Inspection on 29/08/07 for Beechcroft, Cheltenham

This inspection was carried out on 29th August 2007.

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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beechcroft, Cheltenham 22/10/08

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Beechcroft 295 Gloucester Road Cheltenham Gloucestershire GL51 7AD Lead Inspector Ms Lynne Bennett Key Unannounced Inspection 29th August 2007 09:45 Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 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 DS0000069961.V344093.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 Adults 18-65. 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 DS0000069961.V344093.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechcroft Address 295 Gloucester Road Cheltenham Gloucestershire GL51 7AD TBC TBC 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) www.orchardendltd.co.uk Orchard End Limited Miss Amy Clare Ranger Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who may be accommodated is 4. NA Date of last inspection Brief Description of the Service: Beechcroft is a large detached house in the middle of Cheltenham near to local amenities and facilities. It is one of six registered homes owned by Orchard End Ltd a subsidiary of C.H.O.I.C.E. The home provides spacious accommodation for four people with a learning disability and can accommodate one person on the ground floor with additional physical disabilities. Each person has a bedroom with an en suite which includes either a bath or shower. Communal areas include a lounge and separate dining room, large kitchen and sensory room. The Statement of Purpose and Service User Guide are displayed in the entrance hall and copies are available from the office. Fees for the home are assessed on each person’s individual needs in arrangement with their placing authority. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. This inspection took place in August 2007 and included a site visit to the home on 29th August. The registered manager and area manager were in attendance throughout. The registered manager completed an AQAA (Annual Quality Assurance Assessment) as part of the inspection, providing information about the service and plans for further improvement. During the site visit there was an opportunity to speak to parents of a person living at the home and visiting healthcare professionals. A sample of records were looked at which included care plans, admission information, staff files and health and safety systems. The care provided to the person living at the home was observed and discussions with two staff focussed on the care they provide. What the service does well: What has improved since the last inspection? This is the first inspection for this service. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have access to the information they need enabling them to make a decision about whether they wish to live at the home. A comprehensive assessment of the person’s wishes and needs are taken into consideration before offering them a place. EVIDENCE: The home opened in May 2007 and the first person moved into the home in August. Enquiries from a second person wishing to move into the home were being processed at the time of the visit. A Statement of Purpose and Service User Guide were in place and there was evidence that the person living at the home had been supplied with a copy. Although the Statement of Purpose refers to the complaints procedure a copy of this was not on file. (See also Standard 22) Parents and a visiting healthcare professional stated that the admissions process had been extremely thorough supporting the person through transition from children’s services to adult services. Transition meetings had been held from February 2007 involving representatives of the organisation, the placing authority and former placement. The home had been supplied with an Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 9 assessment from the placing authority and they had completed a comprehensive assessment. Staff stated that they had worked with the person at their former placement over a two-week period. Despite this preparation at the time of admission the management of the home had concerns about aspects of the person’s personal care. They contacted us to discuss their concerns and put in place a best interests meeting to make sure that essential guidance, protocols and risk assessments were in place at the time of admission. Close liaison with parents and healthcare professionals was continuing during the first weeks of admission to the home. All involved in the care of this person were satisfied that the management and staff of the home had done as much as possible to ensure a satisfactory transition. The parents were still very involved in the transition to the home, staying locally and spending a considerable amount of time at the home providing support and advice to staff where needed. A statement of terms and conditions has been put in place for the person living at the home. This is a generic document that has been adapted. The correct date needs to be inserted into this. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans are based on the assessed and changing needs of people promoting a person centred approach that focuses on the individual. Any restrictions that may be in place are to safeguard the wellbeing of people. Risk assessments protect people from possible harm. EVIDENCE: Care plans for the person living at the home have been developed from the assessments. Care plans provide a holistic assessment of their physical, emotional, intellectual and social needs. Each care plan indicated the support needed and could be cross-referenced with risk management plans and behavioural support guidelines. Management, key workers, parents and social worker have signed many of these documents although there was some inconsistency in this. For instance a risk management plan indicating restricted access to the front door had not been signed. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 11 Staff said they were beginning to understand the complex needs of the person they support. Communication profiles were in place that they said they have used to develop an awareness of the person’s non-verbal communication. A communication passport had also been provided from their former placement that made good use of photograph, picture and text to provide the person with important information about their life. The registered manager said that this would be adapted to their life at Beechcroft. A referral to the local speech and language therapist had been made. Staff were observed interacting in a positive way. Care plans indicated that the staff were looking at ways in which the person could be supported to become involved in age appropriate activities. There was also evidence that any changes to initial care plans were being recorded, signed and dated. Risk Management Plans included reference to the use of listening devices, alarms and bedsides and the rationale for the use of these. Staff explained their understanding of the use of the listening device and alarms and this was in accordance with the plans. Risk management plans must be put in place for the use of equipment provided in the garden. (See also Standard 14) The manager must ensure that a missing person’s file is set up for the home. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Opportunities to get to know the local environment and participate in a range of activities are being developed for people as they move into the home. People are supported to maintain close contact with family. Monitoring the nutritional content of meals ensures that people have a healthy diet. EVIDENCE: A schedule has been prepared that incorporates activities which the person likes to do. Management said that this would be put in place gradually allowing the person time to readjust to their new surroundings. Most days the person was being taken out in their wheelchair to local shops or parks. A vehicle has been provided which they are able to use. Management have been researching places to use for swimming, hydrotherapy and to go for a tricycle ride. They also anticipate using social clubs in the local area. Music was evidently important to the person living at the home and was available in a Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 13 variety of forms such as musical toys, the music channel on television and radio. A special swing and trampoline have been provided for use in the garden. Risk assessments have not been put in place for the use of these. Management said that they have not been used. A sensory room has been provided on the first floor that was unfortunately not accessible to the person living on the ground floor. As mentioned close contact has been established with parents and will be maintained via telephone, email or visits. Parents were made to feel welcome and spent time in communal areas as well as the bedroom. The person living at the home has 1:1 staffing at all times but risk management plans have been put in place to provide personal space for short periods when in their room. Care plans indicated that the person should be involved where possible in the preparation of meals, whether this is observing or helping. They have been provided with a specially adapted chair and table for this purpose and were observed sitting in this at various times throughout the day. The home had been supplied with a list of the person’s likes and dislikes as well as allergies to certain foods. A menu was being drawn up each week taking this into consideration. Luncheon meat was obviously a favourite with sandwiches being provided at lunchtime. An evening meal of chicken pie and fresh vegetables was being prepared. Full records are maintained for fluid and food intake. Arrangements had been made for a dietician to visit the home. The registered manager had completed the ‘Safer Food Better Business’ course and staff confirmed they had completed food hygiene training. Good practice was observed in the kitchen with hot food temperatures being recorded and prepared or opened food being labelled with the date it was stored in the fridge. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are being met helping them to stay well. Their health and wellbeing are promoted by satisfactory arrangements for the handling of medication and training of staff in specialised techniques. EVIDENCE: Clear guidelines were available for staff about the personal support needed by the person living at the home. Discussions with staff confirmed their understanding of this. Observations of their practice verified that they were following these. The area manager stated that training was being arranged for all staff in the theory and practice of personal care. As mentioned equipment had been provided specifically for the person living at the home and a further assessment with an occupational therapist had been arranged. Care plans indicated that the person may be at risk from pressure sores and a risk management plan was in place. Pressure relieving equipment has been provided. Some staff had an awareness of what they should look for. There was no evidence of a tissue viability assessment or that staff had received any training in this area. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 15 As people move into the home they will be registered with local healthcare professionals. There was evidence that this had been done promptly for the person living at the home and that referrals had been made where appropriate. The registered manager confirmed that a health action plan would be put in place. A pro-forma had been obtained. Management confirmed that medication training was being provided in the ‘safe handling of medication’ and that the registered manager had completed training in assessing the competency of staff in medication administration. The home’s training matrix and certificates on staff files confirmed this. Regular assessments of competency will be put in place. Medication administration systems were satisfactory at the time of the visit. Administration records were completed correctly and medication stored in line with the home’s policy and procedure. Allergies were noted and a synopsis was provided of medication provided. The temperature of the medication cabinet was being taken each day. Concerns highlighted during the admission procedure about the administration of medication had been resolved. One drug is crushed in an appropriate manner. The home had obtained advice from the manufacturers before doing this and from us. The former needs to be recorded. Protocols indicate that only as a last resort can medication be given covertly. Staff had received training in the administration of medication by specialist techniques and further training is planned. Protocols had been put in place by the healthcare professional. Training records were in place and some staff had signed these. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The complaints procedure needs to be accessible to people who live at the home providing them and others acting on their behalf with information they need to make a complaint. Systems are in place to protect people from possible harm due to accidents or abuse promoting and safeguarding their best interests. EVIDENCE: The home has a complaints policy and procedure although at the time of the visit this was not displayed in the home and copies were not in place on people’s personal files. A complaints file was examined and there were copies of two complaints that had been received from neighbours. The action taken by the registered manager was recorded. Another complaint had been received from parents and was being dealt with by the area manager. Management confirmed that four staff have been booked to attend safeguarding adults training. Staff spoken with had attended abuse training and were aware of their responsibilities and what they should look out for. Mental Capacity Act training was also being arranged for staff. There was information in the home about this legislation. Staff confirmed that they attend training in M.O.R.E. (the Management of Response to Emotions) that teaches them ways in which they can effectively use low arousal techniques to help people manage their behaviour. Staff have Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 17 the support of a psychology team who have developed reactive strategies providing them with guidance about how to support people when wishing to self harm. Systems were in place to manage people’s personal finances. There was evidence that regular checks were in place and that any receipts were being cross-referenced with expenditure. The balances at the time of the visit were correct. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,29 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that provides spacious accommodation and which recognises their diverse needs creating an environment that matches their personal requirements. Specialist equipment is provided to those people who need it. EVIDENCE: Beechcroft was totally refurbished prior to registration to provide accommodation of a high standard. The house is in keeping with others in the area and is close to local amenities. It has car parking to the front of the property and a large secluded garden to the rear. The communal areas have been pleasantly decorated and have good quality fixtures and fittings. As people start to move in they are beginning to personalise the home with photographs and possessions. Bedrooms are Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 19 spacious and people can bring their own furniture if they wish. Inventories although in place have not been completed. Bedrooms have en suite facilities including a bath or shower. It has been agreed with us to remove the toilet in the en suite of one person which is not used and which is causing them some confusion. The ground floor toilet will be provided with changing facilities that can be used and will meet their needs. If the room becomes vacant the toilet must be re-installed. Additional specialist equipment has been provided and further consultation is planned with an occupational therapist. The home has problems with storage and it was noted that in the dining room and sensory room several small boxes of equipment were stacked on the floor. An area outside the laundry was also being used to store several items and a wheelchair. At the time of the visit a problem had been found with the drains and an external company was resolving this. There were also problems with the position of a washing machine in the laundry and this was being dealt with. The registered manager said that the organisation’s maintenance department was quick to respond to problems in the home and that repairs to the property were being actioned. It was noted during a tour of the home that a hazardous product had been left in a first floor bedroom. No people live in this area at present. The registered manager said that she would remind staff to store hazardous products securely. Data sheets were in place for these items. Staff confirmed that infection control training has been arranged. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are met by a staff team, who have access to a mainly satisfactory training programme that needs to ensure staff have knowledge about the diverse needs of people living at the home. People have been put at risk by unsafe recruitment processes that are not safeguarding people from possible harm. EVIDENCE: A new staff team has been appointed to the home. Some staff were appointed just before the home was registered and completed their induction programme together. They then worked in other homes in the group until the first person moved into the home. Additional staff were appointed more recently. The team have a mixture of skills and experiences. All have worked in care before but for some this is the first time working with people with a learning disability. Supervision records confirmed that they were being enrolled for the Learning Disability Award Framework that would provide them with information in this Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 21 specialist area. The AQAA confirmed that over 50 of the staff team have a NVQ in Health and Social Care. The files for eight members of staff were examined and found to be mostly satisfactory apart from the following issues: • • There were inconsistencies in the checking of gaps in employment history, for some this had been obtained but for others there were still gaps with no explanation One person had started work with only one reference in place. There was evidence that there had been problems sourcing one reference and that we had been referred to about this. Our advice to record this and find another alternative reference was recorded but not actioned. A second reference was eventually supplied but only after the person had started work. (The area manager explained that systems have since changed and that all recruitment and selection is now being managed locally). A reference had been supplied from a team leader at their personal address and not from the manager of their previous employment. This is not good practice. There appeared to be two references in use, one requested the reason for leaving and another did not. The last time the latter reference was used was in June. New reference requests that comply with the Care Homes Regulations were available for inspection. A front sheet was in place to record when information was received. There appeared to be some inconsistency in the recording of this information. • • • A training matrix was supplied during the visit confirming that people have access to mandatory training, NVQ Awards, Learning Disability Award Framework and training specific to the needs of people living at the home such as epilepsy. The registered manager was also collating information about the person living at the home to increase the understanding of staff about their condition. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The quality assurance system when implemented within the home will involve people living there and their representatives. A consistent approach in the monitoring of established health and safety systems will promote the safety and wellbeing of people living in the home. EVIDENCE: The registered manager has considerable experience in this area of care. She has a DIPSW, NVQ Level 4 in Health and Social Care and the Registered Managers Award. Since joining the organisation she confirmed that she has been able to continue her professional development attending courses in supervision skills, Safe Food Better Business and an assessing medication competency course. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 23 The organisation uses a quality assurance system which involves people living in the home and their representatives although this had still to be developed within this new service. The area manager confirmed that surveys will be sent to people annually and a report would be produced. She also confirmed that Regulation 26 unannounced visits to the home will be taking place. She is often accompanied by a person from another home in the group. Systems have been put in place to monitor health and safety within the home. There was some inconsistency in the recording of these with gaps in the records for monitoring fridge and freezer temperatures, water temperatures and no checks being recorded for emergency lighting. Other records were satisfactory. A fire risk assessment was in place which meets with the Regulatory Reform (Fire Safety) Order 2005. Environmental risk assessments were in place but some of these were not relevant to the home and had not been signed or dated. Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? 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 YA9 Regulation 13(4) Requirement People using the trampoline and swing must be fully assessed for any hazards that are likely to arise and action taken to minimise any risks. This is to safeguard them from possible injury. The complaints procedure must be accessible to people living at the home and to other people acting on their behalf who may wish to make a complaint. This is to ensure people have information about the complaints procedure and whom they can make a complaint to. Staff must not be employed to work in the home until two satisfactory references and a full employment history have been obtained. This is to safeguard people living at the home from possible abuse or harm. A quality assurance system must be put in place and maintained which involves people and their representatives in the review of the service. Systems which have been put in place to check and monitor DS0000069961.V344093.R01.S.doc Timescale for action 30/09/07 2. YA22 22(5) 30/09/07 3. YA34 19(1)(c) Sch 2.3,6 30/09/07 4. YA39 24(1) 30/09/07 5. YA42 13(4) 30/09/07 Beechcroft Version 5.2 Page 26 fridge/freezer temperatures, water temperatures and emergency lighting must be completed regularly as indicated by the homes risk assessments. This is to ensure that people live in a safe home. 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. 3. 4. 5. Refer to Standard YA5 YA6 YA9 YA18 YA20 Good Practice Recommendations The contract or statement of terms and conditions should have the correct date inserted. Care plans and associated documents should be signed by people involved in the care of the person living at the home. A missing person’s file should be put in place. A tissue viability assessment should be in place and the awareness and understanding of the staff team in these issues needs to be improved. A record should be kept of advice received from the manufacturers of medication that is being crushed. All staff should sign the training record for administration of medication by specialist techniques. 6. YA24 Consider how extra storage can be provided within the home. Where people bring their furniture into the home this should be recorded on the inventory provided. The annex 4 sheet provided to monitor recruitment and selection should be completed. Environmental risk assessments should be relevant to the home and signed and dated. 7. 8. YA34 YA42 Beechcroft DS0000069961.V344093.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 DS0000069961.V344093.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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