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Inspection on 20/08/08 for Beechcroft Care Home

Also see our care home review for Beechcroft Care Home for more information

This inspection was carried out on 20th August 2008.

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

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

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

People told us they found their move into the service to be a positive transition and they said they were supported by the staff team. People told us they were "well cared for", "the staff were brilliant and helpful", and that they "had enough to do in the home to keep them occupied". People said their needs were met to a good standard and with "dignity and respect at all times". Feedback provided in the surveys confirmed that people were supported in accordance with their needs, and comments made included "the staff do a great job, nothing is too much trouble", I am so thankful to have such care and attention from all of the staff and management". "the staff are brilliant very caring, always helpful and kind, I would recommend Beechcroft to anyone". "the manager is always very helpful, and efficient". This service provides a comfortable and safe environment for the people living there. People are encouraged to personalise their private space to their own liking and to bring in their own possessions and small items of furniture. The staff team are a committed group who work well together to provide a good standard of care for people living at the home; they are supported to do this through good training and increasing opportunities to obtain the recommended qualifications. The staff have a good understanding of the needs of people and they were observed to be patient, relaxed and professional in the way they communicate and help people retain dignity and individuality. The manager is regarded as approachable and responsive by everybody involved with the service. The service has been generally well maintained and there were satisfactory standards of cleanliness throughout.

What has improved since the last inspection?

This service had 7 requirements and 2 recommendations from the previous visit we carried out. The service has addressed 6 of the requirements and both recommendations The improvements made include: the detail in the care plans has improved so that more information is provided, but further progress with this is required to make them person centred. There was evidence to support that individuals are involved in their care plans and they are now consulted about the contents. The activities that people participant in, is now recorded and monitored to ensure their recreational needs are being met. Peoples consent is obtained before bed rails` are implemented and this is reviewed regularly. This is to ensure they are used only in the best interests of the person. The medication practices have improved in some areas, but again this requires further improvements and monitoring. The recruitment practices have been improved to ensure they safeguard people who live in the service.

What the care home could do better:

The documentation in place would benefit from being reviewed to include the six strands of diversity, which are: race, gender identity, disability, sexual orientation, age, religion and belief. This will make it inclusive to all people. The completion of risk assessments needs to be more robust and an assessment completed as soon as someone moves into the service so that any needs can be identified and a care plan devised. A system is required to ensure this is undertaken and to ensure all risk assessments are reviewed as required to ensure people`s needs are being monitored and met. A monitoring system of the medication practices and records needs to be implemented to ensure staff continue to maintain good standards, and ensure detailed and accurate records are completed. There have been changes in the law to the way controlled medication is stored; therefore the service must ensure their storage meets the new requirements. This is to ensure people`s controlled medication is stored appropriately. A delegate of the provider is required to undertake unannounced monthly visits to the service in order to monitor standards. This issue has been raised in the last two reports and no improvements have been made to address this noncompliance. Good practice recommendations have been made in relation to: Staff training, care planning documentation, and the provision of activities. This is to improve the service that is currently provided.

CARE HOMES FOR OLDER PEOPLE Beechcroft Care Home Nursery Avenue West Hallam Derbyshire DE7 6JB Lead Inspector Claire Williams Unannounced Inspection 20th August 2008 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 Beechcroft Care Home DS0000035748.V370437.R03.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. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechcroft Care Home Address Nursery Avenue West Hallam Derbyshire DE7 6JB 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) 0115 8791635 paul.miller@derbyshire.gov.uk www.derbyshire.gov.uk Derbyshire County Council Mr Paul Miller Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following category 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 40 30th October 2007 Date of last inspection Brief Description of the Service: Beechcroft is situated within a residential area of West Hallam, near Ilkeston. The Home is owned by Derbyshire County Council and is registered to provide residential care for 40 older people, all within single rooms on the ground floor. It has a small car park at the front of the property. The Statement of purpose, service user guide and inspection report is made available to people who use the service and is kept in the foyer. The current fees for this service are £368.00 per week. Extras include hairdressing, chiropodist and toiletries. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for the service is one star. This means the people who use the service experience adequate quality outcomes The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The inspection visit was unannounced and took place over a period of 7 and half hours. In order to prepare for this visit we looked at all the information that we have received. This included: • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The annual quality assurance assessment (AQAA). This is a selfassessment that focuses on how well outcomes are being met for people using the service. • Surveys – we sent these to the people that live in this service and the staff team. We received 4 surveys from people and 9 from the staff members. And one from a health professional. Comments and evidence from these have been included in this report. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of four people representing a cross section of the care needs of individuals within the home. Discussions were held with those individuals as able, together with a number of others about the care and services the home provides. Their care planning and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their care and also for staffs’ recruitment, induction, deployment, training and supervision. We also spoke with two visitors who were in the home at the time of this visit. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? This service had 7 requirements and 2 recommendations from the previous visit we carried out. The service has addressed 6 of the requirements and both recommendations The improvements made include: the detail in the care plans has improved so that more information is provided, but further progress with this is required to make them person centred. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 7 There was evidence to support that individuals are involved in their care plans and they are now consulted about the contents. The activities that people participant in, is now recorded and monitored to ensure their recreational needs are being met. Peoples consent is obtained before bed rails’ are implemented and this is reviewed regularly. This is to ensure they are used only in the best interests of the person. The medication practices have improved in some areas, but again this requires further improvements and monitoring. The recruitment practices have been improved to ensure they safeguard people who live in the service. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 8 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. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 9 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 Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 10 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): National Minimum Standards 1, 3 and 5 (standard 6 not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are assessed and have access to information to enable them, to make an informed decision about moving into this service. EVIDENCE: In the self-assessment the manager told us that all people are encouraged to visit the service for a period of short term care, so they can experience life in this home. This time is used to gather information about the persons needs, and information is provided to them about this service. We spoke to people and their families about the admission process, and they confirmed they were provided with the required information to enable them to be informed about the service and their rights. They also confirmed that an assessment of the support they required was undertaken before they visited this service. This was supported by the records in place in the three files that we examined. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 11 People and their families said they found the admission process to be a supportive one and staff were described as “caring and friendly”. People said they had an opportunity to visit the service and one person said: “I wanted to see if it met my needs and see if I could make it my new home”. Another person said: “I visited different homes, and even tried another one out, but I chose this one as it is homely and I feel comfortable here”. The service does not provide intermediate care and there were no residents accommodated at the time of the site visit with diverse cultural or religious needs. The documentation in place does not cover the six areas of diversity, and therefore is not inclusive to all people. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 12 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): National Minimum Standards 7, 8, 9, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported with respect and dignity, and have care plans in place that reflect their needs. However gaps in healthcare records mean that they do not reflect the support or practice provided. EVIDENCE: In self-assessment the manager told us; personal service plans tailored to individual needs are in place which are reviewed six monthly. They ensure people access to health professionals, and to specialist equipment. He told us risk assessments are is carried out as needed, which are reviewed regularly, by monitoring “scores”/ outcomes. He told us that all staff that administered medication have received training in this area. The care records are available both on a computer system and in paper format. We examined four files and all contained a care plan that had been formulated using the pre-admission assessment. Although their was sufficient information to direct staff on the delivery of care the information provided was not person centred, but task focused. This prevents staff from providing individualised care based on the person preferences and abilities. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 13 There was limited information about the person’s background and about individual’s likes, dislikes, and preferences. People’s routines were recorded but this record was not always dated so it was difficult to ascertain how old the record was and if it was still relevant to the person. People and their families confirmed they had been involved in the development of their care plan and all had been signed by the person, which is good practice. There was evidence to support that the care plans had been reviewed monthly but this practice was not consistent in all of the files, as two files had gaps were some months the care plan had not been reviewed. Some of the comments made on the review of the care plan were limited and did not demonstrate if the person’s needs had changed. Each file contained all of the required risk assessments and risk management plans to help staff support people in a way that will minimise any risks, and to monitor any key health needs. However the date of the assessments indicated that these were completed at least three weeks after people’s admission. One of the risk assessment had not been updated as indicated by the assessment timescales. These issues have been raised in the last two inspection reports and have not been met. Although most people who we spoke with said they have access to healthcare professionals, a visitor commented that they had been asking since February 2008 for their relative to have an eye test due to deterioration in their eyes. They said they had asked several staff members to arrange an optician’s appointment, but was given the same response, and no action had been taken. This issue was addressed immediately during our visit and an appointment arranged. Discussions with staff members demonstrated their knowledge of each persons needs, and they confirmed they had read each person’s care plan and were informed about any changes. All people spoken with and families spoke positively about the standard of care provided and the following comments were made during our discussions: “the staff are brilliant, absolutely marvellous” “ I think they do a great job, they are really caring people” “I think they are excellent and provide good care” “they treat me like a person and have never talked down to me , which is really important”. People told us they receive their medication in accordance with their wishes. Some improvements have been made since our last visit, but we identified Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 14 some re-occurring issues, which included; handwritten instructions not countersigned, and the dosage and frequency not being recorded. This is not good practice and has been highlighted in the last two inspection reports. Once these issues were identified the records were updated to include all of the required information, in order to minimise any errors being made. It was reported that all day staff that administer medication have undertaken some form of training in this area, which included an assessment of their practice. However the night staff who also have some responsibility for medication have not undertaken this training. It was reported that an observation of their practice would be undertaken within the next few weeks to ensure they are competent. It was reported that a pilot scheme is currently in place for night staff to complete national vocational training and one night staff was currently undertaking this, which includes medication training. Due to a change in the law the storing of controlled drugs must now be in accordance with the new legal specifications, and the service needs to ensure there current storage is in accordance with these. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 15 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): National Minimum Standards 12- 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People at the home enjoy lifestyles and routines that suit their varying levels of ability and interest, and have the opportunity to take part in organised leisure and social activities EVIDENCE: In self-assessment the manager told us; that a choice and a range of activities is provided to people. There is information in people’s files about their daily routine, so individuals can say how they would like their day planned out. Two members of staff that have been trained to carry out chair based exercises with people. He told us that people receive nutritious and a choice of meals and relatives are encouraged to dine with individuals. They received 4 stars following a recent environmental health inspection and provide people with a pub style bar. People that we spoke to said they “had enough to do in the home”, and feedback about the provision of activities was positive. People said their expectations were being met and they enjoyed the variety of activities available. Examples of what is provided are: bingo, board games, chair exercises, motivation sessions, hair and beauty, and computer games. In Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 16 addition to this people told us they have a monthly trip out and a variety of external entertainment is arranged. Activities are provided by a member of the care staff who has a dual role of care and activities. She reported that she usually manages to facilitate activities in the week for at least an hour but sometimes this time is compromised by her caring role. This can result in people with high dependency needs not always receiving one to one time due to the limitations of her role. Information about forthcoming events is available on the notice board and in the newsletter that is produced each month for people, and their families. Visitors spoken with said they have enjoyed many events at the service and this is what creates a “homely feel to the place”. A small bar is also available which all those spoken with thought was an excellent idea as it encourages people to socialise. The care plans we looked at contained some information about people’s preferences and likes/dislikes, in respect of activities. There was limited information about people’s background history and life experiences. This information is beneficial as it enables the staff to be more informed about people’s previous lives and experiences. The visitors that we spoke with were very positive about the service. They said they always felt welcomed into the home and commented “it has a relaxed feel”, the staff are always friendly, and “it’s a lovely home”. People told us they liked the food provided, and that choices were always available. It was reported that the cook had information about people’s dietary requirements and their likes and dislikes. The menus are devised around these. One person we spoke with commented “sometimes my family come to my house for dinner which is very nice”. This demonstrates how the service aims to create an inclusive environment. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 17 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): National Minimum Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are able to express their concerns and have access to a complaints procedure and they are protected from harm and have their rights protected. EVIDENCE: In self-assessment the manager told us; all people who live in this service and their families are informed about the complaints procedure. In the entrance of the home they have a complaint and suggestion box. People have regular meetings to raise complaints/concerns and they feel able to discuss concerns with any member of staff. He told us a ‘resident’s forum’ has been set up across the six homes; two representatives from each home attend, where they can discuss issues. It is chaired by a person not connected with any of the homes. He told us all staff have received training in adult protection. People spoken to told us they had no complaints and would not hesitate to raise any issues. People told us they were confident the manager would sort any issues out. All relatives told us that both the staff and manager “listen to them and are generally pro-active in dealing with issues”. Feedback from the surveys also confirmed that the service responds to any issues raised. There have been no complaints received by the service or us since our last visit. Safeguarding adult’s procedures are in place and records indicate that all staff, apart from new starters had attended training about dealing with abuse. The staff spoken to were able to describe an understanding of their responsibilities in reporting suspicions of abuse, and the manager was familiar with reporting Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 18 procedures and how to refer to the Protection of Vulnerable Adults (POVA) list; there have been no allegations made involving people living at the service since the last inspection visit in October 2007. The manager had received information about the Mental Capacity Act and it was reported that training was being planned for the future. It was advised that some forms should be obtained so staff could record decisions people made, which are in line with the requirements of the Mental Capacity Act. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 19 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): National Minimum Standards 19, 23, and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in an environment that is safe and meets their needs. EVIDENCE: In the self assessment the manager told us; they provide a warm, homely environment. Individuals are encouraged to have their rooms decorated to their own choice, and to bring in a limited amount of soft furnishing to make their room feel homely. Individuals have chosen the new furniture, floor covering and wallpaper in the communal areas. He told us that some people choose to have their own telephone lines and all bedrooms have their own television and call system. He said all faults are reported and dealt with promptly and all areas of the home are cleaned to the highest standards. He told us a risk assessment is in place to make the environment safe and free from hazards. We undertook a brief tour of the building and visits to some of the bedrooms demonstrated that the building was safe and that people are encouraged to Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 20 personalise their rooms. Individuals spoken with said they were very comfortable and liked their rooms. People and visitors commented that the home was always clean, and never smelt, this was observed on our visit. It was reported that a programme is in place for the renewal of areas such as the bathrooms and toilets as they are looking worn. People who we spoke with said they liked the communal areas and the layout of the service. People said they have access to various aids and equipment in order to assist them in their mobility and to get around the home. The feedback from the surveys was also positive about the building and people said it met their needs. People said they are involved in decisions about the décor and any changes in their communal and personal accommodation are discussed within ‘residents meeting’. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 27- 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported by a trained and skilled staff team. EVIDENCE: In the self assessment the manager told us they provide a highly trained and professional staff group. He told us that improvements in recruitment of staff could be made in order to get staff into posts quicker. Other improvements included; the employment of staff on a flexible rota to facilitate the covering of shifts to support the needs of the home and people. He told us training has improved and skill for care enables staff to be automatically put forward for training. He said the lengthening of shifts has enabled improved coverage for the home and more time to spend with the service user. He said he would like to improve the rotas to make them more flexible for improved coverage of the home and give staff more access to training that is not mandatory. Examination of the duty roster and information provided in the self assessment indicated satisfactory levels of care staff on duty during the week of the inspection. It was reported that there are currently care vacancies which is having an impact on the service as existing staff are covering these shifts. The feedback from people and their family members indicated that sufficient staff were available when needed and in suitable numbers to provide the right support. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 22 Staff told us they are encouraged to undertake NVQ training, and that there are extensive opportunities for further training – ‘we have many training opportunities’. We looked at the files of three staff for evidence of the procedure that had been followed for their recruitment, and they contained safe and satisfactory information showing that proper checks had been carried out. People said their needs are met and confirmed that staff provided a good standard of care and support, comments made include: “they look after me really well they are good girls”, “The staff are wonderful” “they are kind and caring and we have good banter”. The staff files and the training matrix demonstrated that staff have access to regular training, and there were certificates to support the training received in a files which included their induction. This ensures they have the skills and knowledge to fulfil their role and provide a good standard of care. Discussions with staff demonstrated their understanding and knowledge of peoples needs. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 31, 33, 35, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is managed to ensure it provides a safe environment in which to live and work. EVIDENCE: In the self assessment the manager told us that there has been no change to the management team and all managers are trained to a high standard. He said all managers have completed training in risk management, protection of vulnerable adults, medication code of conduct, first aid, supervision, recruitment and selection, and the organisations policies and procedures. Feedback from people, relatives and the staff team indicated that the management team were approachable and supportive. The manager was described as being “very helpful”, and “always on hand”. However it was Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 24 reported that the communication processes between the managers could be improved following a lack of communication about the need to arrange a healthcare appointment for a person in the service. The systems in place for looking after people’s money was found to be satisfactory and the system in place remains’ unchanged. The self assessment indicated good standards of health and safety activity, and regular servicing of equipment. Observations made around the building indicate that the home is hazard free. People said they are consulted about aspects of the service through the provision of meetings, questionnaires and informal discussions. A report was displayed of the outcome following the most recent quality assurance survey, and this indicated people’s satisfaction. Areas for improvement were also included in the report as was the action the service intends to take in response to these. It is a legal requirement that as part of the quality monitoring system a delegate of the provider visits the service on a monthly basis to monitor the standards, records and to complete a report. However there is still no progress in this area and the previous requirement has not been met. This issue has been identified in the last 3 reports, but has not been addressed by the provider. A delegate has not visited the service and produced a report since March 2007. People and their families told us that they think the service was managed well. The manager was said to provide leadership and direction, and aims to improve the service delivery. The service aims to provide an increased quality of life for people with a focus on equality and diversity and promoting human rights, especially in the areas of dignity, respect and fairness. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 x 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 13(4)(c) Requirement Each person must have a risk assessment completed following their admission to the service. This must then be reviewed at the required intervals. A system must be devised to ensure this is monitored and completed. This is to ensure that people’s healthcare needs are identified and met by the service. A system must be implemented to improve communication between staff and visitors in respect of taking action and arranging healthcare appointments. This is to ensure people receive access to healthcare services. A system must be implemented to monitor medication practices and standards in the service to ensure they are in accordance with the procedures and to ensure people receive their medication as prescribed. All medication records must contain the full prescribed instructions. This is to ensure Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 27 Timescale for action 01/11/08 2. OP8 13 (1) (b) 01/11/08 3. OP9 13(2) 01/11/08 4. OP9 13 (2) 5. OP33 26 people receive their medication as required. The current storage for 01/11/08 controlled drugs must be checked to ensure it complies with the royal pharmaceutical requirements. This is to ensure medication is stored in accordance with the law. The registered person must carry 20/08/08 out the monthly unannounced visits and prepare a written report. This report must be available in the service. This is to ensure they are monitoring the standards in the service (Requirement not met, enforcement action maybe considered). 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 OP2 OP7 Good Practice Recommendations The admission records should be reviewed to incorporate the following areas of diversity: race, gender identity, disability, sexual orientation, age, religion and belief. The care plans should be reviewed every month and the review should reflect if any changes have been identified. The review should be undertaken were possible with the individual. Each person should have a care plan that is person centred and includes their ability to be independent and their preferences on how they would like to receive the support they require. All handwritten medical instructions should be signed and validated by two staff members to ensure they are accurate DS0000035748.V370437.R03.S.doc Version 5.2 Page 28 3. OP7 4. OP9 Beechcroft Care Home 5. 6. 7. OP9 OP12 OP12 8. 9. 10. OP18 OP30 OP36 All night staff should receive medication training if they undertake these tasks as part of their role. Information about peoples past history should be obtained and recorded as part of their care plan. This so people are supported in an person centred way. A designated activities person should be employed or have designated hours for the provision of providing activities, outings, and providing one to one time with people with high dependency needs. The domestic staff should attend safeguarding adults training to ensure they have the skills to respond any situations they may witness. All care staff should access training in mental capacity act, so they are aware of how to support people to make decisions The management team should ensure that all staff are supervised as recommended in the National Minimum Standards six times a year, and have access to regular staff meeting. Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Beechcroft Care Home DS0000035748.V370437.R03.S.doc Version 5.2 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. 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