Inspection on 18/10/07 for Beech House Care Home

This inspection was carried out on 18th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beech House Care Home 20/10/08

Beech House Care Home 03/01/07

Beech House Care Home 17/01/06

Beech House Care Home 12/09/05

Beech House Care Home 13/09/04

Beech House Care Home 12/08/04

Beech House Care Home 16/03/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Beech House Care Home 294 Carlton Road Worksop Nottingham S81 7LL Lead Inspector Jayne Hilton Unannounced Inspection 18th October 2007 07:30 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 Care Home DS0000008630.V352636.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 Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech House Care Home Address 294 Carlton Road Worksop Nottingham S81 7LL 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) 01909 472149 F/P 01909 472149 mdurgahee@hotmail.com Mr Moussa Durgahee Mrs Sabitree Durgahee Mrs Sabitree Durgahee Care Home 18 Category(ies) of Dementia (18), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (18), Old age, not falling within any other category (18) Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2007 Brief Description of the Service: Beech House is a large 3 storey adapted older house on the outskirts of Worksop, offering personal care to 18 older people. The home has well maintained grounds and there is car parking at the rear of the property. The 18 single bedrooms are located on the ground and first floor, with 9 rooms having en suite facilities. There is a passenger lift to give access to both floors. The home has 2 communal lounges, a dining room and conservatory. There are sufficient bathroom and toilet facilities to meet requirements. The owners intend to extend the home, but this has been delayed. This will include 10 additional bedrooms, an activities room and a new office. At the time of the inspection the manager confirmed that the weekly fees ranged from £290 - £344 depending on the residents assessed needs. Additional charges are made for services such as chiropody, toiletries, extra continence aids hairdressing. Information about these costs, were not stated in the Service User Guide however. A copy of the last inspection report is available at the home. ** The Registered Provider has informed us on 12th December 2007 that the facsimile number above is incorrect and that the home does not currently have a facsimile machine. The incorrect facsimile number will be removed for the next inspection report. Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over seven daytime hours and was unannounced. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history including complaints and adult protection referrals, and an annual quality assurance assessment completed by the registered person. The main method of inspection used was called ‘case tracking.’ This involves selecting two service users and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Many of the people who live at this home have a very limited ability to understand and communicate. Therefore many judgements in this report are from observation and reading residents’ records and documents. Five service users and two relative were spoken with. The people selected for case tracking had limited ability to understand and communicate. Therefore many judgements in this report are from observation, discussion with staff and reading residents’ records and documents. Residents who were not part of the case tracking provided other information during the inspection. Three members of staff, the manager and the registered provider were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to service users. Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Ensure service users have all of the information about the home. Review the assessment documentation to ensure service users needs are fully addressed and met. Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 7 Fully review the care plan system to ensure they contain sufficient detail to ensure the personal and healthcare needs of service users are fully met. Improve medication practices so service users are not placed health at risk. Improve the training provision to ensure staff, have the necessary skills to meet the specific needs of service users. Ensure submission of notifications to the Commission of Social Care Inspection as required by regulation, of all events that affect the health and welfare of service users and any deaths. Improve monitoring of water temperatures to further protect service users Six requirements and sixteen good practice recommendations have been made in respect of the above. 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 Care Home DS0000008630.V352636.R01.S.doc Version 5.2 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 Care Home DS0000008630.V352636.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have some but not all of the information about the home. Their needs are assessed, however a review of the assessment documentation is needed to ensure service users needs are fully addressed and met. The home does not provide an intermediate care service. EVIDENCE: A Statement of Purpose was not available on the day of the inspection, however a service user guide/handbook was viewed, a copy is held in service users rooms. The document does not detail what the fee rates charged however. Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 10 There were copies of the previous Inspection reports available in the home and information within the service user guide about how service users or visitors could obtain a copy. Relatives and staff spoken with said they knew about inspection reports on the home. Contracts were not seen for the people case tracked on the day of the inspection, however a sample of prepared contracts were seen for three other service users but these had not yet been signed. There was no evidence that service users are informed in writing that the home can meet the specific needs of service user. Assessment documentation was in place for the service users case tracked. The manager stated in the Annual Quality Assurance Assessment “ All residents have a pre-admission assessment to establish their needs; and a care plan is devised accordingly. The social workers assessment is incorporated into the care plan. Residents and their relatives are informed that the first four weeks is a trial period during which the service users and their relatives are free to make the choice of whether they wish to stay at Beech House. A review is always held after the first four weeks of the service users stay at Beech House involving the service user, their relatives, social worker and staff at Beech House. Those admitted are assured that their needs will be met fully. “We always work very closely with the relatives to ensure maximum delivery of care for the resident.” The current system in use combines the assessment information and care plan, which is somewhat confusing and repetitive. Limitation of space means that information is documented in note form and therefore does not provide staff with enough detail about the service users needs or indeed how these are to be addressed monitored and evaluated. The assessment and care plan documentation requires further development to include service users diversity or cultural needs. It was established through the inspection that the Registration Certificate reflects the needs of people admitted into the home. The Registered Provider has informed us that the fax number above is incorrect and that the home does not currently have a facsimile machine. Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 11 The Care Home Regulations 16[2][a][ii] requires the registered person to provide appropriate facilities for communication by facsimile transmission. Beech House Care Home DS0000008630.V352636.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 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Brief documentation is in place about the care needs of service users, however this needs to be fully reviewed and contain sufficient detail to ensure the personal and healthcare needs of service users are fully met. Some medication practices may place service users health at risk. EVIDENCE: The home is in the process of introducing a new care plan format. Information within the system used, was in note form rather than a detailed plan of action of how the service users needs were to be met and monitored, for example one person is at risk of choking, but the care plan did not inform staff of the position the person needs to be placed prior to eating to minimise the risk of choking. Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 13 There were some particular gaps in how staff should manage any challenging behaviours presented by service users. However although brief, the social and leisure needs and participation of activities, up to date information about falls, medication, personal care and medical problems of service users, how healthcare needs are monitored and recorded such as chiropody and dental care were reviewed regularly. Risk assessment tools are in place for pressure areas and nutrition, however these need to be reviewed monthly. Relatives confirmed that they are always involved with reviews of their relatives care and documentation was in place, however a template introduced for service users/and/or their representatives had not been signed. From speaking with staff it was identified that they were knowledgeable, about individual service users need and they were able to explain how they were meeting these for the individuals discussed. The provider stated in the annual quality assurance assessment, “that the subject of pressure area care is recorded in detail within the mobility and dexterity section of the service users care plan, there is also a body map to indicate at a glance where the pressure areas and sores are. Within the care plan there is also a record of the medical services received that shows which department of the community Multi Disciplinary Team has been attending to the residents needs. Evidence of this practice was seen in the care plans viewed A detailed handover was observed at the commencement of the inspection. Observation of medication adminstration evidenced appropriate practice in respect of oral medication, however eye drops were observed to be administered in the in the dining room, which is not good practice. Where this practice is requested by service users –this should be fully documented within rhe care plan. Eye drops with a use by limitation had not been dated on openeing and therefore a requirement is set in respect of this. It is also recommended that water is supplied for service users to take their medication, rather than use their hot drinks. Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 14 Where this may be requested by service users as a preference –this should be fully documented within the care plan. Although there were records of cool storage of medication, the general storage temperatures of medication were not being monitored and this is recommended. On inspecting the medication records it was established that one persons medication prescription details had been handwritten but there were no signature or witness signature as part of practice of minimising any risk of error. One persons medication chart had an omsission of dosages with no explanation of the reason for the ommissions. One persons care plan stated that they were self medicating but this was found not to be accurate. Risk assesments for people who wish to self medicate need to be implemented. Service users said that their privacy and dignity was always respected and practices observed on the day of the inspection supported this. The registered person reported that if a service user has a home visit from a health or social care professional then the privacy and dignity is maintained by allowing the consultation to take place in the residents room. Beech House Care Home DS0000008630.V352636.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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users mostly find the lifestyle experienced in the home, matches their expectations and preferences and they can exercise choice and control over their lives. They receive a wholesome and balanced diet in pleasing surroundings. EVIDENCE: There is a specific staff member allocated for activties and staff said this is currently three days a week. Activities of darts and bingo were observed taking place on the day of the inspection. Foot masaage was also reported for the people on a one to one basis. Service users and relatives expressed that the provision of activities currently is satisfactory. Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 16 Staff confirmed that service users can be escorted on walks to the shops, but there had been no recent trips out arranged. The staff member also reported that ‘Kareoke’ is particularly enjoyed by service users. One person confirmed that she attends church with her relatives every week. The care plans contain personal profiles of people, but these need to be improved to capture a full life history of the person which should be used when planning and devising social and leisure activities. Service users confirmed that they could see visitors in private and relatives said they were always made welcome. Service users bedrooms were personalised with items they had brought with them upon admission and information about advocacy services was avialable. Service users and staff confirmed that they were able to choose how they spent their day and their daily routines such as bed times. Catering arrangements in the home are well orgainsied and service users confirmed choices were available and records supported this. The menus and general presentation of food appeared nutritious and varied and all service users spoken with praised the quality of the food. People who require assistance with eating were observed to have their needs met, however soft/ liquidised diets are not served in an appetising way as this is mixed together rather than served seperatly. Service users were observed to eat at their own pace without being rushed. Catering staff have undertaken training in Dementia Care and Food Hygiene. Beech House Care Home DS0000008630.V352636.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are confident that any complaints will be taken seriously and ensure service users are safeguarded from harm. EVIDENCE: Beech house has a user friendly complaints procedure that can be found on the notice board as well as in each service users guide located in every service users rooms. The registered person said “Beech House listens to all suggestions and complaints with the desire of acting upon them in a professional manner as per policy”. A complaints book is in place and this can be found in the office, all staff have been made aware of this. The topic of complaints has also been raised in the staff meetings as a measure of awareness. All staff at Beech House are trained in the Safeguarding of Vulnerable Adults. “ All our staff have been trained on elderly abuse in all its forms; how to detect signs of abuse and who to contact if suspicion arises that abuse is Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 18 taking place within the home or indeed the place where a resident has stayed previously. There is a resource pack on abuse that is available for staff to view when they wish”. Records viewed of staff training, interviews with staff and service users and other documents viewed confirmed this statement. Beech House Care Home DS0000008630.V352636.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, 22, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Beech House offers its service users a clean and generally well-maintained environment. The atmosphere in the home is welcoming and homely, however some areas are in need of re-decoration. EVIDENCE: During the partial tour of the premises it was evident that the home was clean and smelled fresh. The home has appropriate equipment including, hand rails hoists, and wheelchairs and bathing aids, The registered person stated in the annual quality assurance assessment Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 20 “We ensure that Beech House is constantly fitted for its purpose so that the residents are able to gain easy access. Beech House is primarily a homely environment and offers security and comfort to the service users”. There was much evidence to support this statement, however service users do not have keys provided to their bedrooms or lockable facilties and this needs to be addressed within the assessment process. [i.e. if service users are not able or do not wish to hold keys, this needs to be appropriatly risk assessed and documented within the care plan] Records were viewed for Water outlet temperatures and prevention of legionella. A sample of water outlet temperatures were taken and found to be very high, however a heating engineer was on the premises and confirmed that he was in the process of fitting regulating valves and the Provider requested that the sampled area be prioritised. The provider agreed to ensure risk assessments were undertaken whilst the work is in process to ensure water outlet temperatures are maintained at a safe level. Not all care staff has undertaken specific training in infection control or food hygiene. As food handler’s, food hygiene training for all care staff is also required [Standard 30]. Staff were observed to wear personal protective clothing and there were no hygiene issues raised at the inspection. The home has a laundry room, sited in a separate building, which contained an industrial washer and dryer, however this and the pantry store were noted to have a damp problem and the floor needs repainting. The provider stated that the buildings would be demolished as part of the planned extension, however this has been delayed. Continence aids and towels were stored openly in bathrooms, which may place them at risk of cross contamination. Toiletries were also observed stored in the bathrooms with hairbrushes etc. Personal toiletry items should remain with the service user and taken back to their bedroom after use in the bathroom. Beech House Care Home DS0000008630.V352636.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff are provided who have basic training to do their jobs. However service users and staff would benefit by additional training on specific needs such as diabetes, epilepsy etc. Recruitment practices protect service users. EVIDENCE: There was training information available within the training records, which provided evidence that most staff have undertaken manual handling training, first aid, food hygiene, health and safety, infection control and health and safety, fire training, Dementia Care and abuse awareness, induction and equality and diversity; certificates were seen as evidence for most of these, however the training provider cannot provide some certificates for twelve weeks. Training is not however provided to meet the specific needs of service users with diabetes, mental health needs, catheter care epilepsy etc. Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 22 Also all staff need to undertake food hygiene and infection control training. Five personal staff files were viewed and were satisfactory. Three care staff support service users during the daytime hours and two staff are provided at night. Sufficient catering hours domestic and laundry are provided. The manager undertakes supervision of staff. Good records of these are kept and staff said they felt they were beneficial. Newly appointed staff, receive a common induction combined with a local induction within six months of their employment. The manager ensures that there is regular staff training for all staff at Beech House in order for the staff to be competent to look after the residents well and meet the continuing changes in needs of the service users. Staff said that the training provision has recently improved. The provider reported that 67 of staff have achieved NVQ 2 [National Vocational Qualifications] Service users and a relative spoken with said that staff, were excellent and kind and nothing was too much trouble for them, these comments were extended to the manager and provider also. Beech House Care Home DS0000008630.V352636.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, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users financial interests are safeguarded and they are mostly consulted about the running of the home. The health & safety of service users and staff at the home are promoted; however improved training, submission of notifications and improved monitoring of water temperatures will further protect service users. EVIDENCE: The registered manager has a level 4 NVQ qualification in management and is an experienced registered nurse. Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 24 The Providers are developing a quality assurance system which is based on seeking the views of the service users and their relatives, as well as health care professionals that visit Beech House. Evidence of completed service user and relative surveys were seen, but they have not yet been evaluated. Surveys for visiting professionals were also seen, but these have yet to be distributed. One relative had raised concern as to the security of the home and that staff do not always ensure the visitors book is used. There was also concern raised from relatives and service users about visitors using the dining room door. Observations on the day of the inspection supported this, concern and a visitor confirmed she had not signed the visitor’s book on entering the home. Written records are maintained for all money transactions in order to safeguard the financial interests of the service users. The manager ensures that where possible the service users are in control of their monetary needs, but if this is not possible then the correct safeguards are in place to protect the residents finances. It was found that a service user had been purchasing some additional continence aids, but there was no statement in the service user guide or contract that this would be expecetd. Relatives meetings are in place at Beech House and take place quarterly. Residents meetings take place fortnightly. Management issues are discussed in regular staff meetings. A selection of records relating to health and safety were mostly satisfactory. There was a Health and Safety policy in place. There were noted gaps in the records for water outlet testing of the conservatory bathroom, which temperatures were found to be very high on the day of the inspection [see Standard 19]. Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 25 The manager had reported that there had been five deaths at the home in the previous twelve months but these had not been notified at the time of the events to the commission as required by Regulation. Another incident had not been reported to the commission also, whereby a service user had wandered out of the home unnoticed. This is a breech of regulation 37 and the provider must ensure that the Commission is informed of the backdated events and ensure all future events that affect the health and well being of service users is notified as required by the regulation. Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 26 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 2 1 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 15 2 X X 3 X 2 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 X 2 3 1 2 Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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 OP2 Regulation 14[1][d] Requirement Timescale for action 18/12/07 2 OP8 OP7 15, 13[4][c] 3 OP9 13[2] Ensure service users are provided with confirmation in writing that after an assessment of their needs the home can meet those needs. Ensure the identified persons 26/11/07 care plan details the position they need to be placed when being assisted with eating to prevent them from choking. Ensure that arrangements are in 18/12/07 place for the recording, handling, safekeeping and administration and disposal of medicines received into the care home. [Ensure that the recommendations from the recent pharmacy audit are addressed as identified in the report.] Ensure water outlet temperatures in communal areas are regulated to a safe temperature of no higher than 43 degrees and documented. The registered person must give notice to the Commission without delay of the occurrence DS0000008630.V352636.R01.S.doc 4 OP19 OP38 13[2], 13[4][a] 17 37 26/11/07 5 OP37 26/11/07 Beech House Care Home Version 5.2 Page 28 of the death of any service user, including the circumstances of death. The outbreak in the care home of any infectious disease, or any serious illness of a service user. Any event which adversely affects the well-being or safety of any service user, any theft, burglary or accident in the care home, any allegation of misconduct by the registered person or any person who works at the care home. Ensure the Commission for Social Care Inspection receive backdated notifications as identified. Ensure that all visitors’ sign in and out of the visitor’s book as required by regulation. 6 OP37 17,schedu le 4[17] 26/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 OP2 OP35 OP7 OP8 OP7 Refer to Standard Good Practice Recommendations The Service User Guide needs to include the range of fees charged and what extras service users may be expected to fund, such as extra continence aids. Include within the care plans how staff should manage challenging behaviours in a consistent way. Care plans must be developed in consultation with service users so they are clear about how staff intend to help them. The care plans must provide clearer instructions to care staff on how the service is to be provided for each person to make sure the care provided is in line with the philosophy of care at the service. Review nutritional and pressure area tools at least monthly Provide water for service users to take their medication, rather than use their hot drinks. [Unless this is specifically DS0000008630.V352636.R01.S.doc Version 5.2 Page 29 4 5 OP7 OP8 OP9 Beech House Care Home 6 7 8 9 10 11 12 13 14 15 OP9 OP12 OP15 OP19 OP24 OP30 OP26 OP19 OP26 OP26 OP30 OP33 16 OP38 requested by the srevice user and documented in the care plan] Monitor and record the storage temperatures of medication Include more detailed life history profiles for service users which can be used to create more, person centred, innovative and stimulating activities Explore the use of moulds for soft diets so they can be presented in a more appetising and dignified way. Re-decorate the kitchen in the interim period of refurbishment. Ensure service users are provided with keys to their bedroom door and lockable facilities unless their care plan states otherwise. Seek out other providers of training to ensure all staff undertakes training in food safety and infection control. Address the damp problem in the pantry store and laundry in the interim of refurbishment taking place and ensure the laundry floor is made impermeable. Ensure continence aids and towels are not stored openly in bathrooms to prevent risk of cross contamination Provide training for staff in Epilepsy, diabetes and continence management. Further develop the quality monitoring systems in the home to ensure service users and their representatives or visitors to the home are consulted about the service provided. Undertake a review of the security of the external doors and monitoring of visitors to the home. Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Beech House Care Home DS0000008630.V352636.R01.S.doc Version 5.2 Page 31 - 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. 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