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Inspection on 20/09/06 for Beechcroft Care Home

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

This inspection was carried out on 20th September 2006.

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

The inspector 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

Beechcroft provides a comfortable and safe environment for the people who use the service. Residents and families were encouraged to personalise their rooms with their own possessions. Positive feedback about the home was received from the residents, and relatives, all spoke positively about the delivery of care and the support provided from the staff team. Some comments made by the residents included: the staff team "are wonderful and receive good care", "they are more than helpful", "the home is good", "and we are well looked after here". The residents also spoke positively about the Registered Manager and the way he manages the home and provides clear and effective leadership. Residents commented that they would not hesitate to raise any concerns with him and were confident that he would deal with any issues immediately. They found him be approachable and liked the way he "makes time for a chat, and that his door is always open". Staff members spoken to were motivated, enthusiastic, experienced and knowledgeable and committed to their roles, to ensuring that the residents receive a good standard of care. They felt well supported by the management team and the training at the home was well organised and effective. The management and staff demonstrate a responsive approach towards residents needs.Residents were offered a choice and variety of meals, and resident`s commented that they enjoyed the meals. Residents also have access to a variety of activities inside the home and benefit from external entertainment visiting the home, and trips out.

What has improved since the last inspection?

The Registered manager has reviewed the pre-admission assessment he uses and this now covers all areas to ensure a full assessment is obtained. All residents had a plan of care in place; this ensures staff members are aware of individuals needs. Several areas of the home have been redecorated as requested, and the path around the home has been made safe for residents to use. All staff members have received access to all of the mandatory training ensuring they are competent to fulfil their roles.

What the care home could do better:

All information from the pre- needs assessments should be used to complete a comprehensive care plan that covers all areas to enable the staff team to deliver the appropriate support and assistance. The care plans need to be reviewed on a monthly basis in order to ensure any changes to residents needs are recorded and the plan is updated. The staff team need to ensure that residents are involved in the development of their plan. Detailed risk assessments must be completed that identifies the risk and how these should be minimised in order to assist staff on how to support residents, and these should be reviewed regularly. Improvements to the record keeping relating to the administration of medication need to be made, in order to safeguard staff and the residents. The registered person or a delegate for Beechcroft needs to make unannounced visits to the home at least once a month and carry out a quality review, in order to be satisfied that the home is being conducted in the manner that it should be.

CARE HOMES FOR OLDER PEOPLE Beechcroft Care Home Nursery Avenue West Hallam Derbyshire DE7 6JB Lead Inspector Key Inspection 20th September 2006 09:15 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.V312964.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. Beechcroft Care Home DS0000035748.V312964.R01.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 9098115 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.V312964.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th January 2006 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. Information about the service is provided in the Statement of Purpose and Service User Guide; both of these documents were made available to residents. Information included on the pre-inspection questionnaire received on 02/06/06 stated that the fees for the home were £348 per week. Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, carried out by one inspector, and lasted 7 hours. The inspection involved assessing key areas as defined by the CSCI. The inspector spoke with 15 residents and 2 relatives, and examined four files (using the Case tracking methodology, which is used to help determine how the home meets the needs of individual residents). A tour of the building was undertaken and time was spent observing residents and staff interaction. The inspector spoke with 3 staff members and examined three files. An assessment was also made of the progress by the registered persons to address the requirements made at previous inspections. The registered manager was on duty during this visit and the findings of this visit were discussed with him Following consultation with these people, it was agreed that they would be referred to as ‘residents’ for the purpose of this report. What the service does well: Beechcroft provides a comfortable and safe environment for the people who use the service. Residents and families were encouraged to personalise their rooms with their own possessions. Positive feedback about the home was received from the residents, and relatives, all spoke positively about the delivery of care and the support provided from the staff team. Some comments made by the residents included: the staff team “are wonderful and receive good care”, “they are more than helpful”, “the home is good”, “and we are well looked after here”. The residents also spoke positively about the Registered Manager and the way he manages the home and provides clear and effective leadership. Residents commented that they would not hesitate to raise any concerns with him and were confident that he would deal with any issues immediately. They found him be approachable and liked the way he “makes time for a chat, and that his door is always open”. Staff members spoken to were motivated, enthusiastic, experienced and knowledgeable and committed to their roles, to ensuring that the residents receive a good standard of care. They felt well supported by the management team and the training at the home was well organised and effective. The management and staff demonstrate a responsive approach towards residents needs. Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 6 Residents were offered a choice and variety of meals, and resident’s commented that they enjoyed the meals. Residents also have access to a variety of activities inside the home and benefit from external entertainment visiting the home, and trips out. 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 Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. Beechcroft Care Home DS0000035748.V312964.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 Beechcroft Care Home DS0000035748.V312964.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are assessed prior to moving into the home and the assessments provided staff with sufficient information to fully identify individuals’ needs and plan care. EVIDENCE: In the four files examined there was evidence to demonstrate that a Care manager had undertaken a needs assessment before a resident moves into the home. This ensures that individual’s needs are identified and that the home can demonstrate that they can meet these needs. The assessments were completed in adequate detail in order to direct the staff on the support and activities the individual requires assistance with. Discussions with residents, and relatives supported that individuals have been encouraged to visit the home, before they moved in. This enables them to “get a feel for the place”, as one resident stated, and to meet the staff and other residents. Some of the residents informed the inspector that they had visited for a period of respite and this enabled them to see “what it was like living here”, before making a decision about moving in permanently. Feedback also Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 10 indicated that residents and their families were provided with information about the home prior to and when they moved into the home. In response to the previous inspection report the Registered manager has updated the preneeds assessment and this now covers all of the required areas. Beechcroft Care Home DS0000035748.V312964.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 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. Residents care plans are not completed in sufficient detail in order to direct and inform staff on how individual’s needs should be met. The medication practices require further improvements to safeguard residents and staff. EVIDENCE: Of the four files examined during this visit, two was for individuals that had recently moved into the home. Although detailed information was provided in the pre-needs assessment, some of this information had not been transferred to the care plans in order to direct staff on the support individuals required. The information was brief in detail and some areas of the care plan was incomplete for example, religious and social needs. Information in relation to residents abilties and preferences, was not recorded, and there was limited evidence to suport that residents had been involved in planning their care. There was some information recorded about individual daily routines, but these were not competed in detail and two out of the four plans did not include reference to indivduals preferred rising and retiring times. There was brief information concerning individual’s likes and dislikes in relation to social activities and in reference to food. Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 12 Information in relation to individual’s health care needs was recorded and there was evidence to support that services are requested when required and residents and relatives confirmed this. All healthcare visits were recorded with outcomes of that visit. Although there was evidence that the care plans were reviewed on a monthly basis, two of the plans had not been reviewed since June, and when changes had been identified the care plan or the record of daily routine record had not been updated to include these changes. Risk assessments were seen in the resident’s files regarding nutrition, tissue viability, moving and handling, and falls. However some of these assessments were out of date and two were not reviewed in accordance with the guidance on the assessment. If equipment was required to support an individual this was recorded within the assessment to enable the staff team to be aware of what equipment to use. These issues were discussed with the Registered manager who stated that a period of short staffing has had an impact on the standard of the files. Discussions held with staff members on duty, and the observations made, confirmed that they were aware of individuals needs, and had a good knowledge of individual’s preferences. The staff members stated that information is passed on verbally so that they are informed of any significant changes. The residents spoken with confirmed that their needs are “more than met by the staff team”, and that the staff team were “good”, “caring”, “understanding”, “attentive” and always treated them with dignity and respect.” Feedback indicated that individuals are able to make choices and therefore are able to choose how they wish to spend their day, and follow their own routines. The relatives spoken with stated that the care provided was “good”, and commented on “how well their relative looked”. They also stated “how informed” they were by the staff team. The medication administration practices of the home were examined. All staff members that administer the medication had undertaken training a while ago, and the Registered manager stated that new revised training was planned for the future. The Medication Administration Records (MAR sheets) examined were generally completed satisfactory. The inspector did note that handwritten medication instructions had not been signed by a second person to validate them. This issue was also highlighted at the time of the last inspection and was discused with the Registered manager. Beechcroft Care Home DS0000035748.V312964.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 at least once during a 12 month period. 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. A range of suitable activities was provided, which met the leisure and recreational interests of the residents. The meals were good offering both choice and variety and catering for any special dietary needs. EVIDENCE: Residents informed the inspector that they were consulted about the provision of activities and felt that these were in accordance with their wishes and preferences. One resident commented to the inspector on how she had enjoyed the recent trip to Blackpool, and the visit to the tower. Information about the in-house activities available was recorded on the notice boards in the dining areas. The activities provided were varied and included movement to music, bingo, and nail care. The residents informed the inspector that they also enjoy entertainment that is brought into the home such as, singers and they commented on how much they had enjoyed the pantomime that they had watched last week. Both the residents and visitors to the home were looking forward to the quiz night that was planned and many family members had signed up to join in. Residents also have the provision of a pool table and a bar to enjoy, and the Registered manager discussed ideas on how to encourage residents to use these facilities more regularly. Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 14 The feedback received from the relatives confirmed how “welcomed” they felt when visiting the home, and how “well informed” they felt, confirming that and that the communication channels were good between themselves and the staff team. The relatives confirmed that they could visit the home at any time without any restrictions, and that they were able to use the resident’s bedroom if they wished or the lounge areas. The inspector was invited to have a lunchtime meal. The Residents spoken with commented that the meals provided met their preferences and they confirmed that choices were available at all times. There was sufficient dining space for residents, and dining tables were well presented with tablecloths, napkins, cutlery, condiments, glasses and jugs of juice. The lunchtime meal was served in an relaxed manner, and staff support was provided as required for those residents who needed assistance. Discussions with the head cook confirmed a good knowledge of the dietary needs of the residents and she confirmed that any individual with specific cultural requirements would be catered for. The menus in place were devised in consultation with the residents, by the hotel and catering manager, and the cook ensures that a balanced and nutritional diet is provided. A brief tour of the kitchen was undertaken, and all food was stored appropriately and fridge and freezer temperatures were generally recorded daily, but the inspector did note several gaps in this record. The inspector provided the catering staff with a copy of the publication devised by the CSCI on “improving meals for older people in care homes” which was devised following consultation with older people. Beechcroft Care Home DS0000035748.V312964.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 inspected at least once during a 12 month period. 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. A satisfactory complaints procedure was in place and people felt that their views were listened to and acted upon. Staff had a good knowledge and understanding of adult protection issues which protects residents from harm. EVIDENCE: The home has a complaints procedure and feedback confirmed that residents are aware of this procedure. Residents informed the inspector that they “were confident that any concerns they raised would be dealt with, without any hesitation”. The complaints procedure was available to all residents and relatives and was included in the Service User Guide, which all residents had received. The Registered manager informed the inspector that he had not received any complaints since last inspection. Residents were protected from potential harm through staff knowledge and training. The required polices and procedures were in place, and staff spoken with had a good understanding of these procedures and confirmed that they had attended safeguarding vulnerable adults training. The Registered manager was due to attend some training in this area in December 2006, and was aware of the procedures to follow in the event of a situation occurring. New staff member’s undertake an introduction to safeguarding adults as part of their induction training. Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Beechcroft is well maintained and furnished, providing residents with a homely and spacious environment to enjoy, which meets the particular needs of the residents. EVIDENCE: All areas of Beechcroft were found to be well maintained, clean, and well decorated at the time of this visit. Residents commented that it was always clean and fresh, as did the relatives spoken with. The communal areas were homely providing a comfortable environment for residents to enjoy, and the dinning areas were spacious and pleasant. The inspector was invited to view some of the bedrooms by the residents. All bedrooms were personalised with resident’s own belongings, and had the appropriate fixtures and fittings available. Residents spoken with were positive about the laundry service provided at Beechcroft. Aids and adaptations were provided and satisfactory to meet the needs of the resident group. All equipment had been maintained within the specified Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 17 timescales. The Registered manager confirmed that he had a programme of routine maintenance and renewal developed, and areas were decorated as required. A system is in place to report all repairs identified. Following the inspection from the Environmental Health Officer the kitchen was due to close for a period of a week in order to be decorated. Alternatives arrangements had been made for the provision of food to be provided for residents during this time. In response to the previous inspection report the paths around the home had been repaired and are no longer a hazard to residents, and some of the wooden facia boards have been painted. Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. 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. Resident’s benefit from being supported by a stable, motivated, experienced and competent staff team. Residents are protected from any potential risk’s, by the homes recruitment procedures. EVIDENCE: Residents were very positive about the standard of care delivered by the staff team and felt that their needs were more than met. Comments made by the residents included: “the staff are wonderful” and “marvellous” and “are always around”. The relatives also spoke very positively about the standard of care the staff team delivered, and commented on how “supportive and friendly the staff team were”. Observations of the staff team supported these statements as staff worked positively with residents and were patient and sensitive to their needs. Discussions with the staff team, confirmed that they had a good knowledge of individuals needs, and staff expressed their commitment and enthusiasm toward’s ensuring residents had a good quality of care. Staff said they feel supported by both their colleagues and their managers, and feel that they are offered good training opportunities. All staff had undertaken training in dementia, and commented how this course enabled them to have the skill and expertise to work “positively” with individuals. Staff felt they worked well as a team and that there was good communication between themselves and the managers. The staff did comment about the recent staff shortages due to Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 19 sickness and holidays. In response to this the Registered manager has reviewed the duty rota in consultation with the staff team, and changed the shift patterns. The staff welcomed this change and commented that they are looking forward to this new system being introduced as it means more staff will be on duty during the busiest times of the day. The inspector examined three staff files, and these contained majority of the information to evidence that all of the required checks have been undertaken. Derbyshire County Council has a thorough and detailed recruitment and selection procedure, and all recruitment documents are held at the human resource department, then copies are sent to the Registered manager. The files supported that staff have access to regular supervision, and had completed all of the mandatory training. Thorough induction training is provided including shadowing of experienced staff, and this was seen as helpful and contributing to staff job satisfaction. The Registered manager confirmed that all staff members apart from the staff recently employed, have completed the National Vocational Qualification (NVQ) level 2. Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 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 manager provides clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities ensuring that the home is run in the best interests of the service users. EVIDENCE: Residents spoke highly of the manager and the staff team, and commented that the manager would deal with any issues that they raised with him. Comments made about the manager included “he is wonderful”, “he always finds time to come and chat to us”. The manager is seen as approachable, responsive, knowledgeable and supportive and displays good leadership skills. He continues to update his skills and knowledge through training, and has completed the NVQ Level 4 in care and management. The inspector was informed that the service manager visited the home regularly, but not on a monthly basis as required. The Registered manager has only received one Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 21 report this year of the monthly monitoring visits undertaken and this was dated 09/05/06. Quality assurance systems were in place. Residents were given the opportunity to contribute to the running of the home through residents meetings, and a resident questionnaire. Regular senior and staff meetings take place in order to ensure everyone is updated on any issues. The management of resident’s finances was examined and this was satisfactory with individual transaction sheets in place and receipts obtained for all purchases made on behalf of individuals. The money held in safekeeping cross-referenced to the balance recorded on the transactions sheets. A staff training matrix was in place, detailing when staff had attended mandatory training. The training records and staff confirmed that they were up to date with mandatory training. Information on maintenance and health and safety records was provided by the Registered manager in the pre-inspection questionnaire. This indicated that matters pertaining to maintenance and health and safety were satisfactory. Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 22 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 3 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 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 3 2 X 3 X X 3 Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15(1) Requirement The residents care plans must be completed clearly and specifically and state the staff action required in order that identified needs can be met. The care plan must include information on all areas specified in National Minimum Standard 3.3 (Previous timescale was 01/03/06) Timescale for action 01/12/06 2. OP8 13(4)(c) 3. OP9 13(2) 4 OP33 26 The plans must be reviewed on a monthly basis and any changes recorded on the plan of care. Each resident must have a 01/12/06 detailed risk assessment that identifies the risk and ways in which the risk can be minimised. This assessment must be kept under review and signed and dated. All hand-written medication 01/12/06 instructions must be signed, and dated by two staff members to validate them (Previous timescale was 01/03/06) The person registered must carry 01/12/06 out the monthly unannounced visits and prepare a written DS0000035748.V312964.R01.S.doc Version 5.2 Page 24 Beechcroft Care Home report. This report must be provided to the registered manager. 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 OP3 OP4 Good Practice Recommendations The staff should ensure that all of the residents details as required by Schedule 3 of the Regulations are recorded within their files. The staff should ensure that information from the preneeds assessment is transferred to the care plan in order to be able to demonstrate that the home is able to meet individual’s needs Residents care plans should include information about their preferred routine, likes and dislikes in relation to hobbies and food, and information about their background. Residents or their representatives should be involved in the development of their plan and be part of the monthly reviews of these plans. An assessment of medication competence, which should be completed on all staff members that administer medication. 3. OP7 4 OP9 Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beechcroft Care Home DS0000035748.V312964.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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