Inspection on 27/09/05 for Beech House (Binfield)

This inspection was carried out on 27th September 2005.

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

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

Other inspections for this house

Beech House (Binfield) 22/10/08

Beech House (Binfield) 31/10/07

Beech House (Binfield) 24/04/07

Beech House (Binfield) 20/11/06

Beech House (Binfield) 02/05/06

Beech House (Binfield) 06/03/06

Beech House (Binfield) 12/04/05

Beech House (Binfield) 05/10/04

Beech House (Binfield) 06/04/04

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

CARE HOMES FOR OLDER PEOPLE Beech House (Binfield) London Road Binfield Bracknell Berkshire RG42 4AB Lead Inspector Debbie Willcox Unannounced Inspection 15:40 27th & 28 September 2005 th 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 (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 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 (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beech House (Binfield) Address London Road Binfield Bracknell Berkshire RG42 4AB 01344 451949 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) Charnley Care Limited Mrs Gill Kirk Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th April 2003 Brief Description of the Service: Beech House is privately owned and offers accommodation and care to 28 older people. The home has 25 bedrooms, 3 of which are double bedrooms. The home is located close to the town centre of Bracknell and within close proximity to rail, bus routes and the M4 motorway. The home has a contract with Bracknell District Council to provide respite services. Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by two inspectors taking 7 hours over a 2-day period. Time was spent talking with people who live in the home, one relative, owner, manager and staff. An audit of records related to care planning, health and safety monitoring, complaints and staff recruitment. There are 7 outstanding requirements from previous inspections. An immediate requirement was issued for door wedges to be removed as these are still being used to hold doors open despite previous requirements made for the registered person to provide automatic self closing devices to ensure service users are protected from the risk of fire. It was evident during the two days of inspection that staff morale is low. There has been a steady turnover of staff and staff vacancies are being covered with a high use of agency staff. The deputy manager has left since the last inspection and no replacement recruited. The senior staff team consists of the manager and 1 senior care assistant. This was clearly insufficient to meet the needs of the home, evidenced by the deterioration in record keeping, health and safety monitoring, staff supervision support and updating of care plans. What the service does well: What has improved since the last inspection? Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 6 A cook has been appointed since the last inspection. Several People living in the home said this has been a positive improvement as the cook provides good, homely cooking. What they could do better: Redecoration of the premises and replacement of carpets and furnishings is long overdue. Walls and woodwork need painting and some plaster in hallways and corridors repairing. Some carpets are in need of replacement and some in need of cleaning. This does not make for a homely environment for those living at Beech House. Management monitoring of the standard of care and record keeping needs to be undertaken by the Responsible Individual/proprietor. Records relating to money and valuables held on behalf of residents must be maintained within the home to ensure that residents money is made available to them and their financial interests are safeguarded. The management of records relating to budget management, contracts, work undertaken and invoicing is poorly organised and must be improved to ensure that records are maintained in the home, organised and open to inspection. Staffing levels were clearly insufficient in the late afternoons and evenings and must be increased to meet the needs of those living within this home. Staff recruitment procedures are not robust enough to ensure that people living in this home are safeguarded. This has been an ongoing concern and any further non-compliance may result in enforcement action being taken by the CSCI. A record must be maintained of medication being received into the home and of its disposal or return to the pharmacist. Insulin stored in the fridge must be stored in a lockable container. Please contact the provider for advice of actions taken in response to this Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 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 (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 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): EVIDENCE: Not assessed at this inspection. Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 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): 7,8,9,10,11 EVIDENCE: The storage of medication, administration of the team time medication, controlled drugs and recording keeping in relation to stock control was seen. The home uses the Boots monitored dosage system. The home did not have a stock record of medication received into the home and returned to the pharmacy. The manager was guided to the Boots medication administration charts and the spaces provided for recording stock received into the home and returned with a box for signatures to enable the home to comply with requirements. Insulin was found stored in the main kitchen fridge in a margarine carton and not a lockable container. One resident who self administers insulin had signed a disclaimer to say they took responsibility for their administration of insulin. However it was observed during the handover of day to night staff that staff are actively involved in checking the dosage of insulin at the point of administration as staff had Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 11 observed the wrong dosage is often taken. There was no written guidance for staff on this as their was no risk assessment or guidance within care plans. As highlighted in previous inspections there is insufficient information regarding residents diagnosed with diabetes, which would guide staff as to medication administration, diet, annual checks and how to recognise and take action when a resident becomes hypoglycaemic. Care plans seen stated a normal diet, no extra sugar. The resident administering insulin told inspectors the GP had instructed that that no foods containing sugar or alcohol should be eaten and meals should be provided regularly avoiding long periods without. This information was not detailed in this residents care plan. A care plan and daily notes for a resident observed by staff to have a vaginal sore and bruising did not have follow up information which would indicate how this had been addressed and monitored. There was no evidence that a GP or District Nurse had been contacted. A variety of risk assessments were viewed. Bathing risk assessments contain guidelines for bathing but do not identify risks involved and no action plan for alleviating risks that could be identified. There are individuals fire risk assessments in place. These identified the number of staff that would be needed in the event of a fire to evacuate from the building. Some identified the need for two staff. The fire procedure described the need to ensure a full evacuation of the home. Given that during the afternoons, evenings and night shifts there are only two staff on duty this matter needs review with a fire officer for guidance. There is an outstanding requirement for care plans to detail residents wishes in the event of death and terminal illness. Service users spoken with said that in the majority staff are kind and helpful. However service users are aware that staff are rushed and stressed especially in the afternoons and evenings. See also staffing standards 27-30. Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 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): 12,13,14,15 Service users can maintain contact with family and friends. The provision of homely cooked meals has improved. Further work is needed to ensure adequate staffing levels to meet the needs of service users at mealtimes and appropriate support with feeding is provided. EVIDENCE: A new cook has been employed since the last inspection. Service users spoke positively about the improvement in what they termed as more homely cooking being provided. The evening meal was observed. Two service users required assisting with eating at meal times. Staff are not able to give their full attention to this task. Staff were seen to be standing over service users being fed rather than sitting down with them at eye level and were also observed rushing off to administer medication and clear tables without finishing the task of feeding. On the menu for tea was soup and bread, because of the time taken to seat residents most had eaten the bread before soup was served. Little communication between staff and service users was observed during the meal. Service users who presented as mentally frail did not always have explanation given to them of what food was being provided. Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 13 A chicken casserole for lunch the following day was left out on top of the cooker to defrost with a note saying ‘please leave out overnight’. The oven was in use and it is not safe to defrost at room temperature. The home has several people diagnosed with diabetes with one persons diabetes controlled with daily injections of insulin. See also standards 7-11 There was evidence of two outside entertainment activities organised including a visiting farm. This was very much enjoyed by service users. Staff arrange bingo sessions on a weekly basis. Discussions with one relative evidenced that visitors are welcomed to the home without restrictions on visiting times. Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 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): 16,18 Record keeping must be improved to ensure an audit trail of concerns and complaints with outcomes recorded. EVIDENCE: The homes complaints book was viewed. This record book highlights the name of complainant and nature of complaint but does not detail timescales for dealing with complaint and outcome. There was evidence of complaints letters having been received by the proprietor but these were not available in the home for inspection. A requirement was made at previous inspections for staff to be trained in responding to abuse of vulnerable adults. It was evident that some staff have now attended this training provided by the local authority and others booked to attend in the future. Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 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): 19,20,21,25,26 Service users cannot be confident that the home they live in is a clean well maintained environment. EVIDENCE: There are 3 outstanding requirements related to the premises since the last inspection. No request has been made to the CSCI to extend the timescales to enable compliance with these legal requirements. The appearance of the home internally has deteriorated since the last inspection. There has been little improvement to the maintenance of the building. Many parts of the home are in need of decoration and replacement of carpets, furnishings and furniture. The hallways and stairways have grubby paintwork to walls and woodwork and plaster damage. Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 16 Bathrooms throughout the home are in need of refurbishment. One bathroom located from within a service users bedroom was seen to be in a poor state. The showerhead was missing. The bath had a bath mat, which was mouldy and badly stained. The bath was found to be dirty and it was evident had not been cleaned for a considerable length of time. The door to a cupboard within this room housing an uncovered hot immersion heater did not close. This room was in need of complete refurbishment and decoration. Several doors throughout the home were found wedged open. There is an outstanding requirement for self-closing door devices to be provided to ensure service users safety in the event of a fire. A fridge door was found to be kept closed using a cooking oil drum as the seal had broken and prevented the door from staying closed. This had been highlighted in an inspection 2 years ago and not addressed by the registered provider. Room 6 carpet was frayed and worn posing a trip hazard. Room 2 carpet was found to be soiled and had a strong smell of urine. Stair carpet from the first to the second floor is in need of replacement. The replaced stair carpet from the ground floor to the second floor has become soiled and is loose on the bottom step. COSHH cupboard located in the laundry room was found unlocked. The door to the laundry room is wedged opened. The downstairs toilet had faeces on the wall and the radiator cover. Several sinks and toilets throughout the home are in need of de-scaling and present as a hazard to the control of infection. Several toilets and bathrooms did not have provision of liquid soap, as the containers were found empty. The home has little in the way of storage space and the dining room and lounge can become cluttered with walking frames, which can pose as a trip hazard. The lounge is a large room with seating arranged around the outside of the room. Walking frames are stored whilst not in use in the middle of the room. It was observed that some service users could not see the television as these blocked their view. Service users said their removal would be appreciated but did not want to make a fuss. Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 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): 27,28,29, Staffing levels must be improved in the afternoons and evenings to ensure service users needs are met. Until the home develops robust staff recruitment procedures evidenced by records maintained service users cannot be assured they will be protected by the homes recruitment practices. EVIDENCE: There is no formal monitoring undertaken by the owner of record keeping or quality assurance monitoring standards of care within the home. On the first day of the inspection it was not possible to view staff records, as the owner did not have access to keys on the premises. Staff records were accessed on the 2nd day of inspection. 3 staff files were viewed. 2 files were of staff recently employed in the home and the other employed within the last 19 months. All 3 files contained job application forms. 2 files contained evidence of CRB and POVA checks. One file did not have evidence of CRB and POVA checks. All 3 files contained written references. However one file had written references from work colleagues and not the most recent employer. None of the files viewed contained contracts or job descriptions. There was no evidence to confirm that staff were eligible to work in the UK apart from one file, which had a copy of a work visa, which had expired. No up to date photos of staff are maintained. Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 18 The lack of robust recruitment procedures in this home has been an ongoing concern. Any further non-compliance may result in enforcement action being taken by the CSCI. Rotas seen did not detail the full names of staff and their job role. Agency staff were referred to on the rota by their first name but no record of surname and the agency supplying them was recorded. On the day of this inspection one staff member had worked both the late shift and was also on the rota to cover the 12-hour night shift, working for 16 hours. Discussions with staff evidenced that this is a regular occurrence. The home has 2 staff on waking night duty over a period of 12 hours from 8-8. It was evident from discussions with night staff that a period of 2 hours each is allowed for breaks during the nighttime period. It was not evident however that staff had been given clear guidance as to how these breaks were to be taken and staff had their own ideas as to what they believed might be the homes policy on this. One night staff member recently employed had not been inducted into the homes policy on the taking of breaks and was unclear. For two staff to be taking 2-hour breaks each during the night would account for 4 hours with only one staff member assisting to the needs of service users. Between the hours of 4-8pm there are 2 staff available to meet the needs of 28 service users and 1 staff member working in the kitchen from 4-6pm. It was evident from observation, discussions with service users and staff that this level of staffing is insufficient and does not enable staff to meet the current needs of those residing in this home. Service users said that during the evening there is not enough staff around. Service users comments made included - ‘we do not like to bother staff unless we really have to. They work so hard, we feel sorry for them’. ‘There are not enough enough staff around in the evening, only 2 sometimes 3’. ‘You can’t always find someone when you need them’. See also standards 12-15. Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 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): 31,32,33,34,35,36,37,38, Consideration must be given to recruiting adequate senior staff to ensure service users live in a well managed home and staff are supported with regular supervision. Without robust accounting and financial procedures in place service users cannot be assured that their financial interests are safeguarded. The management of records must be improved to ensure that records are organised and made available for inspection. Management systems for monitoring health and safety must be implemented and updated to ensure the welfare of service users is promoted and protected. EVIDENCE: Since the last inspection the deputy manager has left and this post has not been recruited to. Apart from the manager and senior care assistant there are no other senior staff. It was clear from observation of records and discussions Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 20 with the manager and staff that standards of staff supervision, safety checks and record keeping have deteriorated. The manager was clearly under pressure and staff morale was low. Low staff morale was clearly impacted by the lack of response in dealing with maintenance issues and lack of improvements to the décor of the home. It was difficult to assess how well service users are safeguarded by the homes accounting and financial procedures. Not all documents requested were available within the home. Record keeping was disorganised, inconsistent and not readily available when requested. The registered manager is no longer managing service users money. The inspectors were informed that the Proprietor now has full responsibility for handling service users money deposited for safekeeping to the home. Records were not available on the premises for inspection as they were kept at the proprietor’s home. This resulted in service users money not being made available upon request. There was no evidence provided that external auditing of service users accounts are undertaken. Contracts to ensure that health and safety monitoring is undertaken are not maintained such as hoist servicing and thermostatic water valve testing. The weekly testing of hot water from outlets accessed by service users had not been undertaken since 31/08/05. The inspectors were informed that thermostatic water valves are not serviced. Lifting hoists including bath hoists have not been serviced as required 6monthly. The last recorded service was 18-months ago. Records evidenced that wheelchairs have recently been serviced. During a tour of the building the COSHH cupboard housing cleaning products was found unlocked. A certificate of insurance in respect of liability was viewed on display and was out of date. The Registered Provider produced an up to date cover note during the inspection. Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 21 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 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 3 1 2 1 x x x 2 1 STAFFING Standard No Score 27 1 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 1 1 2 1 2 Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 22 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 OP29 Regulation 19 Schedule 2&4 Requirement The Registered Person shall not employ a person in the home unless all checks have been undertaken including written r references from most recent employer and CRB and POVA clearance. ORIGINAL TIMESCALE FOR COMPLIANCE WAS 5/12/02 Service Users wishes in event of death or terminal illness to be recorded. ORIGINAL TIMESCALE FOR COMPLIANCE WAS 12/05/05 A daily record of food provided and consumed by service users to be maintained. ORIGINAL TIMESCALE FOR COMPLIANCE WAS 12/05/05. The registered person to ensure removal of door wedges and appropriate safe door opening devices provided. ORIGINAL TIMESCALE FOR COMPLIANCE WAS 12/04/05 Bathroom flooring to be replaced in bathroom sited close to the laundry. ORIGINAL TIMESCALE FOR COMPLIANCE DS0000011071.V250731.R01.S.doc Timescale for action 01/11/05 2 OP11 12,15 01/11/05 3 OP15 Schedule 4,13 01/11/05 4 OP19 23 27/10/05 5 OP21 23 01/12/05 Beech House (Binfield) Version 5.0 Page 23 6 OP21 23 7 OP38 37 8 OP7 14,15 9 OP9 13 10 OP9 13 11 OP9 13 12 13 OP16 OP16 17, 22 22 14 OP27 18 15 OP34 25 (3)(a) WAS 12/06/05 The Registered Person to provide a report to the CSCI detailing an action plan with timescales for refurbishment of bathrooms throughout the home. ORIGINAL TIMESCALE FOR COMPLIANCE WAS 12/06/05 The Registered Person to provide to the CSCI without delay written notifications as required within Regulation 37. ORIGINAL TIMESCALE FOR COMPLIANCE WAS 12/04/05 Care plans to contain a plan for meeting the health care needs of service users including those diagnosed with diabetes. The Registered person to ensure that records are maintained of all medicines received into and leaving the home or disposed of. A lockable container to be provided to store Insulin in the main fridge or a lockable medication fridge to be provided. Care plans and risk assessments to detail clearly written guidance for staff in the level of staff assistance required in promoting independence of service user self administering insulin. Complaints records to detail the timescales taken to investigate complaints and detail outcomes. Concerns and complaints letters to be maintained on the premises and available for inspection. The registered Person must ensure that adequate numbers of staff are employed in the home at all times in such numbers as appropriate for the health and welfare of service users. The Registered Person to ensure that all financial records with DS0000011071.V250731.R01.S.doc 01/12/05 27/10/05 01/12/05 01/11/05 01/11/05 01/12/05 01/12/05 01/12/05 01/11/05 01/11/05 Page 24 Beech House (Binfield) Version 5.0 16 OP35 Schedule 4 (9( 17 18 19 20 21 OP19 OP19 OP19 OP19 OP19 23 23 23 23 23 22 23 OP21 OP21 23 16 (2)(j) 24 OP25 23 25 26 OP27 OP27 Schedule 4 18 27 28 OP38 OP38 23(2)(C) 13 (4) 29 OP29 18 regards to the care home are organised, kept up to date and maintained on the premises of the home and open to inspection. The Registered Person to ensure that a record is maintained on the premises of all money and valuables deposited on behalf of service users for safekeeping and audited by someone other than the proprietor regualrly. Corridors and stairways to be decorated and plaster repaired. Room 6 carpet to be replaced. Room 2 carpet to be replaced. Stair carpeting from the 1st to the 2nd floor to be replaced. Fridge in the storeroom to be repaired or replaced. ORIGINAL TIMESCALE FOR COMPLIANCE WAS 05/12/04 Toilets and sinks throughout the home to be de-scaled. Adequate quantities of antibacterial soap to be made available in toilets and bathrooms. Safe storage space to be found for walking frames other than middle of lounge area and dining room. Staffing rotas to detail the full name and designation of staff employed including agency staff. Night staff to be inducted and trained into the homes policy on the taking of 2 hour breaks during the night shift. Hoisting equipment to be serviced regularly and records maintained. Water temperatures from all water outlets accessed by service users to be tested weekly and recorded. Evidence to be obtained of staff DS0000011071.V250731.R01.S.doc 01/11/05 01/02/06 01/02/06 01/02/06 01/02/06 01/02/06 01/12/05 01/11/05 01/11/05 01/11/05 01/11/05 01/11/05 01/11/05 01/11/05 Page 25 Beech House (Binfield) Version 5.0 30 OP38 13(4) eligibility to work in the UK. The COSHH cupboard to be locked at all times when not in use. 01/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beech House (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 (Binfield) DS0000011071.V250731.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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