Inspection on 02/09/09 for Beechcroft House

This inspection was carried out on 2nd September 2009.

CQC 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 CQC judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beechcroft House 19/02/09

Beechcroft House 28/08/07

Beechcroft House 22/08/07

Beechcroft House 26/03/07

Beechcroft House 09/05/06

Beechcroft House 14/11/05

Beechcroft House 23/05/05

Beechcroft House 15/03/05

Beechcroft House 14/12/04

Beechcroft House 21/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE Beechcroft House St Johns Road Rowley Park Stafford Staffordshire ST17 9BA Lead Inspector Jane Capron Key Unannounced Inspection 2nd September 2009 09:30 DS0000004916.V376787.R02.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechcroft House Address St Johns Road Rowley Park Stafford Staffordshire ST17 9BA 01785 251973 01785 212652 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) Beachcroft Homes Limited Diane Rose Gillingham Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability (6) of places Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP) 25 Physical disability (PD) 6 The maximum number of service users who can be accommodated is: 25 19th February 2009 2. Date of last inspection Brief Description of the Service: Beechcroft House is an extended Victorian town house close to local services and shops. It has a railway station one mile away and is close to the town centre. Beechcroft offers 24-hour personal care, for up to 25 adults. All places are available to older people, and six places are available for persons with physical disabilities. There are communal lounges and a conservatory area for people to make use of. The home has very nice gardens and there is a patio area for people to enjoy. The Home is well maintained and there is a continuous programme of redecoration. The fees the home charges people to live here are published in their service user guide. Readers of this report are asked to contact the home directly for this information. The most recent inspection report is available in the reception area. Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that people who use this service experience quality outcomes. We looked at all the information that we have received, or asked for, since the last key inspection. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the home. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the home. • Information we have about how the home has managed any complaints. • What the home has told us about things that have happened in the home; these are called “notification” and are a legal requirement. • The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. • Relevant information from other organisations • We also spent time talking to the people who use the service and to the staff who support them. We have undertaken a random inspection since our last key inspection to check compliance with the requirements made. The service had addressed all the requirements. What the service does well: People tell us that they like living at the service. They are particularly happy with the quality of the staff feeling them to be caring. Comments include ‘very good’ and ‘excellent’. An assessment of people’s needs is completed before a place is offered to people. This makes sure that the service only admits people if it feels it can meet their needs. People have the chance to visit before moving to live at the service. People are supported to have their health and personal care needs met and people feel that they have their privacy and dignity respected. People enjoy the food and are given a choice at all mealtimes. The service has a complaints procedure and people are aware of this and feel that any issues they raise will be looked into. Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 6 People have a homely place to live. There are sufficient sitting areas, a pleasant dining room and adequate toilet and bathing facilities. People can personalise their bedrooms. What has improved since the last inspection? What they could do better: There are some areas of the medication practices that should be addressed. Suitable risk assessments must be in place for people that self medicate to ensure that they receive their medication as prescribed. Also only medication that needs to be kept below 8 degrees should be stored in the fridge. The service also needs to ensure that suitable risk assessments are in place where risks exist. For example fall risk assessments should be completed and appropriate risk assessments completed for people that use wheelchairs so that they can safely exit the building in the event of an evacuation. We would recommend that the service provides additional activities for people including the opportunity to go out on trips. These should be based on the wishes of the people living there. The service should also consider developing the way it monitors and reviews the service including maintaining records of any audits and of developments made to the service. Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 7 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Beechcroft House DS0000004916.V376787.R02.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 House DS0000004916.V376787.R02.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People considering moving to the service are provided with relevant information to make an informed decision. People have an assessment before moving to the service to make sure that the service can meet their needs. EVIDENCE: The service’s Annual Quality Assurance Assessment tells us that people are provided with information about the service. We saw a copy of the Statement of Purpose and service user guide in the hallway. The manager also told us the service is currently updating its information to provide to people considering moving to the service. We saw a draft copy of this and it contains the necessary information. We would advice the service to consider providing this information in different formats including bigger print. Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 10 An examination of a sample of people’s files confirms that people have an assessment prior to a place being offered. The assessment completed by the service covers such areas as health and personal care needs, mobility, dietary needs, spiritual needs and social interests. One person we spoke to told us that the manager came to see them at home to complete the assessment to check that the service could meet their needs. The service’s provides people with the chance to visit the service to decide if they wish to live there. We spoke to two people, one said their relative visited as she was unable to and the other said they visited the service to check whether they felt it would meet their needs. Beechcroft House DS0000004916.V376787.R02.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the service have their health and personal care needs met but improvements could be made to the care plans so that they are completed in a person centred way. People can be assured that their privacy and dignity will be promoted. Medication procedures are generally robust although improvements need to be made for the arrangements for people that self medicate. EVIDENCE: The AQAA tells us that everyone at the service has an individual plan that is reviewed monthly and that people that wish to can be involved in planning their care. Examination of a sample of care plans confirms that plans are in place that cover people’s needs. Care plans cover such areas a personal care, communication and mobility. However we feel that in some instances these are quite brief and could be more person centred showing how each person wishes Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 12 their care needs to be met. For example one person is registered blind but there was no information about how this affected her or any plan on how to support her apart from stating ‘to speak clearly’. Plans are reviewed monthly and changes added if necessary. The service has assessments in place to support people’s mobility including a persona handling plan but we did notice that there are no fall risk assessments in place. As the accident records indicate falls have occurred we would expect these to be in place. Case tracking confirms that people are supported to have their health care needs met. We saw records that the doctor is called when people are ill and that people have dental and eye checks. A chiropodist visits regularly. Records confirm that people are being weighed although we pointed out to the manager that there are gaps in one record and she was to follow this up. When we spoke to people they confirm that the staff support them to have their health and personal care needs met and how good the staff are. When we spoke to staff they could tell us about people’s needs and how they liked their care to be provided. People feel that the staff respect their privacy and promote their dignity. People tell us that staff always knock on their bedroom door before entering and speak to them in an appropriate manner. People also tell us that staff are discreet when doing personal care tasks. Both double rooms provide privacy screening. None of the bedrooms are lockable and we would recommend that for people that wish it suitable locks are fitted. Where the service is fully administering medication to people good arrangements are in place. Checking the records of two people showed them to be correct with no gaps except for one minor error that the manager agreed to address. At the last key inspection the service was recommended to ensure that two people sign additions to medication administration records. Due to a misunderstanding this has not occurred but the manager agreed to ensure this occurs. Medication is generally stored satisfactorily although we did find that some medication was being stored in the fridge when this was not necessary. The service has some controlled drugs and these are stored, recorded and administered correctly. Some people are partly administering their own medication and in two instances we looked at there was no assessment in place to check that people can do this correctly and that a monitoring system is in place. Staff that administer medication are trained and the manager and a staff member confirms that a system for assessing their competency has been put in place. Beechcroft House DS0000004916.V376787.R02.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service offers people the opportunity to take part in some activities. People are provided with a varied menu that provides them with a choice of meals. EVIDENCE: The AQAA states that the service promotes people to make their own decisions as to how they wish to be involved in their every day lives including choosing whether join in with activities. The service offers people the chance to take part in activities although there are currently no records to show the activities people take part in. On the day we visited gentle exercise was being offered. There was also a schedule of activities displayed in the hallway that included entertainers coming in to provide sing a longs and musical entertainment. One of the people living there also sometimes plays the piano for everyone. A hairdresser regularly visits the service. The service did tell us that the staff also undertook some activities Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 14 including board games but people we talked to seemed unaware of this and some said to us that the area they would like improved was to have more activities. The AQAA stated that the service has a specific staff member that has the responsibility of organising trips out. However no outside trips have occurred this year. We saw that the televisions in both lounges were on throughout the inspection although no–one appeared to be watching them and one person said it was always there as background noise. People with spiritual needs are able to have a minister/ priest to visit them at the service if they wish. People have the choice over where to spend their time. Some people preferring to spend time in their own room rather than in the communal lounges. People can pay for their own phone and can have a newspaper delivered to the service. The service has an open visiting policy and relatives and friends can visit when they wish. One person told us that they went out every week for lunch with a group of friends. People are able to make their bedroom their own. The sample of bedrooms seen shows that people can bring in small items of furniture and a range personal possessions. People tell us they are happy with the meals provided and that a choice is always available at all meals. Meals are provided at set times and most people appear happy with this. People can eat their meals in the dining room or if they prefer in their bedroom. The service can provide people with specialist diets such as diabetic and soft. Beechcroft House DS0000004916.V376787.R02.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are aware of how to raise concerns and feel confident that issues will be addressed. People are protected from harm and staff have knowledge about safeguarding issues. EVIDENCE: The AQAA states that the service has a clear procedure for complaints and that that areas for improvement are sought through questionnaires completed by relatives and people that live at the service. We did see a copy of the complaints procedure in the entrance hall and that it is contained in the information provided to people. People we spoke to said that if they have concerns they tell the manager and feel confident that she will try and sort them out. The service has a book in which it would record complaints. No complaints have been received by the service or the commission since the last key inspection. The AQAA states that it ensures staff are aware of protecting and safeguarding the rights of people through training, supervision and quality monitoring. We observed that the service has a copy of the interagency safeguarding procedures and a staff member we spoke to said she had seen it. Two staff spoken to are aware of issues relating to protecting people and could identify potential symptoms of abuse including being aware of bruising, changes in behaviour and shortage of money. They could also describe the actions they Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 16 would take if they have any concerns. There have been no safeguarding incidents since the last key inspection. The service does not use potentially restrictive practices such as bedrails or curton chairs. The service recruitment procedures included the necessary pre employment checks. Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is generally well maintained and provides people with a clean and homely environment. EVIDENCE: The AQAA states that the service is ‘well maintained, safe, comfortable and homely’. The service provides people with suitable private and communal accommodation. Although parts of the service date back to the 19th century it is adequately maintained although some areas, particularly corridors are scuffed from bangs from wheelchairs. The service tells us that it is continuing to update the standards in the service and that decorating is ongoing. The service is homely and provides suitable seating areas having two large lounges. There is a conservatory that would make a pleasant seating area but this was not being used when we visited apart from as storage for wheelchairs. The service has a light and airy dining room that overlooks part of the garden. Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 18 Bedrooms are on three floors and a vertical lift is provided. Looking at a sample of bedrooms shows them to be suitably furnished; all having a chair and storage facilities. All bedrooms have a nurse call fitted. Bedrooms are personalised with people bringing in small items of furniture and photos and ornaments. There are two double bedrooms although one is used as a single room. The shared room has a moveable screen to provide each person with privacy. None of the bedrooms are lockable and we would recommend that suitable locks are provided. This will enable people to have the choice to lock their bedrooms if they wish. People tell us they like their bedrooms. The service provides adequate bathing facilities having five level access showers and two assisted baths. Adequate toilet facilities are provided. The service is clean throughout. Staff state that they receive training in infection control and there are always plenty of gloves and aprons available. Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28,29.30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staffing is provided to meet people’s health and personal care needs. The recruitment systems in place are protecting people. EVIDENCE: The AQAA tells us that the service provides the necessary numbers and skill mix of staff to support people that live there. Currently there are sufficient staff on duty although for three days a week one of the care staff is the manager which could mean that she is diverted from care duties to complete management tasks. People we spoke said they felt there are enough staff on duty to provide them with the support they need. The sample of staff files shows that the service is undertaking the necessary pre employment checks to make sure that unsuitable people are not employed. This includes two references and a satisfactory Criminal Records Bureau (CRB) and Protection of Vulnerable Adult check (POVA). We did advice the service to maintain suitable records if any checks have been destroyed following an inspection. People living at the service are positive about the staff with comments such as ‘excellent’ and ‘very good’. Training is provided for staff in both Health and Safety issues and in care issues including medication, tissue viability and Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 20 infection control. The service has a high level of staff that have achieved NVQ level 2 and 3. One person is also completing NVQ level 4. Staff confirm that when appointed they complete induction training and that they shadow senior staff until confident to work alone. Staff said that they feel supported to undertake their role having regular staff meetings and receiving individual supervision. Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the service are benefiting from improved management practices. Systems are in place to protect people that live at the service although there are areas still to be addressed. EVIDENCE: The AQAA states that the management team are committed to ensuring the health, welfare and safety of the people that live there. The manager of the service has recently been registered July 2009 on the basis that she undertakes relevant training. The manager informs us that she is currently completing her NVQ 4 and is in the process of registering for Leadership and Management Training. The manager is very committed to provide people with Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 22 a good standard of care and she is continuing to work as a care staff member for three out of the five shifts a week. In the light of the commitment to her training and the demands of managing the service we would expect the service to look at whether two days a week is sufficient time to effectively run the service. When we spoke to the manager we felt that she needed time to develop her management skills in areas such as delegating, monitoring, auditing and care planning. The service provided us with an AQAA. This gave us information about the service. The service tells us that it has a quality assurance system in place and this is outlined in the Statement of Purpose. This states that it includes resident meetings but no meeting has been held since February 2009. The AQAA said that the service undertakes audits relating to admissions, the kitchen and medication but the service could not provide us with copies of these audits and of any action taken to address any issues raised. Information was subsequently sent to us that confirms people living at the service and staff are surveyed and these are analysed. This did show that people had positive views about the service. There was no information to show that issues raised have been addressed. We do feel that the area of monitoring and reviewing the service is an area that needs to be further developed. The service no longer manages or looks after money of people living there. The service’s AQAA tells us that its equipment is serviced. The lift, fire equipment and gas appliances have all been serviced within the last year. Staff are provided with training in Health and Safety although one person we spoke to said that she had not received training in moving people although was doing this work. The service must address this both in the interest of moving people safely and in the interests of the staff’s health. The manager confirmed that this would be addressed as soon as possible. Since the last inspection the service has developed individual fire and evacuation risk assessments for each person living at the service. However there are gaps in some of these for example there is no information over how people using wheelchairs are to be supported to get downstairs in the event of the lift not being available. We are referred this to the fire service for them to provide any necessary advice. The service has been visited by the Environmental Health Department who gave them a five star rating. Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP8 Regulation 13(4)(C) Requirement Timescale for action 15/10/09 2. OP9 13(4)(b) Appropriate risk assessments must be in place to support people with mobility needs to exit the service in the event of the need to evacuate the building. Where people are administering 15/10/09 their own medication a risk assessment must be in place. This will ensure that all medication is administered safely and correctly and that monitoring processes are in place. 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 home needs to develop a person centred approach to care planning so that people’s individual needs and wishes a recorded in relation to their care. Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 25 2. 3. 4. 5. 6. OP9 OP9 OP9 OP10 OP12 Fall risk assessments should be completed. This will help people to be kept safer. Records should be kept of assessments of staff’s competency to administer medication. Two staff should sign all handwritten entries on to the MAR sheet. This should reduce the risk of errors being made. Where people wish to lock their room suitable locks should be fitted. This will enable people to have privacy in their bedroom. The service needs to consider how it is going to offer more activity to people living in the home. This should also include trips outside of the home. When pre employment checks have been checked during inspection process records should be in place to confirm that this has occurred. Consideration should be given as to whether adequate management time is provided to manage the service. The management team needs to continue to develop the quality assurance systems. 7. 8. 9. OP29 OP31 OP33 Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Beechcroft House DS0000004916.V376787.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!