Inspection on 13/02/07 for Beechcliffe Residential Home

This inspection was carried out on 13th February 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beechcliffe Residential Home 25/02/10

Beechcliffe Residential Home 04/12/09

Beechcliffe Residential Home 08/12/08

Beechcliffe Residential Home 10/12/07

Beechcliffe Residential Home 25/10/05

Beechcliffe Residential Home 03/05/05

Beechcliffe Residential Home 11/01/05

Beechcliffe Residential Home 06/07/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Beechcliffe Residential Home 16 Park Drive Heaton Bradford West Yorkshire BD9 4DR Lead Inspector David White Key Unannounced Inspection 13th February 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beechcliffe Residential Home DS0000001227.V328055.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. Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechcliffe Residential Home Address 16 Park Drive Heaton Bradford West Yorkshire BD9 4DR 01274 487207 01274 497352 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) Mr Jarnail Singh Bassan Susan Janette Malcolm Care Home 25 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (25) Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place for MD is for the named service user only. Date of last inspection 25th October 2005 Brief Description of the Service: Beechcliffe is a large detached Victorian building standing in its own grounds in the Heaton area of Bradford. The home can now accommodate 24 service users in a mixture of single and double rooms. The home does not provide nursing care. There is good disabled access into the premises and a large garden available for service users. Car parking is available to the front of the building. The home is fairly close to a number of amenities within the local area including shops, public houses and a large park. The home is also well served by local transport. The weekly fees for the home range from £308.14 to £371 and do not include costs for hairdressing, chiropody, toiletries and personal transport. Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows an unannounced site visit undertaken on 13 February 2007. This visit was carried out by one Regulation Inspector and took 7.5 hours with 5 hours preparation time. Surveys were sent out and received from four relatives and three service users. The report includes information from the Regulation Inspector’s inspection record, which details the history of the home and relevant information about what has been happening in the home since the previous inspection visit. The site visit included an inspection of the premises. The visit involved looking at three service users’ care records, including service users’ assessments, care plans and medication records. Staff rotas, accident records and health and safety documentation were inspected. Three service users, two members of care staff, a cook, an administrator and the care supervisor talked about their experiences in the home and time was spent observing the interaction between service users and staff. The focus of the inspection was on a number of key standards and inspecting the case records of a number of service users to establish whether they corresponded with their experiences of life in the home. There have been some issues with the management arrangements of the home. The registered manager has been absent from work through sickness for over three months and the previous registered manager for the home has been managing Beechcliffe in the interim period. At the time of the site visit both the manager and the registered provider who is based at the home were unavailable. The home has recently appointed a supervisor to work alongside the manager and this person who was very helpful was available throughout the inspection and the findings were discussed at the end of the inspection. What the service does well: Service users receive a good standard of care from a committed staff team who are respectful towards them. Service users are encouraged to make their own choices about how they live their lives. The care planning systems that are in place provide clear information to staff on how each service user’s needs are to be met. Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 6 All the surveys received from relatives made comments that the home is good at keeping them informed about important matters affecting their relative. Service users said that the staff are “kind and caring” and this was observed during the site visit. Staff receive a range of training including training that is specific to the needs of the service user group in the home so that they have a good understanding of the service users’ needs and how these are to be met. What has improved since the last inspection? What they could do better: Urgent action needs to be taken to make sure that service users are not at risk of scalding from hot water temperatures. A formal letter was left at the site visit requiring the registered provider to deal with this. Arrangements also need to be put in place for the monitoring and recording of the water temperatures so that any shortfalls can be identified and the necessary actions taken. Urgent action needs to be taken to make sure service users are not at risks to their health and safety through having access to chemicals that are not securely stored. A formal letter was left at the site visit requiring the registered provider to deal with this. Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 7 The registered provider needs to make sure that a Criminal Record Bureau (CRB) check is obtained on all staff prior to them starting work at the home so that service users’ are not put at risk of potential harm. The registered provider must make sure that all the required safety tests are done and the required safety certificates are in place for the electrical wiring systems in the home, the portable appliance testing and servicing of the lifts and other equipment used in the home in order to maintain the health and safety of the service users. 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. Beechcliffe Residential Home DS0000001227.V328055.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 Beechcliffe Residential Home DS0000001227.V328055.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): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Proper pre-admission procedures are in place so that prospective service users can feel confident that their needs will be met by the home. EVIDENCE: The care records of the mostly recently admitted service user shows that the home has proper pre-admission procedures in place. The records contain information about pre-admission assessments that have been carried out before any decision is made about whether the home is able to meet the person’s needs. People who are thinking about moving into the home are invited to visit beforehand with their relatives or representatives so that they can make a decision about whether they would like to live in the home. This could be seen at the time of the site visit when one person was visiting the home for a second time to get to know the staff and service users. Due to Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 10 the person’s personal circumstances the home is not able to admit this individual into the home under their current registration categories. However the registered provider has submitted an application to vary the registration categories of the home in order to try and accommodate this person. The home does not provide intermediate care. Beechcliffe Residential Home DS0000001227.V328055.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 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ personal and healthcare needs are understood and met by a respectful staff team. EVIDENCE: Service users’ said that they are “well looked after” and spoke in complimentary terms about the staff team. The service users’ looked tidy in appearance and some of them are able to enjoy interaction with each other and the staff team. One service user said that she has recently purchased some new clothing and all clothing is individually labelled to reduce risks of clothing going missing. A comment from one relative survey indicated that clothes sometimes go missing in the home. Whilst acknowledging that this had been a problem at one time when a number of new staff had started working at the home, staff made comments that the situation has since improved now that staff are more familiar with the laundry systems in the home. Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 12 The care records of three service users’ were looked at and these provide good information about the needs of individual service users’ and how these are to be met. This includes a “service user profile” on each service user, which gives information about the person’s likes and dislikes on various aspects of their daily routines. Care plans are regularly reviewed on a monthly basis so that any changing needs can be identified and acted on. A number of risk assessments are in place to cover different aspects of daily living including measures to reduce risks from falling and pressure sores. There is also a risk assessment to promote equality and this considers areas such as the person’s ability to communicate with others and their ability to make sense of information and this is good practice. Care records are specific in saying how people should be supported with their mobility and aids and adaptations are available to help with this. In the care records there is information about the dietary needs and preferences of each service user. Service users’ are weighed on a regular basis and any issues from this are addressed. Referrals to outside agencies such as GP’s and other healthcare specialists are made as appropriate and a chiropodist visits the home on a regular basis. The daily records accurately reflect the cares being given and these are kept up to date. Proper medication systems and procedures are in place and the Medicine Administration Record (MAR) charts are accurate and up to date. A random check of an individual service user’s medication tallied with the records. None of the service users are able to safely administer their own medication and at the time of the site visit no controlled drugs were prescribed for any of the service users. All staff who administer medication have received the appropriate training and a local pharmacist also provides training sessions at the home and inspects their medication systems and procedures. Since the previous inspection visit the commission has received concerns about an incident when a member of staff omitted a service user’s prescribed medication without consulting with a GP because of concerns about the service user’s health. The registered provider has taken actions to prevent a reoccurrence of this incident and all staff have since been reminded of the proper procedures to follow through staff meetings. However, it is recommended that staff have clear written guidance about this to make sure that proper procedures are followed in the future to avoid any possible health risks to the service users. Staff could be seen to be treating service users’ in a respectful manner and providing care sensitively. Most of the service users sit in the lounge with others but are able to spend time in their bedroom if they wish to do so. Service users said that they are able to get up and go to bed when they choose to do so. Beechcliffe Residential Home DS0000001227.V328055.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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ are encouraged to make their own choices about their lives where this is possible and are able to maintain contact with relatives and friends, however service users’ would benefit from having a wider choice of activities in the home. EVIDENCE: The home had previously employed an activities co-ordinator who is no longer working at the home. Staff are now responsible for carrying out in-house activities with the service users’ and these include bingo and music sessions. Some service users’ enjoy watching television and a number of them were seen doing so at the time of the site visit. There is also a weekly church communion service at the home that is organised by the local church. The home does have a minibus and service users enjoy occasional trips out of the home. Staff said that there is no structured activity programme so activities are mainly on an ad hoc basis. Three relative surveys indicate that there could be more activities in the home and within service user’s daily records there is little information about any activities that the service user may have taken part Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 14 in. Two service users also made comments that there are not a lot of activities at the home although one said “I would not be interested in joining in anyway”. It is recommended that the home consider ways of improving the range of activities on offer to enable service users to have more opportunity for social stimulation. Visiting times are flexible so that family and friends can visit the service users at the home. Staff said that visitors usually sit in the dining room with their relatives but can go to the service user’s bedroom if they want more privacy. Throughout the site visit there were no visitors to the home so it was not possible to observe the relationships between the visitors and staff team. Comments from relative surveys indicate that all relatives feel that they are kept well informed of important matters relating to their relative. Service users’ said that they are able to choose their own daily routines as much as is possible and are encouraged to make their own decisions. Service users’ care records contain information about service users’ preferences in their daily routines. A mealtime was observed at lunchtime. The menus are on a rolling programme and the food looked appetising. Alternative meals are available if service users do not like what is on the menu. Liquidised meals are on offer for two of the service users who have swallowing difficulties. Food supplements are available to support people with their nutritional needs and the care records show that weight is regularly monitored and any problems are addressed. Fresh meats, fish and vegetables are bought every week. The cooks have information in the kitchen about all the service users’ individual likes and dislikes. Snacks and drinks are provided between meals and service users made comments that they are “well pleased” with the food on offer in the home. Service users’ can choose to eat wherever they wanted to although most preferred to eat in the dining room. Those service users who need support with eating are assisted to do so by the staff team. Beechcliffe Residential Home DS0000001227.V328055.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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ concerns are listened to and acted on, and the risk of harm is reduced through staff having a good understanding of adult protection issues. EVIDENCE: The home has a complaints procedure that provides information about how to make a complaint and what action will be taken in response to this. Since the previous inspection visit the Commission for Social Care Inspection (CSCI) has received one complaint about the home, which the registered provider was asked to investigate. The registered provider was able to provide information to CSCI to show that they had followed proper procedures in carrying out their investigation and appropriate actions had been taken to resolve the issues from the complaint. Comments from two relatives surveys indicate that not all relatives are aware of how to make a complaint and it was noted that the complaints procedure was not on display in the home although the supervisor explained that a service user had taken it down and it had not been put back up as yet. It is recommended that the management of the home address these issues. The home has an adult protection policy and procedure in place. All staff attend abuse awareness training and this is also included as part of the induction programme for new staff. Observation from the site visit shows that Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 16 staff treat service users with respect and dignity and service users’ said that staff are “kind” to them. Beechcliffe Residential Home DS0000001227.V328055.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, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment is comfortable, however improvements are needed in the health and safety arrangements and practices to promote the safety of the service users. EVIDENCE: The home has an ongoing refurbishment programme and since the previous inspection visit a number of bedrooms have been modernised to a good standard. Most of the bedrooms now have en-suite facilities and it is planned that this work will continue in other bedrooms and to other parts of the building. Bedrooms are personalised and are located near to communal toilets. Accommodation is over four floors and can be accessed by a passenger lift. There is also a stair lift between two of the floors and ramped access to and from the home to support people with mobility problems. There are four Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 18 bathrooms in the home, two of these are assisted bathrooms to support people in getting in and out of the bath and lifting equipment is available to help with this. The communal areas are generally maintained to a satisfactory standard although there are a number of areas in the home that are in need of redecoration and this is being addressed as part of the refurbishment programme. Since the previous inspection visit proper measures have been taken to address the problem with the stair protection rail between the carpet and tiled floor in the bathroom on the first floor so that service users are no longer at risk to their safety and the panel behind the toilet has been replaced. At the time of the site visit the home was generally clean and tidy. A cleaner is employed to maintain standards of cleanliness in the home. Proper arrangements are in place for the washing of service users’ personal clothing and bedding and linen. However in the ground floor bathroom a cupboard containing some chemical products was open and unattended to. The bathroom is easily accessible to service users. This poor practice put service users at risk and a letter of serious concern was issued at the time of the site visit. The home has carried out a fire risk assessment of the building and fire equipment is tested on a regular basis. The Environmental Health Authority undertook a recent visit to the home and the report from this shows that the outcomes from the visit were satisfactory. However, there were some serious concerns following random checks of the water temperatures that were made as part of a tour of the environment. In a number of areas to which service users have access the hot water temperatures were found to be excessively high and put service users at risk from scalding. The supervisor was made aware of this and a plumber was immediately contacted and some of the necessary work was undertaken. Where this work could not be carried out immediately the supervisor made arrangements so that service users did not have access to any area where the water temperatures were excessive. The problems with the hot water temperatures could have caused serious harm to the service users and a letter of serious concern was issued at the time of the site visit. Beechcliffe Residential Home DS0000001227.V328055.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing team are well equipped to meet the service users’ needs and overall proper recruitment procedures are followed to safeguard service users from harm. EVIDENCE: Staffing levels throughout the home are adequate. Currently there are 16 service users living at the home and at the time of the site visit there were three staff on duty. There are usually three staff on duty as well as the manager at all times throughout the day and two waking night staff with another member of staff sleeping on the premises during the night. The duty rotas show that at times in the past there has been only two staff on duty due to staff reporting in sick at very short notice. When this happens the person in charge of the shift tries to arrange extra cover by offering extra shifts to the staff team in the home. The management of the home are addressing issues around staff not giving proper advanced warning about sickness and absence from work and this has resulted in improvements in the sickness levels. Staff feel that staffing numbers have been better over recent months and both they and the service users feel that the current staffing levels are adequate in making sure that service users’ are being met. Since the previous inspection visit the CSCI has received some concerns that some staff are being taken out Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 20 of the home during shifts to cover staff shortages in other homes belonging to the registered provider. The duty rotas indicate that this is not happening and staff said that whilst on odd occasions this had happened in the past, this is no longer the case. Throughout the site visit staff could be seen to be committed in providing good cares for the service users. Through discussion with members of staff it is evident that they act in the best interests of the service users and work hard to meet their needs. The staff records of four recently appointed members of staff were looked at. These records show that following a requirement made at the previous inspection visit two written references are always obtained from the referees’ names on the application forms before appointing a new member of staff into post. In three of the records all the proper checks have been carried out, however in one staff record whilst there is evidence that a POVA (Protection of Vulnerable Adults) first check was made prior to the person starting work at the home, there is no information to show that the Criminal Record Bureau (CRB) check had been applied for and carried out on this particular member of staff and this needs addressing to safeguard the service users from any potential harm. Since the previous inspection visit a training co-ordinator who was employed to organise training in the home is no longer working there. The home has recently arranged for an independent training company to provide staff training and a number of training sessions are arranged as some staff are in need of updated training in safe working practices. Additional courses are also planned for dementia and mental health training and the home has an ongoing NVQ training programme for the care staff. Discussion with staff shows that they have a good understanding of the service users’ needs. Beechcliffe Residential Home DS0000001227.V328055.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, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home is managed with the best interests of the service users’ in mind, improvements are needed in the health and safety arrangements to prevent risks of harm to the service users. EVIDENCE: The registered manager who has attained a management qualification since the previous inspection visit has been absent from work through sickness for over three months. The CSCI and the registered provider are in discussion about the management arrangements of the home and this matter is being addressed through separate correspondence. In the meantime the previous Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 22 registered manager who is very experienced in running the home has taken over the management of the home although she was not available at the time of the site visit. Since the previous inspection visit a supervisor has been appointed to assist the manager with the care responsibilities in the home. Staff and service users said that the manager is “approachable” and staff feel “well supported”. However there are some issues regarding health and safety matters that should have been addressed by the home. The home has a quality assurance system in place. Questionnaires were sent out to relatives last year and returned to the home, although because the manager was not available at the time of the site visit it is not clear what actions have been taken if any from the information provided. Staff meetings are held on a regular basis and staff said they are kept informed about the home and are encouraged to give their views and opinions. The financial arrangements for the service users’ are satisfactory. Personal monies are individually held for the service users and records are well maintained of monies deposited and withdrawn from each service user’s personal account. A random check of one service user’s monies tallied with the records. There are staff supervision and appraisal arrangements in place, however staff are not receiving individual supervision on a regular basis and this needs to happen so that staff are supported in their jobs and management are aware of any issues. As previously mentioned earlier in the report under the heading of environment there are some serious concerns about some health and safety matters. A number of hot water temperatures were found to be excessively high and unsafe and there is no information to show that the water temperatures are being monitored. Staff made comments that a local contractor periodically carries out some water safety checks although it is not clear how often this is taking place. A cupboard containing chemicals had been left open and could be accessed by service users. Some of the required health and safety certificates were not available for inspection so there is no evidence that appropriate action is taken to make sure service users and staff are safe. The electrical wiring certificate could not be found and there were no service records available for the lifts and other equipment. The home has a handyman who is qualified to test the portable electrical appliances, however, there was no documentation available to show that this testing is being done. In one staff file there is no record that a CRB check has been applied for and obtained on a member of staff who started working at the home last year. Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 23 Following the site visit the registered provider and manager were contacted about the lack of documentation that was available in relation to the necessary health and safety checks. They understood that the necessary checks had been undertaken for the electrical wiring systems in the home and a certificate confirming this was sent to the Commission on request. However they reported that the current service records for the lift and other equipment were found to be out of date and the home has arranged for this work to be immediately carried out along with the portable electrical appliance testing. It is necessary for all these health and safety checks to be undertaken and recorded, and for all these records to be available for inspection in order to show that service users’ safety and interests are safeguarded. Staff receive a range of health and safety training. The training records show that some staff are in need of updated training in this area and this has been arranged. All accidents are recorded and the records show that no service user has suffered injuries from scalding as a result of the excessive water temperatures in some parts of the home. Beechcliffe Residential Home DS0000001227.V328055.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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X 1 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 1 1 Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP25 Regulation 13 Requirement The registered provider must make arrangements for the water temperatures to be no more than 43 degrees centigrade in outlets used by service users to prevent risks from scalding. An immediate requirement was issued. The registered provider must make sure that a criminal records bureau check is obtained for new staff employed to work at the home before they start work in order to safeguard service users from harm. The registered provider is required to have the required health and safety records in place, up to date and available for inspection. The registered provider must make sure that the following work is undertaken and recorded in order to prevent risks to the health and safety of the service users: • Portable Appliance Testing (PAT) and servicing is DS0000001227.V328055.R01.S.doc Timescale for action 13/02/07 2. OP29 19 13/03/07 3 OP37 17 13/04/07 4. OP38 13, 23 13/03/07 Beechcliffe Residential Home Version 5.2 Page 26 5 OP38 13 undertaken for all equipment in the home. • Make arrangements for the monitoring and recording of hot water temperatures and to take any necessary actions from this. The registered provider must 13/02/07 take measures to make sure that chemicals that are not in use are securely stored so that the health and safety of service users is not at risk. An immediate requirement was issue. 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. Refer to Standard OP9 OP12 Good Practice Recommendations The registered provider should provide written guidance about what actions staff are to follow when prescribed medication is omitted. The registered provider needs to consider ways of improving the range of activities on offer for service users at the home so that they have more opportunity for social stimulation. The registered provider should take measures to make sure that all relatives are aware of the home’s complaints procedure. The registered provider should continue with the home’s refurbishment programme in order to improve the living environment for service users. Individual staff supervision needs to be carried out on a more regular basis to support staff in their jobs and so that management are aware of any issues. 3. 4. 5. OP16 OP19 OP36 Beechcliffe Residential Home DS0000001227.V328055.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Beechcliffe Residential Home DS0000001227.V328055.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. Re-publishing this information is in breach of the terms of use of that website. 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