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Inspection on 05/07/05 for Beech Spinney

Also see our care home review for Beech Spinney for more information

This inspection was carried out on 5th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Honeysuckle House provides a high standard of accommodation designed to meet the needs of people with complex personal care and support needs. Care plans are written in a way that reflects that service users are treated as individuals and needs and preferences are recorded to enable continuity of care. The atmosphere at the time of the inspection was relaxed and service users were seen to be accessing a full programme of activities throughout the day with appropriate support. All activities had been planned. Family links are valued by service users, family members and staff.

What has improved since the last inspection?

Since the time of the last inspection significant improvements were seen to have been made. The care plans contained all information requested at random by the inspector and support plans for meal times had been developed in consultation with the speech and language therapist. The district nurse had also offered input into support plans. Plans are now signed by the manager of the home and appropriate health care specialists. Staff confirm that they have read and understood them. Policies and procedures in respect of the administration of medication have also been developed and implemented, again with appropriate support. All staff, relatives and health care specialists spoken to on the day of the inspection noted that improvements to the service provision have been made. It was positive to note that the home is benefiting from a full complement of staff and an acting manager who is enthusiastic and very well respected by staff and relatives. It is evident that minimum staffing levels are currently being maintained however feedback into the inspection identifies that not everyone considers that there is always sufficient staff on duty. This situation is being reviewed by the manager who is also looking at numbers of staff working on waking night duty.

What the care home could do better:

From discussions with staff it is evident that they have received training in a variety of subjects. It is now essential that this learning be developed in practice. The manager recognised this need and, in discussions, demonstrated his understanding of the importance of applying new skills to everyday situations. The manager spoke of a holistic approach to supporting people and this would benefit service users. The home must continue to develop effective monitoring and recording procedures within the home and have available all required information on site in order to effectively manage the service. The inspector would like to thank everyone who contributed to, and participated in, this inspection.

CARE HOME ADULTS 18-65 Beech Spinney Ironbridge Telford Shropshire TF8 7NE Lead Inspector Sue Woods Announced 5 July 2005 9.30 am th 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Beech Spinney Address Ironbridge, Telford, Shropshire, TF8 7NE Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01952 432065 01952 432209 CARE (Cottage and Rural Enterprises Ltd) Care Home 7 Category(ies) of Learning Disability (7) registration, with number of places Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Pre-admission assessments must be undertaken on all individuals admitted to the home. 2. An Occupational Therapist report must be produced and forwarded to the Commission within six months from the date of registration. 3. All service users must have a Person Centered Plan initiated within three months from the date of registration. 4. There must be a minimum of three care staff on duty from 7 am - 10 pm in the five-bedded residential unit and two staff in the respite unit. 5. There must be a minimum of two waking staff on duty throughout the night and format on-call arrangements in case of emergency. 6. All new staff must complete the LDAF induction. LDAF foundation training must commence/continue at the earliest opportunity. 7. Service users on respite/emergency placements and those in long term placements must occupy separate premises including day space, facilities and equipment, unless benefits for both groups can be demonstrated. Date of last inspection 26th April 2005 Brief Description of the Service: Beech Spinney is registered with the CSCI as a residential Care Home for a maximum of seven adults with learning disabilities and additional complex needs. The registration consists of a five bedroomed house for five people and an adjoining two bedroomed respite facility. Although not yet operational the respite home (Thistle Lodge) will have a dedicated staff team and will run independantly from Honeysuckle House. All bedrooms have spacious en suite bathrooms and have access (via a tracking hoist if required) to large assisted bathing and showering facilities. Communal space at Honeysuckle House comprises of a large kitchen, dining room and lounge. The gardens are landscaped and easily accessible. Beech Spinney also has use of a resource centre which boasts an indoor pool and a fully equiped sensory room. Beech Spinney is owned by Cottage and Rural Enterprises Ironbridge. The responsible individual is Mr Michael Keighley. Mr Barry Lord is acting manager until the recruitment process for a permanent manager is completed. This arrangement has been agreed with CSCI and will be reviewed in August 2005. Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Beech Spinney took place over a full day and involved the inspector speaking with service users, staff, the manager and two visitors to the home on that day. The manager, deputy manager and a senior care worker were available all day and took an active part in the process. Feedback was received from five health and social care professionals and three written correspondence from relatives. The inspector also viewed care plans, staffing files and other records pertinent to the running of the home. What the service does well: What has improved since the last inspection? Since the time of the last inspection significant improvements were seen to have been made. The care plans contained all information requested at random by the inspector and support plans for meal times had been developed in consultation with the speech and language therapist. The district nurse had also offered input into support plans. Plans are now signed by the manager of the home and appropriate health care specialists. Staff confirm that they have read and understood them. Policies and procedures in respect of the administration of medication have also been developed and implemented, again with appropriate support. All staff, relatives and health care specialists spoken to on the day of the inspection noted that improvements to the service provision have been made. It was positive to note that the home is benefiting from a full complement of Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 6 staff and an acting manager who is enthusiastic and very well respected by staff and relatives. It is evident that minimum staffing levels are currently being maintained however feedback into the inspection identifies that not everyone considers that there is always sufficient staff on duty. This situation is being reviewed by the manager who is also looking at numbers of staff working on waking night duty. 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 Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,4 An effective introductory procedure is in place to ensure that the home will be able to meet the assessed needs of service users admitted. EVIDENCE: The manager and senior staff detailed how a service user had recently visited the respite house as part of the introductory assessment process. The manger stated that a full community care assessment had been provided and she had previously visited with her family for social visits. Input had also been received from the community nurse. It was reported that all visits had gone well and that a dedicated day staff team had been arranged to support her. This was confirmed later in discussions with the staff team. The homes statement of purpose was requested by the inspector but the manager was unable to print off a copy due to a technical error. Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 Care plans form the basis of a consistent approach to care delivery that, when followed, mean that service users receive personal care and support in the way that they prefer. Service users would benefit if communication strategies were used consistently by all staff. EVIDENCE: Care plans have been developed following multi agency input, as service users may not be able to participate fully in this process. This means that plans need to be detailed and comprehensive to ensure all staff work consistently with service users in ways that they prefer. The daily log sheets allow for continuity of care and provide the opportunity for changes to behaviours or mood to be recorded and monitored. These records were seen to be generally well completed. Feedback into the inspection process reflects that while plans and communication methods have improved service users would benefit further from all staff following programmes consistently and applying knowledge to all areas of care practice. Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 10 The inspector had the opportunity to speak in private with two relatives and both gave examples of how they have been consulted in care plans and individual needs and preferences All services users now have an allocated key worker ‘team’ and all feedback suggests that although newly implemented this process is effective and aids communication. Relatives spoken to stated that they had been introduced to key workers and receive phone calls or letters as appropriate. The support plans were seen to be very detailed and all staff that spoke with the inspector were aware of the content of them. However other support aids such as the ‘communication passports’ had not been well used by all staff and this reflects a need to ensure consistency. A speech and language specialist is currently working with staff and service users to develop communication aids and is also offering supporting training. All staff questioned stated that they valued this input. Staff detailed how they support service users to make informed choices about what they eat and what clothes they wear. Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,15,17 Service users lead full and active lives with numerous opportunities to access community resources. Family contact is encouraged and supported by the home enabling service users to maintain and enhance the relationships that they value. Detailed support plans for eating allow service user to receive appropriate and safe support to enjoy meals. EVIDENCE: The majority of the standards in this section were reviewed at the time of the unannounced inspection of the home on 26th April however since that time significant improvements have been made to ensure that activities are planned and carried out. There is an activity wall planner in the office that was referenced by staff throughout the day of the inspection which details a full daytime programme of activates for the week. Staff record what activities take place in the daily records and the manager commented that since the planner has been implemented activities are more likely to happen as staff have time Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 12 to plan and prepare fully. Certainly through observations on the day of the inspection service users were out the majority of the day with appropriate support, undertaking individual and small group activities. Relatives who spoke with the inspector said that they were made to feel welcome to visit at any time. One service user took his mom out for a meal on mother’s day. Staff support service users to send birthday cards and maintain contact with family members. Due to the complex needs of the service user lists of foods that can and cannot be eaten provide essential information. It was positive to note that favourites are also detailed. The lunch observed by the inspector was a relaxed social occasion. Service users use adapted cutlery to enable them to maintain independence where possible and staff, who spoke with the inspector were aware of eating and swallowing plans. Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Systems and plans in place to support service users enable them to receive the support they require in a way that they prefer. Detailed protocols allow staff to safely administer medication EVIDENCE: Support plans were seen to be very detailed and comprehensive. Care plans detailed individual needs and preferences. All plans are subject to regular review. In order to improve service provision staff must now work with health care specialists to implement all plans. It is positive to note that staff were enthusiastic to do this. Please see requirement for standard 6. Protocols for the administration of medication were seen for all service users requiring one. They had been developed in consultation with the community nurse and protocols for the administration of medications taken ‘as required’ had additionally been signed by the consultant psychiatrist. Care plans detailed how service users should be moved and a manual handling risk assessment was reviewed for one service user. The assessment had been carried out by the manager with input from the community physiotherapist. Records demonstrated that plans had been signed as read and understood by Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 14 all staff. Only senior staff had signed the PRN medication protocol, as they were the only ones to administer such medication. Medical appointments are maintained on each file. Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 The home has an effective complaints and whistle blowing procedure that allows complaints and concerns to be dealt with and appropriate actions taken. Service users finances may not be appropriately safeguarded, as the manager does not have all required information. The records do not allow for a clear audit trail. EVIDENCE: There have been two complaints about the service offered at Beech Spinney. The manager discussed one complaint in detail. He was positive about the actions taken as a result and was open to people identifying needs of the service. Staff stated that they had attended training in the protection of vulnerable adults although as certificates were not available the inspector could not establish who the training provider or when the training took place. A requirement relating to training records will be made in a later section of this report. Given the communication needs of service users living at Beech Spinney the manager has identified with Telford and Wrekin’s quality review team the need for advocates to be identified, possibly via the ‘Taking Part’ group to assist service users with decision making. A further meeting to discuss this will be held on 25th July 2005. Records seen for service users finances contained details of transactions within individual accounts. The manger is to review the receipt of personal allowances to ensure service users are receiving their full entitlement. This could not be Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 16 established upon review of the bank statements. The manager felt that safeguards with signatures were effective. The balance in one service user’s tin identified at random corresponded with the record of how much should be in there. Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 Honeysuckle House is purpose built to support people with high support needs and thus offers a high standard of accommodation tailored to meet the needs of the service users living there. Appropriate safety checks ensure that the environment is safe for service users. EVIDENCE: The majority of the standards in this section were reviewed at the time of the unannounced inspection of the home on 26th April. Beech Spinney is purpose build to accommodate people with physical disabilities thus tracking hoists and assisted facilities are fitted throughout. Beech Spinney employs a maintenance worker to attend to all on site jobs, including the maintenance of the hydrotherapy pool at The Dingle. He spoke with the inspector and detailed how he prioritises tasks and takes responsibility for the checking and recording of fire fighting equipment and water temperatures. Staff and relatives stated that service users enjoy access to all areas of the home. Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 18 The pre inspection questionnaire recorded that the fire officer last visited in February 2005 and requirements made were actioned. Likewise this documents details that all other maintenance checks are up to date. Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,34,35,36 Service users may not be adequately safeguarded, as all essential information relating to staff is not available. Minimum staffing levels and added flexibility means that service users have better opportunities to follow their individualised plans. Regular reviews and risk assessments will ensure that this standard is maintained. Staff training records were not available to demonstrate that staff are suitably and appropriately trained to meet individual needs. EVIDENCE: Conditions of registration identify that there must be a minimum of three staff on duty at all times. Following review of the last two weeks rotas and through discussions with the manager and the staff it is evident that these levels are now maintained and exceeded at key times of the day. Staffing levels must remain under review and the manager is required to carry out a risk assessment to support the number of waking night staff on duty given that one service user regularly requires the support of two staff and other service users have identified health care needs. Staff who spoke with the inspector were committed to their roles and were enthusiastic about how the service was developing. Staff spoke about Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 20 numerous training opportunities however there was a lack of documentary evidence that training takes place. The manger stated that CARE’s training coordinator currently retains these but acknowledged that they should be with the staff files. Not all staff had received communication and swallowing training. It was noted that a number of staff recruited to the role did not have previous experience in care work therefore training is vital. The inspector was unable to review the staff training plan for new staff but was encouraged to see via certificates, that formal LDAF induction is now taking place. Through discussions with staff it was confirmed that formal, regular and recorded supervision is now taking place. Staff also spoke of staff meetings and the introduction of key worker group meetings. Staff files were seen to be well organised but, in some instances lacked essential information. It was stated that current manual handling training does not instruct staff as to how to use wheelchairs safely while making the service user feel safe. The manager committed to research future training to cover this issue. There is evidence that staff are aware of the whistle blowing procedure and are confident to use it appropriately. Three of the four staff files reviewed documented that they had received a CRB check prior to their start date. The manager stated that the fourth staff member would not have worked with service users until the CRB had been returned (one week later). Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,39,41,42,43 The enthusiasm and commitment of the acting manager has led to improvements in processes and has positively impacted upon the staff team. As a result service users are receiving a better service. The development of policies and procedures has led to safer practices in relation to the administration of medication and the use of bed rails. The organisation could better support the manager to be more effective by giving him appropriate and up to date information in relation to finances and budgets and by carrying out visits (as per regulation 26) to monitor the quality of the service and offering timely feedback. By using correction fluid the home is not able to demonstrate that records are accurate and reliable as a source of evidence. The home is putting its registration at risk by not fully understanding or complying with the conditions imposed by CSCI. Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 22 EVIDENCE: The acting manager of the home was seen to be enthusiastic and committed. Through discussions with staff and relatives it was evident that he was well respected and supportive. The manager stated that the recruitment process to appoint a permanent manager would take place shortly. CSCI will be notified of the outcome. Records in general have improved since the time of the last inspection although staff were advised that they must not use correction fluid on official documents. The new medication policy was reviewed and found to have been produced in consultation with appropriate specialists. Staff had signed to confirm they had read it. Policies and procedures as detailed on the pre inspection questionnaire will be reviewed when the new manager is appointed. Risk assessments required following the last inspection of the home in relation to the use of bedsides had been completed and one service user had had a new bed as a result. This reflects the homes commitment to providing a safe environment for service users. Moving and handling assessments were seen for one service user and had been developed in conjunction with the physiotherapist. The manager is not currently actively involved in setting or monitoring the budget for Beech Spinney. Information relating to the budget is thus not readily available to allow the manager to make timely decisions about spending. Monitoring sheets produced by CARE are not made readily available to the manager. Only two visits required under Regulation 26 have taken place. There were no reports available for either visit. This must be updated and implemented efficiently with timely feedback provided to the manager. Of the seven conditions of registration the inspector is satisfied that the home is meeting five. Areas requiring attention include the need for service users to have person centred plans, although it was acknowledged that this process has started. The second condition not being complied with is the need for an Occupational therapist report to be produced and forwarded to the commission within six months of registration. The manager did not understand what this condition meant. The inspector will seek clarification from the registration file. Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 4 x x x x x x Standard No 11 12 13 14 15 16 17 x x x 3 4 3 3 Standard No 31 32 33 34 35 36 Score x 2 x 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beech Spinney Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 3 x 2 3 2 v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 24 yes Are there any outstanding requirements from the last inspection? 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 37 Regulation 8(1&2) Requirement The home must appoint a permanent manager and that person must apply for registration with CSCI Staff must be aware of and use communication strategies developed for individual service users Timescale for action 18/08/05 2. 6 12(1&3) 13(1b) 27/07/05 3. 23 17(2) Sch 4 As the manager is appointee for 18/08/05 all service users he must develop and implement a system of monitoring service users monies Staffing levels must be reviewed via risk assessments to ensure there are sufficient staff on duty at all times Staff files must contain all information as required under Schedule 2 of the Care Homes Regulations 2001 The home must have a record (on site) of staff training needs and training completed to demonstrate staff are qualified and competent 03/08/05 4. 32 18(1a) 5. 34 4(1c) 03/08/05 6. 35 18(1a&c) 27/07/05 Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 25 7. 8. 9. 41 43 43 17(2) 10(1) 43(1) 26 Correction fluid must not be used 20/07/05 on records within the home The home must comply with its conditions of registration 20/07/05 Unannounced monthly visits to 03/08/05 the home must be carried out by a representative of the organisation and reports must be made available to the manager and CSCi of the outcomes of that visit RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Beech Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn SHREWSBURY SY2 5DE 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 Spinney v221486 e56 s63123 beech spinney v221486 ai 050705 stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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