Inspection on 03/10/05 for Beech Trees

This inspection was carried out on 3rd October 2005.

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

The inspector 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 Trees 10/04/06

Beech Trees 23/05/05

Beech Trees 21/10/04

Beech Trees 23/06/04

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Thorndene

Insight - Eastchurch

Southfields

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

CARE HOME ADULTS 18-65 Beech Trees 1A Kirby Road Horsell Village Woking Surrey GU21 4RJ Lead Inspector Pauline Long Unannounced Inspection 3rd October 2005 10:20 Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 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 Trees DS0000055261.V255426.R01.S.doc Version 5.0 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 Adults 18-65. 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 Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beech Trees Address 1A Kirby Road Horsell Village Woking Surrey GU21 4RJ 01483 276195 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) scilla.roerookhurstcare.co.uk Brookhurst Care Limited Mrs Mai-Ling Foster Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the adults accommodated, one (1) may also fall within the category PD (physical disability). 23rd May 2005 Date of last inspection Brief Description of the Service: Beech Trees is situated in a quiet residential area of Horsell Village, a short distance by car from Woking town centre. Beech Trees is a tastefully converted older style property, which is a home for young adults with a learning disability. The home is also registered for one young adult with an associated physical disability. The accommodation consists of six individual en suite bedrooms, five of these being on the first floor and one on the ground floor. There is no lift access to the first floor. Communal areas consist of a dining room, sitting room and easily accessible kitchen and laundry room. Both the dining room and sitting room have French doors leading to a medium sized secure back garden. The home has a small area for parking at the front, but parking is available on the road outside. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the CSCI year April 2005- March 2006 and was unannounced. The inspection was carried out by one inspector and lasted for four hours. The service had a welcoming atmosphere. On the day, four of the residents were out at day activities. One resident had just returned from a weekend at home, her mother stated that, she was very happy to be back at Beechtrees. On the day, the new manager was present and had been in post for one week. The provider joined in the inspection process for a short period of time. Discussions were had with both. Documents inspected, included service users files, care plans, staff records, policies and procedures. Two members of the care staff were spoken to during the course of the inspection. One relative was spoken with and a full tour of the home and garden took place. The feedback from the residents was limited in view of their communication difficulties. CSCI would like to thank the residents and staff for their hospitality and cooperation during the inspection. What the service does well: This home presented a welcoming environment and atmosphere for the residents. The manager’s approach was very open. The manager and care staff demonstrated a good knowledge of the residents care needs and this was reflected in the wellbeing of the residents who were at the home on the day. The home is committed to ensuring that the residents maintain contact with family/friends and the local community. There are many various activities offered both in and outside the home. On the day four of the six residents were out of the home at various activities. The home should be commended on the level of activities they offer. It was observed that there are close relationships between the residents and staff. It was positive to note that the home promoted the residents skills in relation to the use of kitchen and the homes the computer and internet. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Although some of the previously made requirements had been met, the home still has to address some areas which now must be a priority for attention. Failure to comply with these may result in CSCI seeking legal advice, if these continue to remain unmet. The homes certificate of registration was not displayed correctly. The registration certificate must be displayed in its entirety. None of the resident’s contracts of care service provided were signed. To ensure the healthy, safety and protection of residents, all resident’s contracts must be signed by the resident or their representative. The care staff did not follow the homes medication procedures. To ensure that the resident’s health safety and well-being is protected, all of the staff must follow the homes medication policies and procedures. Not all of the staff have received formal Adult Abuse training. To ensure the protection of residents all staff including the manager must receive Protection of Vulnerable Abuse training. Staff were not following the homes policies and procedures regarding residents financial protection. In order to ensure that residents are protected from abuse, all staff must follow the home’s procedures regarding resident’s finances. The overall cleanliness and decoration in the home was poor. In order to ensure the health, safety and well-being of the residents attention must be paid, to ensure that all areas of the home are kept clean and well decorated. The sealant in the bathrooms and shower areas was cracked and coming away from the walls. In order to ensure the safety of the residents, the sealant around the baths and showers must be replaced. The overhead light and lamp in the sitting room were not working. In order to ensure the safety of the residents, the lighting in the sitting room must be repaired. The bulbs were replaced before the inspection concluded. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 7 Various liquid soaps are kept in the bathrooms, washing up liquid was easily accessible in the kitchen. In order to ensure the health and safety of the residents, these cleaning materials must be stored in accordance with the (COSHH ) Control of Substances Hazardous to Health. Care staff are not receiving the required number of formal one to one supervisions. In order to ensure that residents are protected from abuse, all staff must receive the required six formal one to one supervisions per year. The home has not developed a service user questionnaire. In order to ensure that resident’s and others views can be sought, the home must develop and implement a service user questionnaire. Clear and up to date records are not kept in respect of health and safety and resident’s finances. In order to ensure the health, safety and protection of residents from abuse, record keeping in these areas must be improved. There is no wheelchair access to the garden. In order to ensure that the needs of wheelchair users are met, a ramp must be fitted to the outside of one of the garden doors. Requirements have been made in these areas. Please refer to pages 27 and 28 of this report 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 Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 2,3,4,5. Care needs assessments are in place. The arrangements in place for prospective residents to “ test drive” the home are good. Resident’s contracts are in place, but not signed by a resident or their representative. EVIDENCE: No new residents have been admitted since the last inspection. Each resident had an assessment of needs, which, in the first instance was carried out by the registered provider and the manager at the home. All aspects of daily living needs were assessed, indicating that the manager and care staff would be fully aware of individual residents care needs. There was evidence to suggest that a social services, community care assessment had been sought for social services referrals. One relative stated that, she was very happy with the care, the food was excellent and the staff are very nice. However she felt that her daughter was not having enough activities and was spending a lot of time in her bedroom. This was brought to the attention of the manager on the day, and she gave a satisfactory explanation as to reason why. Each prospective resident is offered the opportunity for several visits to the home prior to a trial assessment period. These periods range from a lunchtime visit, to a weekend stay. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 10 The residents files sampled on the day had a detailed contract in place. This was presented in a clear and easily read format. However it was disappointing to note of the contracts were not signed by either a resident or their representative. A requirement has been made in this respect. Please refer to pages 27 and 28 of this report. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 6,7,8,9. The staff had a good understanding of the resident’s needs and choices, these were well met. Residents were enabled to make decisions and take appropriate risks. Service users and their representatives are consulted at times. Information on residents is stored securely and confidentially. EVIDENCE: All of the residents had comprehensive care plans. The care plans sampled, identified the tasks to be undertaken and gave an insight into the personal and health care needs of the resident’s. The care staff complete a monthly evaluation / review form on each resident. It was pleasing to note, that in the short period of time since the manager started she already had a good insight into the residents needs. On the day of inspection, residents were observed being enabled to make choices safely. Risk assessments are in place, some had been reviewed. Staff were at hand to offer support and supervision to residents, whilst also being mindful of residents choice. The staff provided guidance to residents with regard to making lunch, their facial expressions and body language Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 12 indicating that they understood and were happy to help with the lunch. One resident indicated agreement by giving a “thumbs up” sign The home does not hold regular residents meetings, however one relative stated that, the home keeps in regular contact with them and that they are invited to review meetings. A requirement has been made in these areas. Please refer to pages 27 and 28 of this report. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 11,12,13,15, The staff enable the residents to maintain fulfilling lifestyles in and outside the home. The home promotes contact with family, friends and the local community. EVIDENCE: The residents at Beech Trees are not in paid employment. They do however go to many and various day activities, this was pleasing to note. Whilst the staff accompany them to these various activities, they are enabled to have a degree of independence, and the opportunity to meet with other people outside the home. On the day two residents had just returned from a line dancing class which, according to staff they enjoyed. The routines in the home are times determined only by the timings of the visits to and from day’s activities. The care staff stated, that the residents are encouraged to carry out some of the domestic tasks around the home and to help with the shopping and the cooking as appropriate. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 14 The residents in the home on the day were observed moving around the home with out restriction. One relative stated that she can turn up at the home with out prior notice and is always welcomed. The home is committed to ensuring that the residents maintain their relationships with their family and friends. On the day of the inspection one resident had just returned from a weekend at home with her family. Her mother stated that she enjoyed being at home, but loved to return to Beechtrees. Her body language and facial expressions indicated that she was happy. All of the residents receive regular visitors. Many of the families keep contact by phone. Residents are supported to use the Internet connection within the home. There were photographs around the home from previous activities and trips, the photographs reflected smiling faces, which indicated enjoyment. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 18,19,20. The staff had a good understanding of the residents support needs. This was evident from the positive interactions and relationships observed. The health needs of the residents were well met. Medication procedures were not followed. EVIDENCE: Care plans included clear guidelines on any support each resident required with personal and health care. Physical and emotional needs of the residents were also detailed in the care plans and daily records, which included visits to the doctor, dietician, dentist and reviews of care. The home has a clear medication system. All of the care staff on duty were conversant with the policies and procedures regarding medication. However on the day these procedures were not followed. All of the medication record sheets were checked and were not properly completed some staff signatures were missing. All of the medication record sheets had an up to date photograph of each resident. None of the residents in home administers their own medication. There were records with regard to resident’s activities and care given being. Each resident had a personal journal, in which the general activities of daily living in the home were recorded. The manager stated that, she was going to Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 16 review all of the paperwork and the process for recording aspects of daily living. A requirement has been made with regard to medication. Please refer to pages 27 and 28 of this report. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 17 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 the following standard(s): 22,23. The home has satisfactory policies and procedures in place for dealing with concerns, complaints and the protection of the residents. EVIDENCE: CSCI has received no complaints about this home since the last inspection. The home has received some complaints since the last inspection and there was evidence to suggest that they had been dealt with satisfactorily. One relative stated that she had received a copy of the complaints procedure, however if she had any concerns then they would be discussed with the staff. All of the residents are allocated key-workers. The manager and care staff stated “if the residents were unhappy with anything this would be communicated by body language, behaviour or facial expression if they were not able to verbalise their concerns”. There have been two referrals under the Protection of Vulnerable Adults Procedures (POVA). Investigations have taken place and to date they are ongoing. The new manager was aware of the Surrey Multi Agency Abuse Procedures. Dates for abuse training had been discussed with the Proprietor. Discussions with a new member of staff evidenced that Adult Abuse was included in the homes induction programme. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 18 A requirement has been made in these areas. Please refer to pages 27 and 28 of this report. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 19 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 the following standard(s): 24,25,26,27,28,30. The standard of the environment within this home, currently meets the needs of the residents. However several areas require attention. Resident’s bedrooms suit their needs and promotes their independence. Bathrooms and toilets provide sufficient privacy. The overall cleanliness in the home is poor. EVIDENCE: The resident’s bedrooms were personalised. They were comfortably furnished and the quality of decoration was satisfactory. One of the wardrobes doors had been removed for repair. There were many soft toys sitting around on the beds and there were photographs of family members and other personal items. Some of the rooms had many colourful sensory pieces of equipment, for example lava lamps and water based pictures in evidence. One bedroom had various colourful fairy lights, and brightly coloured beaded curtains between the main bedroom and en-suite. The bedrooms appearance would be enhanced if the bed linen was ironed. The main sitting room would benefit from redecoration. The walls and skirting boards were soiled and require cleaning. The furniture was soiled and requires cleaning. There was a lack of pictures on the walls, making the room look cold and un-welcoming. Musical instruments and games were tidied away behind the sofas. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 20 The decoration in the hallways and other communal rooms requires attention. The sealant between the kitchen cupboards and the floor was very dirty. All of the carpets were soiled and require cleaning. The home has recently purchased a carpet cleaner, but there was no evidence to suggest that it had been used. The bathrooms and communal toilet’s were satisfactory. However it was noted that not all of them had a waste bin, there was a pair of dirty gloves left sitting on the cistern in one of the bathrooms. Requirements were made in these areas. Please refer to pages 27 and 28 of this report. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 21 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,35,36. The home employs an efficient staff team who provide a good quality of care to the residents. Recruitment practices are improved. Training has a high priority in this home. Staff do not receive regular one to one supervision. EVIDENCE: The home has clear policies and procedures for staff recruitment. Three staff have been recruited since the last inspection. Staff files seen on the day demonstrated that recruitment and selection practice had improved. All staff had satisfactory Criminal Records Bureau CRB) and Protection of Vulnerable . Adults (POVA) checks and two references. There were 2 care staff, and the manager on duty on the morning shift. Two members of staff had called in sick. As a result, the proprietor assisted with the residents transportation issues. There are no domestic or kitchen staff employed at the home. The cooking and cleaning is part of every one’s day-today work. The dependency levels of the residents on the day indicated that the present staffing ratio was adequate. However the manager and proprietor should reassess the staffing levels, with regard to the level and frequency of residents activities and distance to travel to those activities. Training in the home is given a high priority, in particular non-verbal communication skills. Staff talked about their job roles, there was clarity and awareness of the different roles and responsibilities within the home. Staff also discussed the training opportunities in the home. Training courses carried out since the last inspection include: Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 22 • • • • • • • • • • • Medication. Manual handling. First Aid . Health and Safety. Makaton. Child protection. Autism. Teachh Vulnerable Adults Protection. Induction and foundation. Epilepsy Training There is a supervision programme in the home. The manager and deputy manager would carry out the formal one to one staff supervisions. However there has been no manager at the home since the end of July 2005. Formal one to one supervisions have not been achieved. It was positive to note, that since the new manager started she has managed to carry out three one to one supervision meetings. A requirement has been made in these areas. Please refer to pages 27 and 28 of this report. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 23 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41,42. The home has clear policies and procedures in place. The standard of record keeping relating to health and safety in the home is poor. The Manager is experienced and competent to run the home. EVIDENCE: As stated earlier in this report, the manager has just been recruited to the post. She stated that she is at present undertaking The Registered Manager Award. The manager had a very open approach. From observation of her interactions with a resident it was clear that there was an atmosphere of openness and respect. The residents facial expressions and body language indicated that he was comfortable in the manager’s company. Staff spoken with on the day stated that, the new manager has a very open approach, and that she joined in with all the work. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 24 The manager was unable to produce a service users questionnaire, she stated that she was not aware that the home had one. This was discussed with the proprietor, who explained that she is still developing a process in which the home can seek the views of the residents and others, as to how the home is doing. It is disappointing to note that this has not yet been achieved. The standard of recordkeeping at the home is not satisfactory. Records are stored appropriately, securely and confidentially. Daily, weekly and monthly tests with regard to fire alarm tests, fire drills and monitoring of food hygiene, fridge and freezer temperatures were not carried out or recorded consistently. One light bulb was not working. The manager had this replaced during the inspection. As mentioned in the summary of this report, various liquid soaps were kept in the bathrooms, washing up liquid was easily accessible in the kitchen. The kitchen cupboard could not be locked. Requirements have been made in these areas. Please refer to pages 27 and 28 of this report. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 25 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 3 3 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 2 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 2 2 LIFESTYLES Standard No Score 11 N/A 12 N/A 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beech Trees Score X 3 2 X Standard No 37 38 39 40 41 42 43 Score X 3 1 3 2 1 3 DS0000055261.V255426.R01.S.doc Version 5.0 Page 26 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 YA 34 Regulation PartII Regulation 2001 5(1)(c ) Requirement The registered person(s) must ensure that the home’s certificate of registration is displayed in its entirety. The registered person(s) must ensure that residents contract for care are signed by the resident or their representative. The registered person(s) must ensure that all staff adhere to the home’s medication policies and procedures. Medication records must be signed, when medication is administered. The registered person(s) must ensure that all staff including the manager receive Protection of Vulnerable Abuse Training. Previous timescale 23/7/05 not met. The registered person(s) must ensure that all areas of the home including the carpets are kept clean. Previous timescale 23/6/05 not met. The registered person(s) must ensure that the home has a planned maintenance and renewal programme for the fabric and decoration of the DS0000055261.V255426.R01.S.doc Timescale for action 10/10/05 2 YA 5 10/12/05 3 YA 20 12(1)(a) 13(2) 10/10/05 4 YA 23 13(6) 10/11/05 5 YA 24 23(2)(d) 10/10/05 6 YA 24 23(2)(d) 03/01/06 Beech Trees Version 5.0 Page 27 home. 7 YA 24 The registered person(s) must ensure that the sealant around the baths and showers is replaced as necessary. 12(1)(a) The registered person(s) must 13(4)(a) ensure that all substances hazardous to health are stored according to COSHH guidelines. The storage of liquid soaps in the bathrooms must be risk assessed and reviewed. 13 The registered person(s) must (3)(4)(a(b(c ensure that all staff are aware of the infection control policies and procedures in the home. Dirty gloves must be disposed of appropriately. 13(6) The registered person(s) must 17 ensure that at all times staff Sch follow procedures relating to 4(9)(a)(b) residents personal monies. 12(1)(a) The registered person(s) must 18(1)(a)(c) ensure that all care staff receive regular formal one to one supervision, and that records are kept. 24(1)(a)(b) The registered person(s) must (2)(3) ensure that resident’s meetings are introduced in to the home. 24(1)(a)(b) The registered person(s) must (2(3) ensure that a service users feedback questionnaire is developed and implemented. 12(1(a) The registered person(s) must 3(a(c) ensure that all record keeping Sch 4 relating to health and safety are improved. Records must be up to date and accurate. 23(2)(n) The registered person(s) must ensure that a wheelchair ramp is fitted outside one of the garden doors access. 23(2)(b) 03/11/05 8 YA 42 10/10/05 9 YA 42 10/11/05 10 YA 23 10/10/05 11 YA 36 10/12/05 12 13 YA 39 YA 39 10/12/05 10/12/05 14 YA 42 10/11/05 15 YA 24 10/12/05 Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 28 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 33 Good Practice Recommendations The registered person(s) should consider reviewing the staffing levels in light of the amount of activities they offer. Beech Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Trees DS0000055261.V255426.R01.S.doc Version 5.0 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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