Inspection on 07/02/06 for Beech Lawn

This inspection was carried out on 7th February 2006.

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

The inspector 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 Lawn 05/02/08

Beech Lawn 13/03/07

Beech Lawn 06/09/05

Beech Lawn 15/02/05

Beech Lawn 01/09/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Beech Lawn Beech Lawn Nursing & Residential Home Higher Lux Street Liskeard Cornwall PL14 3JX Lead Inspector Kerensa Livingstone Unannounced Inspection 7th February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beech Lawn Address Beech Lawn Nursing & Residential Home Higher Lux Street Liskeard Cornwall PL14 3JX 01579 346460 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) Beech Lawn Care Home Ltd Mrs Julie Ann Weale Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability over 65 years of age of places (4), Terminally ill over 65 years of age (2) Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Total number of service users not to exceed 30 Date of last inspection 6th September 2005 Brief Description of the Service: Beech Lawn is a care home with nursing, for a maximum of 30 older people. It is a listed property with purpose built extension situated near the centre of Liskeard in a quiet residential area. Accommodation is provided in 25 single and 2 double rooms, all rooms have television points, and if required telephones can be installed at the service users expense. Service users requiring nursing care are provided with ground floor accommodation. A stair lift provides access to the first floor. There is a sheltered courtyard garden/patio at the rear of the home, providing a sitting area for the service users. At the front of the home is some off road parking, with a car park to the rear of the property. The home has a Registered Manager, Mrs Julie Weale who is in charge of the day-to-day management of the home. Mr & Mrs Stratton visit the home on a regular basis. A qualified nurse is on duty at all times and additional health care is arranged as required e.g. dentistry, chiropody. Social and entertainment activities are provided. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection was conducted over a full day, finishing at six o’clock. This was the Inspector’s first inspection of the home. The Inspector had the opportunity to meet and speak to a considerable number of the Service Users, who were extremely forthcoming and informative about their life at Beech Lawn. The atmosphere within the home was welcoming and the staff were very helpful during the inspection. What the service does well: What has improved since the last inspection? There is a considerable amount of work being undertaken on the home, the dining room, lounge and hall have all been redecorated and recarpeted. New chairs have been bought for the lounge. A clinical room is being completed and the new laundry is functioning. New sink vanity units are provided and these are popular with the Service Users. Several rooms have been recarpeted. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, & 5 Although service users generally have the information they need, an up-todate Statement of Purpose and Service User Guide has been provided since the last inspection and is due to be circulated. Contracts are currently provided to privately funded Service Users only. All prospective service users are assessed prior to moving into the home. EVIDENCE: The Registered Providers have reviewed the Statement of Purpose and Service User Guide as a combined document. The Service Users Guide must be circulated to all Service Users and prospective Service Users. The Statement of Purpose must include the information detailed in Schedule 1 of the Care Homes Regulations. The Registered Providers and Inspector discussed the importance of the Service User being provided with the required information for example the summary of the statement of purpose, complaints procedure, a standard form of contract, the most recent inspection report, contact details for the Commission of Social Care Inspection, terms and conditions of accommodation including fees, in addition to Service Users views of the home and description Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 9 of accommodation and qualifications of the staff. Copies of both documents have been sent to the Commission for Social Care Inspection. All privately funded Service Users have a contract, they are provided with a copy and a copy is held by the administrator. This includes a statement of terms and conditions with the home. Further information pertaining to the home is to be provided to service users within the service users guide. The Registered Provider must provide all Service Users with a standard contract for the provision of services and facilities between the home and the Service User, in addition to the Social Services contract. Since the inspection a comprehensive contract has been compiled and this includes the room number as recommended at inspection. Service users and their representatives know that the home they enter will meet their needs. The Registered Manager has developed the training programme available to staff. Trained nursing staff are encouraged to attend external training courses in order to update and meet the requirements of PREP. There was evidence that qualified nurses cascade the information obtained on training courses to the care staff. A training information and material is available for staff. Training records were available for inspection. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Emergency admissions are not usually undertaken by the home due to the bed availability and the need for a pre-admission assessment to be undertaken. On the day of the inspection, there was only one residential bed available. The Registered Manager encourages Service users and their relatives, to visit the home prior to admission. All prospective Service Users are assessed prior to admission to the home, the Inspector was informed. Following a recommendation at the last inspection the document used for this care needs assessments has been reviewed. It is recommended that this includes the information detailed in National Minimum Standard (NMS) 3.3. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 The Service Users health, social and personal care needs are met in a manner that respects their privacy and dignity. Medicines were observed to be administered safely. The Registered Manager must ensure that there is evidence that the Service User has the opportunity to contribute to the planning of their care. EVIDENCE: The Service Users plans of care are comprehensive, clear and detailed taking into account physical, psychological and social needs. Risk assessments are completed for all Service Users. The Deputy Manager advised the Inspector that the service user and/or their representative was involved at the information gathering stage, it is recommended that the plan of care is drawn up with the Service User agreed and signed by the Service User and/or representative (if any). The staff are committed to promoting and maintaining the health of the service users, ensuring that they receive access to appropriate health care services. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 11 All service users are registered with a General Practitioner. Service users have access to external health care services such District nurses, dentists, chiropodist and optician as required. Service Users informed the Inspector wherever possible they are supported to maintain their independence, however help is available as required. The home has established links with other specialist services such as dietetics, Speech Therapist and the local Primary Health Care teams. Service users are supplied with appropriate continence aids. Pressure relieving equipment such as Airwave mattresses and various cushions were evident. Moving and Handling assessment, wound classification, Pratt nursing scale and Barthel Activities of Daily Livings scale assessment tools are used within the home. There is a designated qualified nurse who takes responsibility for the medicines, ensuring the home is not overstocked and keeping an overview of the medicines administered. The Medication Policy and Procedure has been recently updated. All staff should sign to indicate they have read and understood the policy, in addition to providing a specimen signature. A qualified nurse only administers medication. There are two small medication trolleys on the ground floor and a further one on the first floor. The Inspector was informed that the staff find that these trolleys are suitable. A new treatment room is being built and this will provide a much needed area for the safe storage of medicines. The Inspector observed that medicines were safely dispensed to the Service Users. The MAR sheets all have a photograph of the service users with them; and were signed and dated appropriately. There were no Controlled drugs (CD) on the day of inspection, however other medicines that are stored as Controlled Drugs such as Temazepam were stored appropriately, the CD Register was signed and dated appropriately. The medicines checked were accurately recorded. There is a Home Remedies Policy and this is to be added to the Medicines file with the Drug Error Procedure. Evidence of the pharmacy reviews should also be kept in this file. There is a designated medication fridge, which is locked and the temperature checked daily. Staff were observed to treat service users with respect, spoke in a courteous manner and knocked prior to entering bedrooms. The Inspector spoke at length with Service Users regarding how it was to live at the home, all without exception felt that there right to privacy was upheld and they were treated with respect. Service users have access to a telephone; several were seen to have their own private lines. Clothes are individually sorted in the laundry to ensure that service users only wear their own clothes, one Service User praised the efficiency of the laundry system within the home. Medical examinations and treatments are provided in the service users own room. Screening is provided in shared rooms. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 12 Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. On inspection there was no evidence that individual’s plan for their increasing infirmity and death. The Inspector was advised by the Deputy Manager that personal preferences of service users regarding the management of their illness and / or resuscitation where appropriate is recorded within individual care records and documentation used within the home provides space for this. Service users are enabled, whenever possible, to spend their final days in their own rooms, surrounded by their own personal belongings. Support and advice is sought where necessary form other professionals e.g. Macmillan nurses, district nurses and general practitioners, with records maintained detailing their involvement. Policies and procedures are in place for handling dying and death and available to the staff at all times. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 & 15 The daily life within the home is determined by how the Service Users choose to spend their time. Service Users enjoy living at Beech Lawn. There is a need for greater variety and choice in the menu, this is something one of the Providers had identified as needing action and therefore is likely to be promptly resolved. EVIDENCE: The home operates an ‘open’ visiting policy, with visitors welcome at any reasonable time. Service Users confirmed that their visitors are made to feel welcome by the staff. Service users are able to choose who they see and do not see, and are able to receive visitors in private if they wish. A visitor book is maintained. A recent trip to a local pantomime was a big success the Service Users told the Inspector. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 14 Service users are helped to exercise choice and control over their lives. Personal allowances are managed by the administration department, with receipts and records maintained of all monies. The Service User’s rooms are personalised and personal possessions are brought into the home. Service users and/or their representatives are enabled to access their own records if required, this information should be provided in the Service Users Guide. Service Users informed the Inspector that they exercised control and choice over their lives. Lunch and teatime were sociable occasions; that for many of the service users was taken in the dining rooms. Mealtimes appeared unhurried, with service users given sufficient time to eat. The food was presented in an attractive and appealing manner. Service users commented that the food was always hot, wholesome and plentiful. On the day of the Unannounced Inspection, lunch was ham, egg, chips and peas, followed by Eve’s Pudding and custard. Alternatives of a Jacket Potato and yoghurt were available. Several Service Users commented that they would like more choice at lunchtime and a little more variety. The Inspector and Provider discussed the need for a choice to be available at lunchtime, this had been highlighted previously and the Provider plans to introduce more variety and choice to the menu. There are several choices at teatime. Although the five week rotational menu is not rigidly stuck to, the recorded puddings were repetitive e.g. Angel Delight, Arctic Roll, Fruit and custard. Cold drinks were available during the meal, with tea or coffee offered after the meal. Baking had taken place on the day of the inspection; there was a selection of cake and flapjack for the Service Users teatime meal. Records are kept as required and a nutritious diet is offered. Fresh fruit and fresh vegetables are available. One Service User commented that the food was ‘excellent’. There are two comfortable, homely dining rooms, with one used by those able to generally attend to their own needs; and the other smaller room kept for those requiring more assistance from staff. Staff offered assistance in a discreet and sensitive manner. Mealtimes can be taken in individual rooms if service users are unwell; or prefer not to go to the dining room. Each service user is offered three full meals per day. Special diets are catered for and pureed meals were observed to be served as separate items. It is recommended that the menu be written on a board in the dining room, as this was not done on the day of the inspection. The kitchen is small, rather domestic in nature and acknowledged not to be ideal, although the Cook informed the Inspector that they managed. The Inspector and Providers discussed the need to speak to the Fire Officer regarding the kitchen to dining room, as this is a fire door and was being propped open during the service of lunch. The Environmental Health Officer visited the home on the 1st of February 2006 and was satisfied with the standards being maintained. The Providers plan to relocate the kitchen in the future. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 15 Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 16 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): 18 The Registered Manager must ensure that all staff receive training about the action to be taken in the event of an allegation of abuse being made and a clear procedure detailing who must be contacted must be compiled. EVIDENCE: A Protection of Vulnerable Adults policy is in place. It was identified at the last inspection that this must be supplemented by a Protection of Vulnerable Adults procedure, which provides clear instruction to staff as to the steps to take in the event of an allegation of abuse (including local contact details for the relevant agencies). This is yet to be done and must be prioritised. All staff must receive training about the action to take in the event of an allegation of abuse being made. Recent training provided to the qualified staff indicated that a management meeting would take place prior to the matter being reported, the allegation must be reported to the Care Manager, Social Services immediately and to the Commission for Social Care Inspection under Regulation 37. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20, 21, 22 & 24 The Service Users live in a comfortable and homely environment that meets their needs. The Service Users stated that their individual accommodation meets their needs. Locks should be provided, environmental risks must be assessed, a risk management plan introduced and timescales set for action. Specialist equipment is provided on an individual basis. EVIDENCE: Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 18 There were two dining rooms and a lounge being used on the day of the inspection, these areas are comfortably furnished and decorated. The main TV lounge appeared pleasant, homely and well used by the service users. There is another lounge that was observed to be used for staff breaks and Service Users did not use it during this inspection. There is no designated staff room. One dining room, lounge and hallway has recently been redecorated and recarpeted. New chairs have been purchased for the lounge. There is adequate natural light and ventilation. There were no unpleasant odours in the home on the day of the inspection. The Service Users informed the Inspector that they liked the environment of the home. Service users have the specialist equipment they require to maximise their independence. Advice and assessment would be sought from other professionals, when necessary, in order to meet the specific needs of individual service users. Service users have access to all parts of the home, some service users may need assistance from the staff to access some areas. There are grab rails and handrails in place around the home to promote and support independence. Call systems are available within each room. Storage is in short supply and some space will be created when the clinical room is operating. The Providers are aware of this and seeking to address this in future plans. Service users have sufficient and suitable lavatories and washing facilities. There are accessible toilets close to the lounge and dining areas and individual bedrooms. There are two bathrooms with assisted bathing facilities on the ground floor. All rooms have wash hand basins. Rooms appeared comfortable and furnished to meet the needs and preferences of the service users. Adjustable beds are provided for service users receiving nursing care. Rooms are carpeted; and the Registered Providers are in the process of replacing carpets that are showing signs of wear. Screening is provided in the shared rooms to afford privacy. Service users are able to personalise their rooms and this was evident in many of the rooms inspected. New sink vanity units are provided and these are popular with the Service Users. A lockable space is provided in all rooms, however no room have a lockable door. A door lock should be fitted to all private accommodation, which is accessible to staff in emergencies, unless the risk assessment suggests otherwise. The Registered Provider has commenced a programme of installing hot water thermostats throughout the home (total immersion areas, such as baths, have already been completed). The Inspector reiterated the requirement for areas that have been identified as high risk to be regulated, based upon risk assessments that have been completed. A monthly check of temperatures within the home indicated that some of the temperatures that were regulated were above the 43 degrees. The Deputy Manager planned to discuss this with the Maintenance person. Advice should be sought from the Environmental Health Officer, in relation to hot water, if the Providers have any uncertainty. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 The Service Users needs are met by the numbers and skills of the staff group. EVIDENCE: On the morning of the unannounced inspection, there were twenty-eight Service Users with two qualified nurses, five care staff, one housekeeper, cook with assistant and maintenance staff on duty. There would be only one qualified nurse on at the weekends. On the afternoon shift, there is one nurse and four carers, whilst at night there is one nurse and two carers. Service users needs appeared to be met by the numbers and skill mix of staff. A staff rota is available within the home that demonstrated which staff are on duty at all times of the day. No staff are employed under the age of eighteen years of age and there is a qualified nurse on duty at all times. There are designated catering, housekeeping and laundry staff, although some undertake several roles. All staff have been provided with a General Social Care Code of Practice as recommended at the last inspection. The Service Users informed that the staff are ‘kind’, ‘excellent’ and ‘fun’. The comments were, without exception, were very positive. As the registered manager was not on duty on the day of the Unannounced Inspection it was not possible to clarify the records that are being kept of interviews. The need to provide more detailed information that was available for inspection was discussed with the Deputy Manager. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 20 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, 35 & 37 There is clear leadership in this home and it is run in the best interests of the Service Users. However there are several ongoing issues that require action. EVIDENCE: Feedback is actively sought from service users and their representatives about the services provided to them. This is undertaken through service user questionnaires, which can be submitted anonymously. Service user and relative meetings are held regularly. As part of the annual development plan and quality monitoring. Since this inspection the registered manager has compiled a summary of the findings and a copy has been sent to the Commission for Social Care Inspection. This must be made available to all Service Users. The views of other stakeholders must also be gathered. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 21 The Inspector was informed that the contact details of the health and safety executive and environmental health department is displayed, following a recommendation at the last inspection. The Registered Manager is a Registered General Nurse with considerable general nursing experience and previous management experience. She has achieved her National Vocational Qualification Level 4 in management and her Deputy Manager is currently studying for this qualification. It was evident to the Inspector that there is clear leadership within the home. The Registered Manager ensures an open, positive and inclusive atmosphere. This was confirmed by the very positive comments from service users, visitors and staff. There are regular staff meetings where staff stated they are encouraged to contribute new ideas. The Registered Providers visit the home regularly as part of the management team. The Registered Providers shall supply a report to the Commission for Social Care Inspection following a monthly visit, which complies with Regulation 26 of the Care Homes Regulations 2001. The home uses a corporate set of Policies and Procedures, the Deputy Manager and Inspector discussed how these must reflect the reality in the home. The importance of informing the Commission for Social Care Inspection of anything under Regulation 37 was also discussed. Service users are encouraged to control their own affairs where possible, but the home holds money on behalf of most of the service users. Accurate records are kept regarding all transactions and accounts are kept separately. The Registered Manager does not act as appointee for any of the service users. A spot check of a service users account tallied with the records. There is a safe for the safe keeping of Service Users valuables and all rooms are provided with a lockable space. The Administrator and Inspector discussed the importance of providing a receipt for any items deposited. Records that are required by regulation to be maintained on behalf of service users are kept up to date and secure. Service users have access to their records if they so wish. There is a Visitor’s Book. Data Protection legislation was discussed in relation to a ‘Communication Book’, the Deputy Manager stated she would resolve this. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 X 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 4 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X 3 3 3 X 2 X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 X 3 X Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5 Requirement The Registered Provider is required to ensure that all Service Users are provided with a statement of terms and conditions between the home and the Service User. The Registered Manager is required to enable Service Users to make decisions with respect to the care they are to receive, taking into account their wishes and feelings. The Registered Manager shall be making arrangements by training staff and other measures prevent Service Users being harmed or suffering abuse or being placed at risk of harm or abuse. The Registered Provider shall make arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of the Service Users e.g. door locks. Door keys should be provided unless the risk assessment suggests otherwise. The programme of fitting hot DS0000055098.V277227.R01.S.doc Timescale for action 01/07/06 2. OP11 12 01/07/06 3. OP18 13(6) 01/04/06 4. OP24 12(4a) 13(4) 01/07/06 5. OP25 13 01/04/06 Page 24 Beech Lawn Version 5.1 6. OP31 26 water thermostats must be determined by the findings of risk-assessments that take into account the individual service user and the service users room. This requirement is carried over from the previous inspection. Previous timescale not met 01/11/05 The Registered Providers shall supply a report to the Commission for Social Care Inspection following a monthly visit, which complies with Regulation 26 of the Care Homes Regulations 2001. 07/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP2 OP3 OP7 OP15 OP15 Good Practice Recommendations For the contract of terms and conditions to include the room to be occupied. For the Pre admission information to include the information listed in National Minimum Standard (NMS) 3.3. It is recommended that the plan of care be drawn up with the Service User agreed and signed by the Service User and/or representative (if any). For the Service Users to be offered a choice of meals at lunchtime. For the cook to undertake the Intermediate Food Hygiene training. Beech Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD 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 Lawn DS0000055098.V277227.R01.S.doc Version 5.1 Page 26 - 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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