Inspection on 19/08/08 for Beech Tree House

This inspection was carried out on 19th August 2008.

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 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 Tree House 31/08/06

Beech Tree House 30/01/06

Beech Tree House 13/07/05

Beech Tree House 18/01/05

Beech Tree House 03/08/04

Beech Tree House 10/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Beech Tree House High Street Keinton Mandeville Somerton Somerset TA11 6DZ Lead Inspector Jane Poole Unannounced Inspection 10:00 19 August 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 House DS0000016082.V367927.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 House DS0000016082.V367927.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Tree House Address High Street Keinton Mandeville Somerton Somerset TA11 6DZ 01458 223369 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) Westcare (Somerset) Ltd Mrs Tracy Ann Woolfrey Care Home 16 Category(ies) of Dementia (16) registration, with number of places Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following category: Dementia (Code DE). The maximum number of service users who can be accommodated is 16. 31st August 2006 2. Date of last inspection Brief Description of the Service: Beech Tree House is a care home, providing personal care, for 16 older people with dementia care needs. Situated in the village of Keinton Mandeville, the property was built around 100 years ago and extended to accommodate 16 people. Accommodation is on the ground and first floors with the majority of bedrooms on the ground floor. There is a stair lift giving access to the first floor. The home is secure and the old house retains many of its original features, which give the home a domestic and homely feel. The house has a large, wellmaintained garden and a mini-bus is available to transport service users. The home is owned by Westcare (Somerset) Ltd and the registered manager is Tracey Woolfrey. Beech Tree House DS0000016082.V367927.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 2 star. This means the people who use this service experience GOOD quality outcomes. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. Before the inspection the manager completed an Annual Quality Assurance Assessment (AQAA.) This gave information about the homes achievements and their plans for further improvement in the coming year. 9 people living at the home, 8 members of staff and 2 health and social care professionals completed questionnaires prior to the inspection. Some of their comments have been incorporated into this report. On the day of the inspection the inspector was able to talk with people living and working at the home, tour the premises, observe care practices and view records. The following is a brief summary of the inspection findings and should be read in conjunction with the whole of the report What the service does well: Beech Tree House provides a comfortable homely environment for the people who live there. All areas are well maintained and the standard of cleanliness is good. There is a clear management structure and staff receive training appropriate to their roles. The management team works alongside care staff to offer ongoing support and guidance. Staff are well motivated and enthusiastic about their jobs. People living at the home were very complimentary about the staff and stated that they were all kind, caring and patient. Everyone felt that they were treated with respect at that any concerns raised would be listened to. Everyone who wishes to live at the home has their needs assessed to ensure that it is the right place for them. Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 6 There is ongoing monitoring of healthcare needs and the home seeks advice from professionals outside the home to ensure people receive appropriate care. What has improved since the last inspection? What they could do better: The home uses some colour coding and signage to assist people to orientate themselves around the home. The home should continue to keep up to date with best practice guidelines for environments for people who have a dementia. In two rooms the call bells could not be accessed from the beds and this should be addressed to ensure that everyone is able to summon assistance when required. There is currently only one bathroom, which is appropriate to the needs of the people who live at the home. There are plans to make a shower room to give people greater choice but this has not yet been actioned. Care plans would benefit from being further developed to give clear guidelines for staff and to ensure that people receive care in their chosen and required manner. Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 7 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 House DS0000016082.V367927.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Anyone wishing to move into Beech Tree House has their needs assessed and has an opportunity to visit the home to ensure that it meets their needs and expectations. Intermediate care is not provided. EVIDENCE: The home has an up to date Statement of Purpose and Service User Guide. These accurately reflect the services offered by the home and what is included in the basic fee. All 9 people living at the home who completed a questionnaire stated that they had received a contract. Everyone answered YES to the question ‘Did you Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 10 receive enough information about this home before you moved in so that you could decide if it was the right place for you?’ The home sees and assesses anyone wishing to move into the home to ensure that it is able to meet their needs. The manager gave evidence that the needs of the existing people living at the home are also considered to make sure that anyone new is compatible with the people who already live there. The inspector saw copies of pre admission assessments in personal files. Prospective residents and their representatives are able to visit the home before making any decision about moving in. The contract of residence states that the first 4 weeks of a persons stay are a trial period for both the home and the new resident. Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 11 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. Physical and mental healthcare needs are monitored and people access outside professionals according to their individual need. People living at the home are treated with respect. EVIDENCE: Everyone living at the home has a care plan and the inspector viewed a sample of 5. All contained a care plan based on the activities of daily life. These gave basic details about the persons’ abilities and needs and were personal to the individual. They did not always give clear instructions for staff to follow. For example one said that the person required the assistance of one carer to help with dressing but did not elaborate on what the assistance needed was. However when speaking to care staff it was evident that staff had an excellent knowledge of each individual and communication in the home was very good. Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 12 There was evidence that care plans are discussed with each person living at the home on a monthly basis. There are good relationships with local healthcare professionals and there is evidence that the home seeks re-assessments when they feel that they can no longer meet a persons needs. Health and social care professionals who completed questionnaires answered ALWAYS to the question ‘Does the care service seek advice and act upon it to manage and improve individuals healthcare needs?’ The home keeps daily records that include the fluid intake of each person to ensure that people at risk of de-hydration are monitored. The inspector observed that people living at the home were offered hot and cold drinks throughout the day. Assessments in respect of nutrition, pressure damage and moving and handling were seen in personal files. People living at the home who completed questionnaires answered ALWAYS to the question ‘Do you receive the medical support you need?’ One person commented that staff are always willing to take people to appointments outside the home if family are not available to do so. All appointments are recorded, these show that people have access to a range of healthcare professionals. People spoken with during the inspection said that a chiropodist, nurse and optician visit the home on a regular basis and that the doctor is always called if they are unwell. On the day of the inspection a doctor was called for a person who was exhibiting behaviour that may have indicated that they were in discomfort or pain. One health and social care professional wrote “As a team we are all very happy with the home and the standard of care that it delivers.” All staff at the home have received training in the safe administration of medication. The home uses a Monitored Dosage System (MDS) for medicines. Currently no one living at the home administers their own medication. The Medication Administration Records (MARs) were viewed. These were clearly signed when received into the home and when administered or refused, which gives a clear audit trail. It was noted that some hand written entries on the MARs had not been signed and witnessed which is good practice to minimise the risk of human error when writing out prescriptions. There were no personal protocols in place for medication that is prescribed on a PRN (as required) basis. Two entries seen stated ‘for agitation’ There was no description of how each person may display agitation or at what stage the Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 13 medication should be given. This is particularly important for people who may be unable to ask for additional medication or express their needs verbally. Throughout the day it was observed that people were spoken to in a kind manner and that privacy and dignity was respected. The inspector saw that staff knocked on bedroom doors before entering and that assistance was given in a discreet and sensitive manner. Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 14 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. The quality of food in the home is good and there is a varied menu. Activities are being expanded upon to ensure that everyone receives adequate social stimulation. EVIDENCE: In the last 12 months the home has focussed on improving the activities available to people. Returned questionnaires showed a mixed response to the question “Are there activities arranged that you can take part in?” 6 people answered ALWAYS, 2 said USUALLY and 1 person said SOMETIMES. One person commented “activities have improved in recent months.” People spoken to on the day of the inspection were generally happy with the social stimulation in the home. People said that there were trips out in the good weather and that staff assisted them with games and puzzles. Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 15 Reminiscence sessions have been introduced and there is a monthly trip out for those who wish to go. One person said that they had recently been to some lovely gardens and another said that they had been out to a shopping village nearby. The manager said that they are hoping to introduce a ‘night owl club’ in the evening, which will ensure that there are always activities available for people who like to go to bed late or get up in the night. Local church representatives visit the home regularly and there are monthly Church of England and Roman Catholic services. These services are open to all and two people spoken with said that they very much enjoyed both services. People living at the home are also encouraged to maintain their household skills and one person said that they sometimes helped in the kitchen. One member of staff said that they have plenty of time to spend with people. Throughout the day there was interaction between staff and people living at the home. Some people commented that they enjoyed the company of others and that there was “always someone to chat to.” There are no strict routines in the home. People said “you can do what you like within reason.” People said that they could have visitors whenever they liked and friends and relatives were always made welcome. Everyone asked was happy with the food in the home. There is a four-week menu that gives a variety of meals and uses fresh seasonal vegetables. The days’ menu is displayed in the dining room. There is always a choice of two meals with one being a vegetarian option. The inspector observed the main meal of the day. Food was well presented, portions were ample and everyone was offered extra helpings. People said that drinks were always available and this was observed during the day. Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 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. 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 living at the home are comfortable to raise concerns and feel that any worries would be listened to. EVIDENCE: The home has policies and procedures on recognising and reporting abuse, making a complaint and whistle blowing. Currently the whistle blowing policy does not give details of how to contact the Commission for Social Care Inspection (CSCI.) This was pointed out to the manager who gave assurances that this would be added. No complaints have been received by the home or the CSCI since the last inspection. Some people who completed the homes recent quality assurance questionnaires said that they did not know how to make a complaint. As a response to this the manager has written to people and sent out copies of the procedure. All staff who completed questionnaires said that they knew what to do if someone living at the home or their advocate had concerns about the home. Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 17 Staff working at the home have received training in the protection of vulnerable adults and those spoken with had a clear understanding of issues of abuse. Both health and social care professionals who completed questionnaires answered ALWAYS to the question ‘Has the care service responded appropriately if you or the person using the service has raised concerns about their care?’ One person wrote “any concerns have been appropriately communicated and dealt with.” People living at the home have unrestricted access to all communal areas and their personal rooms. Everyone appeared comfortable and relaxed. People said that ‘you could always talk to a member of staff if you were unhappy or concerned about anything’. One person said “anything you want you just have to ask and they are always willing to help.” Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 18 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, 20, 21, 22, 24 & 25. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All areas of the home are comfortably furnished in domestic style. Standards of cleanliness are good. The home would benefit from addition bathroom facilities to give people greater choice. EVIDENCE: Beech Tree House is a large older style house that has been extended to provide accommodation for up to 16 people. All areas are fitted with a fire detection and call bell system. Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 19 All communal areas of the home are on the ground floor and are accessible to people with all levels of mobility. There are two lounges and a dining room. There is a pleasant well-kept garden that can be accessed from one of the lounges. The carpet in the main lounge is heavily patterned. This is not in line with current best practice for people with a dementia and one person was observed continually bending down to ‘pick’ at the carpet. There is some signage in the home. Personal accommodation is arranged over two floors with the majority of rooms being on the ground floor. There are 14 single bedrooms and one double. 12 rooms have en-suite toilet facilities. Bedroom doors are colour coded to assist people to identify their personal rooms. A sample of bedrooms was viewed and all seen had been personalised to reflect the tastes of the individual. In two rooms the call bell pull cord could not be reached from the bed. Two rooms seen did not have lamps bedside the bed and this was rectified before the end of the inspection. There is one assisted bathroom in the home and this is located on the ground floor. Other bathrooms in the home have not been adapted to meet the needs of the people who live at the home. There is no assisted bathing or showering facility on the first floor meaning that people have to come downstairs to use the bath. At the last inspection in July 2006 it was stated that the home were planning to turn one bathroom into a level access shower to give people greater choice. This work has not been carried out and the homes Annual Quality Assurance Assessment states that this is a planned improvement to be completed in the next twelve months. Since the last inspection electric storage heaters have been covered to minimise the risks of scolding. The laundry for the home is located on the ground floor and is also used as storage for records. The laundry is adequate for the current needs of the home. There are suitable hand-washing facilities around the home and protective gloves and aprons. Risk assessments have been carried out in respect of the storage of these items. All areas seen by the inspector were clean and fresh on the day of the inspection. People spoken with were happy with the accommodation provided. Everyone who completed a questionnaire answered ALWAYS to the question ‘Is the home clean and fresh?’ Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 20 Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. An appropriately trained and well-motivated staff team supports people living at the home. The robust recruitment procedure minimises the risks of abuse to people who live at the home. EVIDENCE: 8 members of staff completed questionnaires before the inspection. Their answers and comments demonstrated a genuine commitment to providing a high standard of care and enthusiasm for their jobs. Staff observed, and spoken with, during the inspection were very enthusiastic and well motivated. All said that it was a very happy place to work and that they felt well supported by the management. People said that there was good communication in the home, which included comprehensive shift handovers, regular supervision sessions with the manager and team meetings. One person wrote “our communication is one of our strong points within the home.” Another person said “Communication between staff and management is very good.” Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 22 The home employs 9 care staff, 5 (55 ) have a National Vocational Qualification (NVQ) in care at level 2 or above. The other 4 members of staff are working towards this award. There is a comprehensive induction programme in place, which is in line with the ‘skills for care’ core standards. Staff spoken to felt that the induction that they received was very good and prepared them for working in the home. One member of staff wrote on their questionnaire “the induction was very thorough and gave me the confidence to fulfil my role as a carer.” Everyone said that they received training that was appropriate to their job. Records seen showed that people have received training in health and safety issues and other appropriate subjects including care of people who have a dementia, the protection of vulnerable adults, risk assessment and the management of aggression. Supervision records showed that all staff had been given information about the Mental Capacity Act. Everyone asked felt that there were adequate numbers of staff on duty throughout the day and night. People said that additional staff had been made available when people had been unwell and required extra support. The recruitment records of the four most recently employed members of staff were viewed. These demonstrated a robust recruitment procedure that minimises the risks of abuse to people living at the home. Appropriate checks had been carried out and written references obtained before the person began work. The manager has recently begun to involve people living at the home in the selection of staff and is looking at ways to develop this further. People living at the home were very complimentary about the staff who worked with them. Comments included “staff are positive, they always have time and patience to talk to people” and “they make you feel at home.” One person wrote on their questionnaire “all the staff are patient and caring.” One health and social care professional wrote “The staff have an excellent manner and liaise appropriately with my team.” Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed and there is a commitment to ongoing improvement. EVIDENCE: The registered manager of the home is Tracey Woolfrey who has worked at the home for 8 years and is currently undertaking a National Vocational Qualification in care at level 4. In addition to the registered manager there is also a deputy who takes responsibility for the home in the absence of the manager. The manager and Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 24 deputy work alongside other staff to offer ongoing support and guidance. Formal supervision and appraisal sessions are also carried out. The manager was available throughout the inspection and was able to demonstrate an excellent knowledge of staff and people living at the home. The inspector noted that everyone appeared very relaxed and comfortable with the manager. People said that the management in the home was very approachable and always ready to ‘get involved.’ Prior to the inspection the manager completed an Annual Quality Assurance Assessment (AQAA). This demonstrated a commitment to listening to the views of people and to ongoing improvement. The home has various ways to monitor the quality of care and seek the views of people using the service. There are regular staff meetings and minutes of these showed that a wide variety of issues are discussed. Six monthly questionnaires are sent out to all interested parties and the results of these are collated and action taken to address any issues raised. The inspector viewed the most recently returned questionnaires and noted that these showed a high level of satisfaction with the service. The home does not act as a financial appointee or power of attorney for anyone. They do not hold money on behalf of anyone living at the home. Any items or services above the basic cost are invoiced with the monthly bills. All areas of the home are well maintained and staff have received training in health and safety issues. The stair carpet is becoming worn and may potentially pose a trip hazard. This is highlighted in the AQAA and will be replaced in the next 12 months. The fire detection system is regularly serviced and tested on a weekly basis. All lifting equipment is serviced by outside contractors and all portable electrical appliances are tested on an annual basis. All accidents in the home are recorded and these are analysed on a monthly basis to ensure that action is taken where appropriate. Up to date certificates of insurance and registration are displayed. Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 25 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 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 2 2 x 3 x 3 STAFFING Standard No Score 27 3 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x N/A 3 x 3 Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action 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 OP22 OP7 OP9 OP9 OP22 Good Practice Recommendations The manager should ensure that bathrooms are appropriate to the needs of service users. Recommendation made at last inspection. Care plans should be further developed to ensure that there are clear guidelines for staff to follow. All hand written entries on medication administration records should be signed and witnessed. There should be individual protocols in place for the use of ‘as required’ medication to ensure that this is administered in line with individual needs. The manager should ensure that call bells are accessible to enable people to summon assistance. Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beech Tree House DS0000016082.V367927.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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