Inspection on 26/03/08 for Beech Tree Care Home

This inspection was carried out on 26th March 2008.

CSCI found this care home to be providing an Poor service.

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

Other inspections for this house

Beech Tree Care Home 10/08/09

Beech Tree Care Home 26/09/08

Beech Tree Care Home 26/09/07

Beech Tree Care Home 02/05/06

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

CARE HOMES FOR OLDER PEOPLE Beech Tree Care Home Sprents Lane Overton Hampshire RG25 3HX Lead Inspector Michelle Presdee Unannounced Inspection 09:30 26 March 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beech Tree Care Home DS0000066182.V359161.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 Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Tree Care Home Address Sprents Lane Overton Hampshire RG25 3HX 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) 01256 771353 01256 771336 arklelodge@schealthcare.co.uk Southern Cross Operations Limited vacant Care Home 61 Category(ies) of Old age, not falling within any other category registration, with number (61), Physical disability (12) of places Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 2007 Brief Description of the Service: Beech Tree is a care home providing personal and nursing care for up to 61 service users in the older persons category. The home is situated near to Basingstoke in the village of Overton. The home consists of a three storey building which was purpose built. There are forty-seven single rooms and seven shared rooms most of the single rooms have en-suite facilities. There is a passenger lift and a small-enclosed garden with easy access for wheelchair users. The range of fees for the home is £335.00 to £700.00 per week. There are no additional charges. Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience Poor quality outcomes. During this unannounced key inspection the deputy manager, a manager from another Southern Cross home and administrative person assisted us (the Commission). The deputy manager in the home was acting as the manager, as the manager who was about to submit an application to become registered had just resigned. We were advised the managers’ job had already been advertised and interviews had taken place. We spoke with six members of staff, two visitors and ten residents. We observed the non-verbal communication of people who had communication difficulties. We looked around the home and saw all lounges, the kitchen, the laundry, the conservatory and 10 bedrooms. The home sent us their Annual Quality Assurance Assessment (AQAA) on time. This and other paperwork seen on the day including assessments, care plans, staffing records and medication records has helped form the judgements made in this report. What the service does well: The home undertakes good assessments and includes family members in this process. Care plans hold good information and are reviewed on a regular basis. Social activities have recently been started and the activities co-ordinator is hoping to arrange individual activities as well. Visitors can visit at any time and can see their relative in private or in the communal areas of the home. Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 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 Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have accurate assessments of their needs and are confident the home can support them. EVIDENCE: Whist looking around people’s rooms it was noted all had a copy of the service user guide and statement of purpose. These detailed current information reflecting the deputy manager was currently managing the home and detailed the current charges. The home’s AQAA states that prospective service users and their families are invited to spend a day at the home and visit for lunch or other meals. A trial period is usually offered to anyone wishing to move into the home. The AQAA advised us most enquiries convert to admissions. The assessments of two residents were viewed; both resided on different floors in the home. The assessments were of the same quality and detailed good information on a Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 9 person’s overall needs. Evidence was seen that family members had been involved in the assessments. Staff spoken to stated, they worked a key worker system, which they felt worked well. All staff spoken to stated, they felt the assessments gave them a clear picture of the persons needs when they were in the home. People spoken to on the day knew who there their key workers were and most were happy with the care they received. One person stated she was “miserable and did not want to be in the home and did not always like her carers”. The person was unable to be specific. Whilst we were in the room she asked for a drink, as she was unable to reach her jug of water and juice. A member of staff came in and prepared two beakers of juice for her, which were left within her reach. The home does not provide intermediate care. Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a plan of care to meet each person’s health, personal and social care needs. Medication is managed in a safe way. Support is given in a way that maintains dignity but is not always given on time. EVIDENCE: The care plans of two residents on different floors were looked at. It was noted these detailed clear information on their needs. Information included details of risk assessments, pressure areas, dependency levels, moving and handling, nutritional assessments malnutrition risk assessments where necessary, continence assessments, personal hygiene and medication. Information was recorded of a person’s preferences, social interests and hobbies. Care plans had been reviewed on a regular basis and notes added where necessary. The importance of dating and signing care plans was discussed as Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 11 in some cases the reviews had not been dated or signed. Body maps were used to record evidence of skin flaps or pressure sores. It was agreed a new one should be used each time, as it was difficult from those seen to establish the current situation. Daily and nightly notes were maintained giving clear information. Four residents were seen who were bed bound and all had bed rails. The care plan of one of these people was seen, demonstrating a risk assessment had been completed on the bed rails. However the care plan needed to be amended to reflect the person was now unable to get out of bed unaided. It was noted fluid intake charts, turning records and nutritional intake charts were maintained. One resident who was bed bound was asked by us if he would like a drink, he nodded as was unable to talk. A member of staff was called, as he was unable to do this himself. The staff member assisted him in a caring and dignified manner and did not rush the person. Ten residents were spoken to all except one felt the carers were able to meet their needs, “lovely”, “smashing”, “we are well looked after”, “They do the best they can” were some of the comments made by them. Care staff spoken to felt they were able to meet the needs of residents, if fully staffed and adequate people were on duty. One staff member stated they would benefit from extra staff after lunch when they are busy. The majority of relative surveys received stated they felt the home met the needs of their relative. One relative spoken to stated, she felt the home had begun to recently improve in all areas. Care plans detailed information on each person’s health needs. A range of health professionals visits the home including dentist, optician, continence nurse and chiropodist. From notes seen it was possible to establish staff followed up on appointments to ensure health needs are met. If necessary the home will arrange for staff to escort residents to health appointments. The home manages all the medication in the home. Only qualified staff are involved in the medication process. The home uses a monitored dosage system, which is delivered monthly. Each of the three floors has their own medication trolley, where medication is stored. A medical room is available where residents can see professionals in private if they prefer. It was noted each trolley has a copy of the procedures, which all staff sign to say they have read and understood. Medication and records were sampled and it was noted these were accurate. Each sheet of medication contains a photograph of the resident to help avoid errors. A protocol had been drawn up for prescribe as necessary medication (PRN). The records of one person were looked at for PRN medication and it was found the protocol was being followed. It was noted weekly medication was well organised so the risk of errors were eliminated. Controlled medication was being stored appropriately and records matched the medication held. Records Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 12 had been signed appropriately. Creams were seen in several residents’ rooms these should be stored in area, which eliminates the risk of residents taking the creams. Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with some group activities but individual activities need to be arranged to meet all people’s needs. People where able can exercise choice in areas of daily living. Visitors are made welcome to the home and can visit at any time. Residents receive a well balanced diet with a choice being available but not all residents enjoy the meals. EVIDENCE: Residents spoken to confirmed social activities in the home had just improved as an activity organiser had just been employed. Prior to this, residents stated very little had happened and resident surveys reflected that there was not enough social activities happening. The new activities co-ordinator spoken to states she was looking forward to working with the residents. At the moment she stated she was providing activities twice a day, am and pm and was trying to work out with residents what they would like. It was noted on the notice board in the reception two weekly timetable of events were displayed, both having no dates, making it impossible to know what events were taking place. The timetable, which was left on the board by a member of staff, stated Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 14 painting was taking place that morning, but the activity, which took place, was musical bingo. A notice was displayed on the notice board stating the library called but this had the previous name of the home displayed on it. Holy Communion is offered in the home on a monthly basis. One resident spoken to confirmed he enjoyed reading and stated there was a selection of books to read. Residents joining in the bingo enjoyed this. Staff stated residents had taken part in an Easter Bonnet competition, which family members had been invited to. One resident stated they would like more outings, which had also been recorded in a service user survey. The activities co-ordinator did state she was hoping to arrange some individual activities. The home’s AQAA received in July 2007 stated they plan to increase the carer support and introduce ‘yesterday, today and tomorrow’ training for their staff. The deputy manager confirmed training for this has not yet taken place. Two visitors spoken to on the day confirmed they could visit at any time and were always made welcome. Residents spoken to stated their visitors could always call at any time and they had the choice to see them in their room or in the communal areas. From discussions with residents and visitors it was evident residents have choices and control over their lives. Residents were asked to join in social events but their choice was respected if they did not wish to join in. Care plans record how a person wishes to be addressed. One resident enjoyed listening to Irish music in his room. Menus are arranged on a rotating basis. The menu is displayed in the home’s attractive dining room and menus are displayed on each table. Residents spoken to confirmed a choice was always available at each mealtime. Comments about the meals were mixed, one resident stated, “the meals are not too bad” another stated, “The meals are not what I always like”. From the service user surveys one resident had ticked they always liked the meals, one resident had stated “used to be better but of late they are not presented well and do not taste good”. The cook, who was spoken with, had good records of what each person liked and disliked. Records detailed what each person had eaten on a daily basis. She stated she often spoke to the residents in the dining room and had no complaints. She advised us she would speak to each resident on an individual basis. Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People know how to complain and know their concerns will be looked into. The home safeguards people from abuse and neglect. EVIDENCE: The AQAA states all residents are issued with a copy of the complaints procedure, which is incorporated into the service user guide. All residents spoken to stated, they would have no concerns complaining to the deputy manager. Visitors and staff spoken to stated if they had any concerns they would discuss it with the deputy manager who all had confidence it would be sorted out. All residents in the surveys stated they would know how to make a complaint. Four relatives in surveys stated they knew how to make a complaint one stating, I have made a complaint and the complaint was acted upon immediately”. A file is maintained of all complaints, and copies of all complaints made to the home and what action had been taken were seen. Five complaints had been made to the home since the last inspection all had been actioned within the agreed timescales. The home had copies of a safeguarding adults procedure and prevention of abuse procedure. All policies and procedures are available to staff. Members of staff spoken to were aware of the whistle blowing procedure and what action Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 16 to take if abuse was suspected. The home has a training session booked on Adult Protection for staff on the 1st of April. Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All areas were clean and provided people with a warm and comfortable environment. Parts of the environment did have an unpleasant smell, but efforts are being made to reduce this. EVIDENCE: On the day of the inspection we were shown around all areas of the home and saw 16 residents in their own rooms. The décor and cleanliness of the home was generally good. In some areas especially on the second floor, outside of bedrooms there were some unpleasant smells. Outside of these areas there were signs to say the carpets in these rooms were being cleaned which entailed shampooing the carpets. Domestic staff spoken to stated this was done on a daily basis and it was hard keeping up with the cleaning of carpets. Some of the bedrooms seen had stained carpets. One had a join near the door, which had come loose posing a risk to residents and staff. One resident in a Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 18 survey had stated the home “usually smells”. A relative in a survey had stated, “The home needs upgrading and the smell of urine attended to”. The acting manager advised the home is due to replace all old and stained carpets. Residents spoken to on the day felt their rooms were kept clean. One resident in a survey had stated, “Beds need to be made properly”. When looking around beds had been made properly. In one room it was noticed the bed had been made with a stained pillowcase and in another room a bed had been made with a stained sheet. Residents spoken to felt there beds were made properly and all stated they were warm at night. When walking around the home it was noted one room was being redecorated. The room had been left open and was open for some time with scissors, paint and decorating equipment, which could pose a risk to residents. Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels mostly meet the needs of people but at times it can take time for call bells to be answered. People are supported by a group of staff that benefit from training. Recruitment procedures offer protection for residents. EVIDENCE: On the morning of the inspection three registered nurses were on duty with four senior carers and one care assistant. The acting manager who is a qualified nurse was also on duty. We were advised there is usually 8 care staff on duty throughout the day. Five are on duty in the evenings going down to four from midnight, all working a waking duty. Domestic staff cover the seven days, a laundress works five days and the kitchen is covered 7days a week by a cook and kitchen assistant. Care staff spoken to stated, when the home was fully staffed with no staff on sick leave or annual leave they could meet the needs of residents. Some felt recently the morale of staff had improved and they were supporting each more, others still felt morale was low. One member of staff claimed extra staff after lunch would be beneficial as this was a very busy time. From observations at times all staff were very busy and call bells took time to be answered. On two occasions it took five minutes for call bells to be Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 20 answered. One service user in a survey stated, “Call response times need to be improved”. Two relative surveys stated, “Call button response times need to be/should be improved. Another stated, “answer calls from resident quicker (much quicker)”. Staff were observed to be looking at the call bell system but were already attending another resident. Whilst walking around the home in the afternoon it was noted on two occasions one resident was shouting in her room, it took staff some time to speak to her, but when they did the resident became more settled. Residents spoken to felt the care staff worked hard and tried to meet their needs. All residents spoken to stated they had no difficulty understanding the care staff. A course of 12 English lessons has been booked for all foreign staff. We were advised over 50 of staff have achieved a National Vocational Qualification Level 2 and above. The staffing records of the last three members of staff to be employed were viewed. These contained most of the necessary paperwork and checks. For one person it was not possible to read the information on the photocopy of the birth certificate, it was agreed the person would be asked to bring another copy. For another person the professional reference had not been received but evidence was seen this had been chased up and two personal references were on file. The home keeps a good training record for all staff and certificates are kept on staff members files. All three members of staff had completed an induction, but this had been completed in one day. A requirement from the previous report was for new staff to have an induction and evidence to be kept in the home. The acting manager felt the new staff were completing the “Topps” induction programme, however no evidence could be found and only a blank copy could be found in the office. The acting manager suggested staff had taken their files home. However the six staff spoken to were unsure what the induction included and none were aware of the new files. Training in all the key areas was taking place on a regular basis. Staff spoken to felt the training was adequate to equip them to do their jobs. Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The lack of a manager creates weaknesses in the management of the home and does not ensure that it is run in the best interests of people. Finances are well managed and run in the best interests of resident’s. Health and safety practices are mainly promoted and protect residents EVIDENCE: The home has been without a registered manager since early 2006. The person who was managing the home and going to apply to become the registered manager has recently resigned. The deputy manager was managing the home on a temporary basis and explained interviews had already taken place for a new manager. The deputy manager explained she was receiving support from an operational manager and the manager from another home, who assisted Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 22 with the inspection for some time. It was clear when speaking to staff this had had a detrimental effect on them. Staff spoken to stated they received differing messages from different managers and were unsure sometimes of how to proceed. Staff also claimed at times it was difficult having an existing member of the nursing team as the manager as there was confusion over her role. Requirements regarding the management of the home will be repeated in this report. The AQAA stated the home has a monthly audit and a report is made. The manager from another home who is supporting the acting manager stated he had carried out regular audits on the home. These had demonstrated the home was not meeting their own standards, but the improvements needed had been identified and were already being improved upon. Records and staff spoken to demonstrated staff had not received regular supervision, this was a requirement made in the previous report. One person who had been in the home for nearly five months had received one supervision session. No evidence could be found that she had been supported in some of the issues she had raised during supervision. Staff spoken to on the day confirmed they had not received regular supervision. Three surveys received from relatives stated the home never keeps in touch with them. One relative stated, “Over the past few years the home has gone from private ownership and is now managed by a large company. Several managers have come and gone since the change over. I feel the general approach is now less personal”. Another relative stated, “We are not always kept informed, my relative has fallen and we have not been informed”. The home’s administrator is in charge of managing resident’s finance. She explained a new system has recently been introduced with accounts being held with Barclays bank. We were shown evidence of a clear audit trail of all money coming into the home, receipts being given and finances being banked. The records of one service user were looked at and these detailed all correct transitions with the total being correct. Staff receive training in areas of health and safety on a regular basis. The AQAA advised us two-hour sessions on fire, infection control, health and safety, abuse and protection of vulnerable adults, food awareness and nutrition and moving and handling are arranged on a regular basis. On the day it was noted one room was left unattended and open, which had decorating equipment, which could pose a risk to residents. It was also noted creams were left out in residents rooms, these should be stored in an area, which is not available for other residents to pick up. The kitchen was well organised and health and safety practices were followed. Temperatures of fridge, freezers and food were maintained. The laundry was well equipped and well organised. The laundress and domestic all staff were aware of health and safety practices. Concerns were expressed over the number of hours they had to do laundry Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 23 and domestic duties. The linen cupboard was viewed and there were only a few spare flat sheets for the air mattresses, which staff stated put pressure on the laundry staff. The fire logbook was seen, which demonstrated all necessary tests are being carried out in the agreed timescales. Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 1 X 2 Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP30 Regulation 18 Requirement Staff must receive a suitable induction programme and evidence of this must be available for inspection. This requirement was previously made on 26/9/07 and should have been achieved by 31/10/07. A manager must be appointed to manage the home. This requirement was previously made on 26/7/09 and should have been achieved by 31/11/07. All staff must receive effective and regular supervision. This requirement was previously made on 26/7/09and should have been achieved by 30/12/07. Timescale for action 01/06/08 2. OP31 8 01/07/08 3. OP36 18 01/07/08 Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beech Tree Care Home DS0000066182.V359161.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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