Inspection on 30/10/07 for Beechcroft Care Home

This inspection was carried out on 30th October 2007.

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

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

Other inspections for this house

Beechcroft Care Home 20/08/08

Beechcroft Care Home 20/09/06

Beechcroft Care Home 16/01/06

Beechcroft Care Home 21/03/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Beechcroft Care Home Nursery Avenue West Hallam Derbyshire DE7 6JB Lead Inspector Helen Macukiewicz Key Unannounced Inspection 30th October 2007 09:00 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 Beechcroft Care Home DS0000035748.V347593.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.V347593.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) 01629 580000 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.V347593.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th September 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. The Inspection report is made available to people who use the service and is kept in the foyer. The manager stated that the fees for the home were £368.00 per week. Extras include hairdressing, chiropodist and toiletries. Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and lasted 7.5 hours during one day. 5 preinspection questionnaires were received from people living in the home. Most had been completed with the assistance of a member of staff. Findings from these questionnaires are included in this report. The Manager had completed a self-assessment of the home and information from this was used in the planning of this inspection. Computer held records of all contact between the Home and the Commission for Social Care Inspection since the last Inspection were also referred to in the planning of this visit. During this Inspection discussion with people who use the service and their relatives took place. Time was spent in discussion with the Manager and staff. Eight care files belonging to people who use this service were looked at in detail and their care was examined to see how well records reflect care practices within the home. Relevant records belonging to the home were also examined such as complaints and policy documents. A brief tour of the home took place including some bedrooms. What the service does well: All residents care files that were seen had a clear and detailed pre-admission assessment recorded in them. One resident said ‘you can’t fault it - it’s lovely here’. Relatives and residents on the day were very satisfied with the care they get. Comments included ‘I am full of praise for the home’, ‘my relative wouldn’t be here now if it wasn’t for this home’, ‘the homes’ magnificent, they can’t do enough for the old people – you can’t fault it’ and ‘they are well looked after’. All residents and relatives confirmed that staff treat them with respect and that their privacy is maintained. During the Inspection there was plenty of evidence to support that daily social events take place. All residents and relatives spoken with on the day of the Inspection said that the food is good. Residents were satisfied with the system for making complaints and felt that the manager was approachable. Relatives and residents were highly satisfied with the staff. Comments included ‘staff here treat people like their family, they have a lot of tolerance’, ‘staff are Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 6 always willing to help’, ‘there’s always someone around in the night’, and ‘the staff are always pleasant’. Staff receive good levels of training. The manager is aware of his responsibilities and has reported incidents to the Commission for Social Care Inspection as needed throughout the year since the last Inspection. One relative said ‘nothing is too much trouble for Paul (the manager)’ another said ‘I have total confidence in Paul’. What has improved since the last inspection? What they could do better: All files contained a ‘plan of care’ although these lacked sufficient detail to advise staff what care the resident required. Most care files had not been signed as agreed by the resident or their advocate and many consent forms were also missing a signature. Improvements are needed to the management of medicines within the home. Records of social care need to reflect the actual care given in this area. None of the relatives spoken with knew how to contact the Commission for Social Care Inspection or their role in the complaints procedure, and few knew of the availability of the Inspection report. One resident had not consented to the use of bed rails. Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 7 In terms of recruitment, the manager was unaware of the need to obtain written verification why the person had ceased to work in employment with vulnerable adults. Monitoring visits made on behalf of the registered provider are not taking place as regularly as required. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beechcroft Care Home DS0000035748.V347593.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.V347593.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): Standards 1, 2 and 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People have the information they need to choose a home that will meet their needs. EVIDENCE: In the pre-inspection information provided by the manager, he said that the information about the home (Service Users Guide and Statement of Purpose) had been updated in the last 12 months so that it contained more specific information about the activities undertaken. Also that information is provided at a level to which people can understand. This is available in large print,audio and different languages . The information accurately reflected the accommodation and services provided on the day of this Inspection. This information was readily available to Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 10 residents, being placed in several areas of the home. Relatives confirmed that they had been given written information about the home. The managers’ pre-inspection information also recorded that service users can pre-visit the home, with family or advocate, usually a day visit, or for a period of three weeks short term care. This time is used to gather information about the service user, and to share information about the home. All residents care files that were seen had a clear and detailed pre-admission assessment recorded in them. Relatives were able to support that an assessment of need is undertaken by the home and that they received information about the home prior to placing their relative there. One relative confirmed that there was a 3-week trial period at first to see if they liked it, that they were made to feel welcome and that they were also part of the assessment process. Two relatives, independent of each other, said they had been that satisfied with the home that they would choose to live there themselves if they ever needed a care home. One resident said ‘you can’t fault it - it’s lovely here’. Beechcroft Care Home DS0000035748.V347593.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): Standard 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. Care records and medication systems do not reflect the good practice in the home or support that people receive the care they need. EVIDENCE: The Manager said that a new computerised system had been set up to record residents care needs. Six peoples’ care files were seen. All had some risk assessments in place although most files had at least 1 essential risk assessment missing. Risk assessments were not being regularly updated as indicated by the assessment timescales, and some had been completed some time after the resident had been admitted. These were all requirements of the last Inspection report that have not been met. Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 12 All files contained a ‘plan of care’ although these lacked sufficient detail to advise staff what care the resident required. Many had not been updated with important changes to care needs. Some care plans did not reflect the actual needs of the resident as described through their daily logs. Residents who had a degree of dementia type illness did not have appropriate care plans in place to meet that type of need. Some essential basic information was also missing. These were all requirements of the last 2 Inspection reports that have not been met. Most care files had not been signed as agreed by the resident or their advocate and many consent forms were also missing a signature. In questionnaires completed by residents, most felt that they did receive the care they require but one felt this only happens sometimes. Three felt they could get medical attention when needed but 2 felt this was not the case. Care files did however support that residents receive the services of the G.P, dentist, optician and Chiropodist. There was also evidence of liaison with hospitals and district nurses. Despite gaps in record keeping, relatives and residents on the day were very satisfied with the care they get. Comments included ‘I am full of praise for the home’, ‘my relative wouldn’t be here now if it wasn’t for this home’, ‘the homes’ magnificent, they can’t do enough for the old people – you can’t fault it’ and ‘they are well looked after’. Finally ‘we have been pleasantly surprised how well our relative is looked after and how happy he is’. One visiting professional, in their pre-inspection questionnaire recorded that “reviews of the service user I was involved with have been very positive. The service user has settled well and gives positive feedback re the care provided”. All residents and relatives confirmed that staff treat them with respect and that their privacy is maintained. Visitors all confirmed that their relatives are always nicely dressed and clean. Since the last Inspection the Manager had reported that 2 residents have sustained falls whilst in the home that required hospital treatment. There were adverts for falls awareness training sessions in the office and the Manager said that staff regularly attend such events. A new hoist has been purchased to complement the equipment already available within the home. The administration of some medicines was observed and also a check of storage areas and stocks of controlled medicines. Administration: Medication administration was largely satisfactory although the practice of signing in advance of medications being taken was observed. Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 13 Records: The medication administration records contained some gaps so it was difficult to know whether residents had been receiving their medication as needed. Some hand written alterations had not been signed by a second person to support the instructions was correct and some signatures on one record had been crossed out without explanation. The need for 2 signatures on hand written records was a requirement of the last 2 Inspections that has not been met. Storage: Some inhalers, which a resident self-administers, had been left out in their bedroom, this area was unlocked and had been left empty. One container of eye drops had not been dated upon opening so it was hard to assess when the medication expired as it has a short ‘shelf life’. One container of a liquid medication awaiting return to the chemist had not been stored in an appropriate medicines cupboard The storage of controlled medicines was satisfactory and a check on stock proved correct. In the managers pre-inspection information he stated that staff have received medication training and that he hopes to plan more in the next 12 months. Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 14 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): 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 live a varied and fulfilling lifestyle although records do not support this is the case for all. EVIDENCE: In the managers pre-inspection information he recorded that they are ‘planning to offer a wide range of religious services, whether it be in the home or visiting local worshipping places, to meet the individual needs. Outings will be planned taking into consideration those with additional needs, or who have increased disabilities and have been more restricted in the past. Staff have had sensory training. This training as highlight the need for us to make the following changes,update the loop system, menus in large print,and to have a wider range of audio library books’. Also that ‘a deputy manager, and a care assistant designated to provide a choice and a range of activities. E.g Outings, entertainment within the home. Documentation on outings and activities completed. Also photographs of these are displayed.’ Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 15 During the Inspection there was plenty of evidence to support that daily social events take place. These were well advertised around the home. One relative knew that residents had recently been on a trip to Ilkeston Fair. One resident confirmed they regularly go out to the shop. Residents said they play dominoes, do exercise and play Bingo, attend knitting sessions and musicals. One said ‘we have a lot to do’. Residents also said they had been on trips out to Skegness, Blackpool, Denby Pottery and were looking forward to going out for a Christmas Lunch. The home was decorated for Halloween and special food was being made in preparation for a Halloween party. Staff showed photographs of a similar event that had taken place the previous year. In their completed questionnaires most residents felt that there were usually enough activities planned. It was evident that the home provides a varied and regular social programme for residents. However, care files did not fully reflect the efforts made. Most showed that residents have had an assessment of their preferred daily routine and some had a basic social care plan in place. However, care files did not provide staff with clear instructions about what residents social needs were and how to meet them. Although there was a record of the social activity for some residents, those who were less able to participate in group activities/trips or who were socially isolated through choice, had little or no evidence that their social needs were being met. The Manager was able to verbally describe how staff achieved this. This was not reflected in records made. Residents described a flexible daily routine and said they could do as they wished and go out when they wanted. They are able to have a choice about not only their daily routine but also about things more generally such as the choice of wallpaper for the general areas of the home as well as their bedrooms. A small shop had been set up within the home, run by staff so that residents who were not able, or choose not to go out can purchase their own toiletries and snacks, allowing them to have more choice and control over their lives. A bar selling alcoholic beverages also run by staff is open nightly and is also popular with residents. All residents and relatives spoken with on the day of the Inspection said that the food is good. Comments included ‘the chef will cater for individual needs’ and ‘you can have lunch here on a Sunday for a small fee (relatives)’, The menu for the week was on display in each dining room and accurately described what was being prepared. There is a kitchenette near all bedrooms and residents said they could use these facilities anytime. Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 16 Residents questionnaires prior to this inspection also showed that they are generally happy with the meals provided. A questionnaire completed by a visiting professional recorded in a section for areas the home does well “ liaises with relatives, social events in the home, personal care, good meals”. In the managers pre-inspection information he recorded that ‘on listening to the views of the service user we have changed the times of the meals Eg instead of a flexible breakfast period the service users chose a set time of 8.30am. By opening a bar at 6.00pm until 8.00pm at night, the service user gets a choice of an alcoholic drink or soft drink being served as requested at meetings’. ‘Cultural evenings are planned to introduce the service users to sample foods from around the world’. And ‘regular meetings with the service users highlight choices of foods preferred and activities to be undertaken,- all recorded’. Beechcroft Care Home DS0000035748.V347593.R01.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): 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. Peoples’ rights to complain are upheld and they are safeguarded. EVIDENCE: The managers pre-inspection questionnaire stated ‘In the service users guide it informs residents and families of DCCs complaints procedure. In the entrance of the home we have a complaint and suggestion box. Service users have regular meetings to raise complaints/concerns. Service users feel able to discuss concerns with any member of staff. A residents forum has been set up across the six homes, two representatives for each home attend, where they can discuss issues. It is chaired by a person not connected with homes.’ The Commission for Social Care Inspection has not received any complaints about this service since the last Inspection. The Homes’ records showed that they had received 4. The Manager had not signed off 2 of the complaints although they had been dealt with. There were incomplete records of 1 complaint, which simply stated that it had been passed on. rec In their completed pre-inspection questionnaires three residents said that they did not know how to complain, and two said they did. However, all residents Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 18 and relatives spoken with on the day of the Inspection were satisfied that they could make a complaint. One relative said that a problem they had was sorted out straight away. Another relative said ‘if you have a problem you go and see Paul (the manager) he is very approachable and has got time for you - we have no complaints’. A further relative said ‘the staff are approachable, I’m sure they would do something about it’. One relative said that the staff are often aware of their concerns even before they approach them about things. One resident also said ‘if you want to know anything you only have to go and see Paul (manager) if you are worried he will help you’. Staff confirmed that they have received safeguarding training and get yearly updates. The manager had a list of all staff who had attended updates this year and a date for when the remainder were booked to attend this. There were safeguarding procedures available at the home. None of the relatives spoken with knew how to contact the Commission for Social Care Inspection or their role in the complaints procedure, and few knew of the availability of the Inspection report. One resident had not consented to the use of bed rails. Beechcroft Care Home DS0000035748.V347593.R01.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): Standards 19 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, which is suitable for their needs. EVIDENCE: In their pre-inspection questionnaires residents said they find the home clean. The manager recorded in his information that ‘service users are encouraged to have their rooms decorated to their own choice. Bring in a limited amount of soft furnishing to make their room feel homely. Service users have chosen the new furniture, floor coverings and wallpaper in the communal areas. Some sevice users choose to have their own telephone lines. All individual bedrooms have their own television and call system’. And ‘ we have a 5 year development plan for the continual upgrading of the fabric of the building’. In Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 20 terms of what could be improved, the manager stated ‘upgrading of toilets. Modernisation of sink units and wardrobes in the bedrooms’. During this Inspection, one resident said ‘It’s like a four star hotel’. Residents confirmed they could have a key to lock their bedroom door if they want. One said ‘you can lock your door – it’s safe enough’. Residents gave a tour of the home and said that they could have televisions, radios and telephones in the bedrooms if this was needed. New chairs for the lounges had been delivered. Some areas of the home had been redecorated to a good standard. One resident said ‘it’s a nice place here, I love being here’. Residents and relatives said they find the home clean and tidy. Comments included ‘there is carpet cleaning regularly, all rooms are thoroughly cleaned and the beds are changed regularly’. Equipment in the laundry was sufficient to enable cleaning of soiled laundry. Beechcroft Care Home DS0000035748.V347593.R01.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): 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 cared for by staff who are suitable, well trained and competent in their role. EVIDENCE: Relatives and residents were highly satisfied with the staff. Comments included ‘staff here treat people like their family, they have a lot of tolerance’, ‘staff are always willing to help’, ‘there’s always someone around in the night’, and ‘the staff are always pleasant’. One resident said ‘they are all very good – every one of them, they all mix with you, it’s like a family’ and ‘staff come straight away if you call for help’. Staffing rotas showed sufficient numbers of staff were planned for each shift. The Manager described problems in meeting adequate staffing over the past year, but felt this had now fully resolved. Three staff files were seen to check procedures for the recruitment of staff. The home follows Derbyshire County Council procedures. Files were largely satisfactory although the manager was unaware of the need to obtain written verification why the person had ceased to work in employment with vulnerable adults. Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 22 Staff receive good levels of training. Records of this were seen in staff files. The manager said that training records will be computerised next year enabling better identification of training needs. Most staff had received medication training and one staff member said they were booked on a course in November. Staff confirmed they have received training in all mandatory areas such as food hygiene, moving and handling and fire safety, they also confirmed that they get yearly updates in most areas. They have also attended training on dementia care, tissue viability and COSHH. Staff also confirmed they receive a TOPPS induction when they first start employment in the home, and work with another person for a few shifts. Then it is expected that they will move on to do a National Vocational Qualification (NVQ) in care to level II or above after 6 months. In his pre-inspection information the manager recorded that 75 of staff have achieved NVQ’s and the remainder are working toward these. Staff files showed that certificates are given out once inductions are successfully completed. In his pre-inspection questionnaire the manager stated that ‘training has improved. Skills for care enable staff to be automatically put forward for training. Lenghthening shifts has enabled improved coverage for the home and more time to spend with the service user’. Beechcroft Care Home DS0000035748.V347593.R01.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): 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 home in run in the best interests of the people living there. EVIDENCE: There has been no change in manager since the last Inspection. He has been approved by the Commission for Social Care Inspection. In his pre-inspection information he recorded that ‘ all managers are trained to a high standard. Unit manager hold an N.V.Q 4 in care and registered managers award. One deputy with similar to the above. One deputy with N.V.Q 3 in care and one deputy working towards N.V.Q 3 . We have been trained in risk management’. Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 24 The manager is aware of his responsibilities and has reported incidents to the Commission for Social Care Inspection as needed throughout the year since the last Inspection. One relative said ‘nothing is too much trouble for Paul (the manager)’ another said ‘I have total confidence in Paul’. There are systems in place within Derbyshire County Council to ensure that internal quality assurance within the service takes place. However, the monthly monitoring visits had not been taking place. Records showed that the last visit occurred in March 2007. This was a requirement of the last Inspection that has not been met. Within the home, annual satisfaction surveys take place. This was happening around the time of this Inspection and representatives from Age Concern had been used to assist residents in completing these, to ensure impartiality. The results of last years survey were on display in the foyer for all to see. A few residents from the home attend ‘Residents forums’ held in rotation across Derbyshire County Council homes. These are designed to share good practice and allow residents to have a say in the running of the homes. Minutes of meetings were seen. All residents and relatives said they were very happy with the systems for dealing with personal finances. Some financial records were seen, these supported that two signatures are obtained and that purchases are receipted. Also that records are regularly checked for accuracy. A sample of service records for equipment used in the home was seen and was up to date. General risk assessments of the home were also seen and the manager confirmed he regularly checks these in case reviews are needed. Beechcroft Care Home DS0000035748.V347593.R01.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 X 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Beechcroft Care Home DS0000035748.V347593.R01.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 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 timescales were 01/03/06 and 1/12/06) The plans must be reviewed on a monthly basis and any changes recorded on the plan of care. Care plans must demonstrate that residents or their advocates have been involved in and agreed to their plan. 2. OP8 13(4)(c) Each resident must have a 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. (Previous timescale was 1/12/06) DS0000035748.V347593.R01.S.doc Timescale for action 31/12/07 31/12/07 Beechcroft Care Home Version 5.2 Page 27 3. OP9 13(2) All hand-written medication instructions must be signed, and dated by two staff members to validate them (Previous timescales were 01/03/06 and 1/12/06) Medication records must not be signed until the person has actually taken the medication. Medications with a limited ‘shelf life’ must be dated upon opening. Medication awaiting return to the chemist must still be stored in an approved medicines cabinet. Medication charts must not contain unexplained gaps or have signatures crossed out without explanation. All medicines being selfadministered such as inhalers must be correctly stored within the person’s bedroom or held by them at all times. 31/12/07 4. OP12 16(2)(n) 5. OP18 13(7) 6. OP29 19(1)(b) 7. OP33 26 Care plans must demonstrate that consultation with residents about social activities has taken place and support that their social needs are being met. Informed consent must be gained prior to use of bed rails. Care plans must be able to demonstrate this has been gained and that the need for bed rails is reviewed at regular intervals. Written verification why a person has ceased employment in a position working with vulnerable adults must be obtained prior to appointment. The registered person must carry DS0000035748.V347593.R01.S.doc 31/12/07 31/12/07 31/12/07 31/12/07 Page 28 Beechcroft Care Home Version 5.2 out the monthly unannounced visits and prepare a written report. This report must be provided to the registered manager. (previous timescales given 1/12/06) 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 OP7 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. Systems should be in place to ensure that residents and relatives know how to contact the Commission for Social Care Inspection and about the availability of the Inspection reports. 2. OP16 Beechcroft Care Home DS0000035748.V347593.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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