organised for individual staff members. This has not yet occurred and needs to be put into place. The Registered Manager and staff stated that there is encouragement to undertake National Vocational Qualification level 2 training and that the home was meeting the National Minimum Standard of 50 of staff with National Vocational Qualification level 2 training, and also that two staff are due to start this training. The Registered Manager has obtained the Skills for Care induction programme to be used for new staff. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 23 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): 31,33,35,36,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are not fully in place to protect the health and safety of residents. EVIDENCE: Residents and staff said that they thought the Registered Manager the home was run in a positive and friendly manner. There was no evidence on staff records that staff have one to one supervision. The Registered Manager said this issue would be followed up. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 24 There was evidence of a Management Meeting but no Staff Meetings have been held. It is again recommended that meetings be held regularly to discuss all important matters, promote teamwork and consistency and ask staff if they would like to add items to the agenda. There are no Residents Meetings held. It was recommended that residents / relatives meetings be held and recorded so that all concerned have the opportunity to air their views on the running of the home. The Registered Manager said a Quality Assurance system had been ordered but not yet completed. Questionnaires need to be supplied to residents to gauge their views as to the services the home provides and it is recommended that other interested parties be supplied with questionnaires – GPs, District Nurses, relatives etc and for Action Plans to improve services if necessary to be in the Statement of Purpose. There is a Health and Safety folder with Risk Assessments for safe working practices. There are a number of issues missing from this regarding the need for, e.g. radiators with covers in some areas to protect residents from burning (covers have been installed to a number of radiators since the last inspection), window restrictors etc, and no records of hoist maintenance or wheelchair servicing (the latter is carried out by the Registered Provider according to the Registered Manager). The Registered Manager said this would be followed up, which are important for promoting and protecting the health and safety of residents. The Registered Manager stated that there were no outstanding Requirements from the last Environmental Health Officers Report, though this could not be found. It needs to be available for inspection. The Registered Manager does not keep records of residents monies, as she stated that these are dealt with by residents or their relatives. Fire Precautions: System testing was on required weekly schedules for fire bell testing, regular fire drills had been carried out and there was a completed fire risk assessment in place. Regular monthly checks had not been carried out for emergency lighting since 2006. The Registered Manager said this issue would be followed up and put into place. Staff members were asked about the fire procedure and were aware of what to do. Fire extinguishers had been serviced in 2007. Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 25 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 4 STAFFING Standard No Score 27 1 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 1 Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 15 Requirement Care plans need to fully detail all care needs to include full Risk Assessments and medical checks and be shared with the resident/representative. Timescale for action 07/11/07 2. OP18 13 Residents need to be fully 12/08/07 safeguarded from abuse by the Registered Providers carrying out statutory recruitment checks. Staffing levels need to be reviewed at weekend shifts to ensure that residents needs are met at all times The Registered Providers should ensure that essential staff training is carried out. The Registered Provider must ensure that Health and Safety systems protect residents, and that there is evidence of regular servicing of essential equipment. 07/09/07 3. OP27 18 4. OP30 18 07/02/08 5. OP38 13 30/10/07 Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 27 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 That the home’s assessment form for prospective residents includes all issues contained in the National Minimum Standard. It is recommended that damaged paintwork is attended to as soon as possible and that a shower is installed to provide choice of bathing facility for residents. The Registered Manager should provide regular formal supervision to staff. The Registered Providers need to carry out a yearly Quality Assurance audit and include results of this in the Statement of Purpose, and to arrange regular staff and residents / relatives meetings. 2. OP19 3. 4. OP36 OP33 Beech House DS0000001806.V340876.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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. Extracts may not be used or reproduced without the express permission of CSCI - 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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