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Inspection on 08/12/08 for Beechcliffe Residential Home

Also see our care home review for Beechcliffe Residential Home for more information

This inspection was carried out on 8th December 2008.

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

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.

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

What the care home does well

The staff are approachable, have a caring attitude and try hard to create a warm and friendly atmosphere. The admission procedure is thorough and the manager will not admit people unless she feels that the staff can provide the level of care and assistance they require. Feedback from relatives was generally positive about the standard of care provided and indicated that all the staff are caring and sympathetic to people`s needs. Comments include "my mother has only been at the home a short period of time but I have been more than happy with her care and thefriendliness of the staff" and "I feel Beechcliffe provides a good service to all the people it looks after."

What has improved since the last inspection?

The home has been without a registered manager for about eighteen months and since the last inspection has experienced staffing problems, which has made it difficult for the service to move forward. It is however anticipated that a manager will be appointed in early 2009 and areas of concerns raised in the body of this report will be addressed. The recent appointment of a general manager has improved the overall situation and provided the acting manager and staff with the support they need to manage the home more effectively.

What the care home could do better:

The ongoing programme of refurbishment must be continued to make sure that standards are maintained and improved and people live in a safe and comfortable environment. Care plans must give clear guidance to staff on how people`s needs are to be met. So that they receive the level of care and support they require. People`s weight must be accurately recorded and any significant weight loss investigated, so that their general health and wellbeing is not compromised. A new controlled drugs cabinet needs to be installed so that controlled drugs can be stored safely and in line with current legislation. People need to be offered a range of appropriate social and leisure activities, so they have the opportunity to lead a full and active life. Recruitment and selection procedures must be followed at all times so that people can be confident that they are being cared for by staff that are suitable to work in the caring profession. Effective quality assurance monitoring systems need to be put in place so that shortfalls in the service are identified sooner and people can be confident that the home is run in their best interest. More needs to be done to provide staff with the supervision and support they need to carry out their roles effectively.

CARE HOMES FOR OLDER PEOPLE Beechcliffe Residential Home 16 Park Drive Heaton Bradford West Yorkshire BD9 4DR Lead Inspector Steve Marsh Key Unannounced Inspection 8th December 2008 10:00 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.V373399.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.V373399.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 satnam@pcslimited.net 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 Vacant Post 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.V373399.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 categories: Old age, not falling within any other category - Code OP Dementia - Code DE(E) Mental disorder - Code MD(E) The maximum number of service users who can be accommodated is: 25 The place for MD is for the named service user only. To admit one named service user in the category of DE 2. 3. 4. Date of last inspection 10th December 2007 Brief Description of the Service: Beechcliffe Residential Home is a large detached Victorian building standing in its own grounds in the Heaton area of Bradford. The home provides accommodate for twenty-five people 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 people to enjoy during the summer months. 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 weekly fees range from £380.00 to £420.00 and do not include costs for hairdressing, chiropody, toiletries and personal transport. Beechcliffe Residential Home DS0000001227.V373399.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 One Star. This means the people who use this service experience adequate quality outcomes. The inspection process included looking at records, observing staff at work, talking to people living at the home and visitors, talking to staff and looking around the property. Before the visit we had provided some people living at the home, their relatives, staff and other health care professionals with survey questionnaires so that they could share their views of the service with us. We received three questionnaires back from people living at the home, five from relatives and one from a health care professional. The information they provided has been used as evidence in the body of the report. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. The home has been without a registered manager for about eighteen months and the provider is experiencing some difficulty appointing to the post. Until a new manager is appointed a member of the company’s senior management team has been designated as acting manager and is responsible for running the home on a day-to-day basis. Feedback was given to the acting manager at the end of the visit. What the service does well: The staff are approachable, have a caring attitude and try hard to create a warm and friendly atmosphere. The admission procedure is thorough and the manager will not admit people unless she feels that the staff can provide the level of care and assistance they require. Feedback from relatives was generally positive about the standard of care provided and indicated that all the staff are caring and sympathetic to people’s needs. Comments include “my mother has only been at the home a short period of time but I have been more than happy with her care and the Beechcliffe Residential Home DS0000001227.V373399.R01.S.doc Version 5.2 Page 6 friendliness of the staff” and “I feel Beechcliffe provides a good service to all the people it looks after.” What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can Beechcliffe Residential Home DS0000001227.V373399.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Beechcliffe Residential Home DS0000001227.V373399.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.V373399.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 and 5 – Standard 6 is not applicable to this service. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s needs are assessed before they are admitted and they can visit and stay for a trial period to make sure that the home is right for them. EVIDENCE: The home has produced a service user guide, which is made available to all people considering using the service. The guide needs updating but still provides good information about the service, which helps people to decide whether or not the home can meet their needs. The records showed that people’s needs are assessed before they move into the home. The manager told us that people are encouraged to visit before making a decision about moving in although in some cases it is relatives who visit on behalf of the person needing care. Beechcliffe Residential Home DS0000001227.V373399.R01.S.doc Version 5.2 Page 10 The manager confirmed that people are able to stay at the home for a trial period, which gives them the opportunity to experience at first hand the standard of care and facilities provided. People offered a place at the home are always supported throughout the admission process and care is taken to make sure they settle into their new environment. Beechcliffe Residential Home DS0000001227.V373399.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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s healthcare and personal needs are generally met in a way that maintains their dignity and independence however staff are not accurately monitoring people’s weight, which might put their health at risk. Care plans do not always give staff clear guidance, which means that care may not always be given in a way that takes account of people’s individual preferences and abilities. EVIDENCE: Care plans have been completed for all people living at the home, which cover all aspects of their social and healthcare needs. There was some evidence to show that wherever possible people are involved in the care planning process, which means that they are consulted about, how they want their care and support to be provided. Beechcliffe Residential Home DS0000001227.V373399.R01.S.doc Version 5.2 Page 12 The care plans we reviewed were completed to a satisfactory standard although in some instances they did not give clear guidance to staff on how specific needs were to be met. For example the daily report for one person showed that they could become agitated and physically aggressive at times. However, there was no care plan or risk assessment in place to give staff guidance on how to manage their aggressive outbursts. People living at the home said that they were generally pleased with the care and attention they received. Comments included “we are all well looked after ” and “all the staff are kind and caring.” Relatives said that they were pleased with the standard of care and facilities provided and staff treated people with respect. Comments included “ I feel my relative is well cared for and I am always kept informed of any significant changes in her condition” and “I am more than happy with my mother’s care – the staff are always patient and understanding”. All people living at the home are registered with a general practitioner and are supported in having access to the full range of NHS services. The input of other healthcare professionals is recorded in the documentation available, which shows that staff are seeking advice if they have concerns about an individual’s health. People are weighed on a monthly basis however we found that in at least one instance staff had recorded that someone had lost a substantial amount of weight without reporting the matter to the manager for investigation. This is unsafe practice and might lead to people’s health care being put at risk. The manager said this matter would be addressed immediately. On reviewing the medication system we found that overall medicines are managed safely. A few minor discrepancies were discussed with the manager and immediate action was taken to address the issues raised. However, the home must purchase a new controlled drug cabinet to meet the current legislation. Beechcliffe Residential Home DS0000001227.V373399.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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. More could be done to provide people with a more extensive range of recreational and leisure activities both within the home and the wider community. EVIDENCE: The manager said that the daily routines are flexible and people are encouraged to make choices about how they will spend their time whilst living at the home. Through discussions with staff and people living at the home it is apparent that only limited social and leisure activities take place. Feedback from relatives also shows that they feel the home could do more to provide a stimulating environment. Comments included “the home could try and do a little more activities with people that are able” and “people appear to spend a lot of time just sitting around with very little to do.” No one has specific responsibility for organising social activities and therefore it is left to care staff to do what they Beechcliffe Residential Home DS0000001227.V373399.R01.S.doc Version 5.2 Page 14 can when they have time. There are however plans to employ an activities coordinator, which will greatly improve the service and people’s quality of life. The manager confirmed that entertainers do visit the home and the people living there are fortunate to have the use of a mini bus for trips out. Local church leaders visit the home on a regular basis and people are assisted to attend their chosen place of worship if they wish to do so. Feedback from relatives shows that they are able to see people in their own room if they wish to do so and visitors are always made to feel welcome and offered light refreshment. Mealtimes are sociable occasions and each person takes all the time they need to eat their meal. There is a good choice of dishes on the menu, and alternatives are offered if people prefer something different. Staff are aware of people’s needs and preferences and assistance is offered discreetly to people who need prompting or are unable to manage to eat independently. Hot and cold drinks are freely available to people both day and night. Comments from people included “the food is very good and I look forward to my meals” and “I have no complaints at all about the food – we certainly get well fed.” Following a Food Hygiene Inspection by the Environmental Health Department the home was awarded a three star rating (out of a possible 5 stars). Beechcliffe Residential Home DS0000001227.V373399.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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Although safeguarding policies and procedures are in place some staff still require training to make sure they are fully aware of their roles and responsibilities relating to the protection of vulnerable adults. EVIDENCE: There is a clear complaints procedure in place and people who were able said that they would have no problems approaching the manager if they had any concerns about the standard of care being provided. Questionnaires returned by relatives also clearly indicated that they were aware of the complaints procedure and who to contact if they had any concerns. Adult protection policies and procedures are in place although the training records show that a number of staff still require appropriate training in the recognition and reporting of abuse. The training matrix provided by the general manager shows that this training will be completed early in 2009. Feedback from staff indicates that they are aware of the home’s policy on “whistle blowing” and were aware of what to do if they felt any practices put in place at the home were not in the best interest of the people using the service. Beechcliffe Residential Home DS0000001227.V373399.R01.S.doc Version 5.2 Page 16 Policies and procedures are available regarding staff involvement in the financial affairs of people living at the home, which does not allow them to become involved in the making of, or benefiting from their wills. Beechcliffe Residential Home DS0000001227.V373399.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,People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The ongoing programme of refurbishment must be continued to make sure that standards are maintained and improved and people live in a safe and comfortable environment. EVIDENCE: Some parts of the home are still in need of upgrading and there is an ongoing programme of refurbishment and renewal in place. We asked the provider to provide us with an updated copy of the refurbishment plan. Work is also still outstanding to comply with an enforcement notice served by the Fire Service in July 2008. The provider must make sure this work is carried out in line with the agreed timescales to avoid further action being taken. All the communal areas including lounges and the dining room are situated on the ground floor of the home, conveniently close to toilet facilities. Both the Beechcliffe Residential Home DS0000001227.V373399.R01.S.doc Version 5.2 Page 18 toilet and bathroom on the ground floor require refurbishing to bring them up to an acceptable standard. The bedrooms we looked at were furnished to a satisfactory standard although a number would benefit from decorating. The manager said that on admission people are encouraged to bring personal possessions into the home to personalise their room and it was evident during the tour of the building that many people had done so. People who were able said that they were generally satisfied with the standard of accommodation, and were pleased that they had been able to furnish their rooms with personal possessions. Feedback from relatives showed that they had mixed feeling about the standard of accommodation although the majority felt it was satisfactory. Comments varied from “some areas of the home are in urgent need of modernising” to “I am happy with the standard of accommodation and facilities provided.” On the day of the visit the home was reasonable clean and tidy, although no cleaning staff were on duty due to illness. Externally the grounds are well maintained. Beechcliffe Residential Home DS0000001227.V373399.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 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Staffing levels are not always being maintained or recruitment and selection procedures followed, which may put people at risk. EVIDENCE: The manager confirmed that the home has recently experienced staffing problems and is currently recruiting for care staff. We raised concerns with the manager about night staffing arrangements as the rota clearly showed that on some occasions agreed staffing levels were not being met. The manager acknowledged that the home had struggled to maintain staffing levels but confirmed that this matter would be addressed immediately. Feedback from two relatives also indicates that they feel that there is not always enough staff on the evening shift to meet people’s needs. Comments included “I feel staff are overworked and under pressure particularly on the evening shift” and “although the staff are kind and caring they always appear to be in a rush especially when I visit during the evening.” The home has a thorough staff recruitment and selection procedure, which includes obtaining at least two satisfactory written references and a Criminal Record Bureau check before new staff start work. Beechcliffe Residential Home DS0000001227.V373399.R01.S.doc Version 5.2 Page 20 We looked at the employment files of four care staff. In two instances only one written references had been received, in one instance there was no written references at all on file and references for the fourth member of staff had been requested from a family member and a friend. This is unsafe practice, which might put people using the service at risk. The manager confirmed that this matter would be addressed immediately and a recruitment checklist would be put in place to make sure that in future no one would be employed before all the relevant documentation had been received. The manager confirmed that all new staff receive induction training although she was unsure if the training provided was in line with the Skills for Care Common Induction standards. These are nationally agreed induction standards designed to help new staff get the skills and knowledge they need to care for people. Following induction training there is an expectation that staff will study for a National Vocational Qualification (NVQ) at either level two or three depending on the post they hold. On the day of the visit the manager had difficulty finding some records relating to staff training due in part to the fact that the training officer had recently left the company. However since the inspection the general manager has confirmed that a new training officer had been appointed and has provided us with a staff-training matrix and a training plan for 2009. Information provided by the general manager shows that the home intends to provide all staff with updated training in all key areas of their work in the first eight months of the year. We have asked the home to confirm in writing when the training has been completed so that we can be confident that people are being cared for by skilled and competent staff. Beechcliffe Residential Home DS0000001227.V373399.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36, 37 and 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The absence of a registered manager and the lack of effective quality assurance monitoring systems means that shortfalls in the service are not being identified and the home is not always being run in the best interest of people living there. EVIDENCE: The home has now been without a registered manager for about eighteen months and the providers are experiencing some difficulty appointing to the post. Until a new manager is appointed a member of the company’s senior management team has been designated as acting manager and is responsible for running the home on a day-to-day basis. Beechcliffe Residential Home DS0000001227.V373399.R01.S.doc Version 5.2 Page 22 The general manager and provider also visit the home on a regular basis to deal with any queries/concerns raised by either the staff or people living there. However, given the issues raised in the body of the report regarding poor recruitment practices, staffing levels and care planning we have concerns about the management of the service. Regular audits of policies, procedures and staff training would have highlighted the shortfalls in the service without us having to bring them to the attention of management through the inspection process. There are some quality assurance monitoring measures in place including sending out survey questionnaires to people living at the home and their relatives. The survey gives people the opportunity to express their views of the service and is an important part of the quality assurance monitoring process. It was recommended to the manager that survey questionnaires are also sent out to other health care professionals to enable them to comment on how they feel the home is meeting stated aims and objectives. The manager was asked to forward us a summary of the next survey results indicating what action the home is taking to address any concerns or suggestions. All staff should receive formal one-to-one supervision with their line manager on a regular basis to discuss care practices, training needs and their personal development. However, it was apparent when talking to staff that in the absence of a registered manager and because of staffing difficulties they had not had supervision for a considerable period of time. More needs to be done therefore to provide staff with the supervision and support they need to carry out their roles effectively. The home holds money in safekeeping for a number of people and transaction sheets are in place showing income, expenditure and a balance. The manager confirmed that only senior staff deal with financial transactions and regular audits are carried out to make sure the records are accurate and in good order. However, we found that in some instances the transaction sheets were not being kept up to date, which clearly indicates a shortfall in the auditing system. Record keeping at the home is generally poor mainly as a result of the previous manager and clerical staff having set up new systems and then leaving the homes employment. It was therefore difficult to find some of the information required as part of the inspection process including maintenance and service records. The manager is currently addressing this matter so that the home is able to evidence that people are living and working in a safe environment. Beechcliffe Residential Home DS0000001227.V373399.R01.S.doc Version 5.2 Page 23 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 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 2 X X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 2 2 Beechcliffe Residential Home DS0000001227.V373399.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement Care plans must give clear guidance to staff on how people’s needs are to be met. So that they receive the level of care and support they require. A new controlled drugs cabinet must be installed so that controlled drugs can be stored safely and in line with current legislation. People must be offered a range of appropriate social and leisure activities, so they have the opportunity to lead a full and active life. The home must provide us with an updated programme of planned refurbishment so that so we can be sure people are living in a safe and comfortable environment. Recruitment and selection procedures must be followed so that people can be confident that they are being cared for by staff that are suitable to work in the DS0000001227.V373399.R01.S.doc Timescale for action 31/01/09 2 OP9 13(2) 28/02/09 3 OP12 16(m) 31/01/09 4 OP19 23 28/02/09 5 OP29 19 31/01/09 Beechcliffe Residential Home Version 5.2 Page 25 caring profession. 6 OP33 24 Effective quality assurance monitoring systems must be put in place so that shortfalls in the service are identified sooner and people can be confident that the home is run in their best interest. 31/01/09 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 OP33 Good Practice Recommendations It is recommended that as part of the quality assurance monitoring system survey questionnaires be sent out to other health care professionals to allow them to express their views and opinions of the service provided. Beechcliffe Residential Home DS0000001227.V373399.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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.V373399.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!