Inspection on 22/08/07 for Beechcroft House

This inspection was carried out on 22nd August 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 House 02/09/09

Beechcroft House 19/02/09

Beechcroft House 28/08/07

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Beechcroft House St Johns Road Rowley Park Stafford Staffordshire ST17 9BA Lead Inspector Sue Jordan Unannounced Inspection 22nd August 2007 09:45 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 House DS0000004916.V342870.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 House DS0000004916.V342870.R01.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 Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25), Physical disability over 65 years of age (6) of places Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD(E) - Registered for 6, 2 of whom may be 50 on admission Date of last inspection 26th March 2007 Brief Description of the Service: Beechcroft House is an extended Victorian town house close to local services and shops with the railway station being one mile away, close to the town centre. Beechcroft offers 24-hour residential care, for up to 25 adults. All places are available to older people, and six places are available for persons with physical disabilities. The Home is well maintained and there is a continuous programme of redecoration. The Home charges from £377 to £425 per week. The residents buy their own newspapers, toiletries and pay for private hairdressing, dentistry and chiropody. Beechcroft is presently without a registered manager. The Home is being managed by an experienced senior care worker supported by the owners and staff. There are plans to submit a registration application to the Commission for Social Care Inspection. On the day of the inspection there were 17 people resident in the Home. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a total of five and a half hours. This was a ‘key inspection’ and the core standards were assessed. The methodologies used were: A day of pre-inspection preparation, including scrutiny of the Commission for Social Care Inspection Annual Quality Assurance Assessment completed and returned by the owners, and of the five questionnaires completed by residents and/or their relatives. During the visit, a number of residents were chatted to and observations were made of non-personal care tasks. The cook was interviewed, as were a number of the care staff. Discussion and feedback was held with the owners and the acting manager. The medication systems were examined and a tour of the environment undertaken. Residents’ care records were checked and the records of two new staff employed since the last inspection, including recruitment and training documents. Health and Safety was discussed. Of the eighteen requirements remaining from the Key Inspection in March 2007, fifteen have now been met. Five requirements and three recommendations have been made. What the service does well: The acting manager does not admit anyone into the Home unless his or her needs have been assessed. In the case of Local Authority referrals people are assessed by social workers and copies received before agreeing admission. The acting manager also undertakes an assessment of any potential resident. The questionnaires completed by the residents and/or their families were generally positive regarding the quality of care provided in the Home. Some of these results are included in the main body of the report. The residents have access to a range of medical professionals to maintain their health and wellbeing. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 6 Families and visitors are made welcome and there are private areas for the residents to meet with them, if required. The food is home-cooked and there is a plentiful supply of fresh fruit, vegetables and milk. Choices are available, which are taken advantage of by some of the people using the service. All of the people involved in this inspection were positive about the staff and their caring attitudes to the residents. Beechcroft House is well situated in its own private grounds and close to Stafford town centre. It provides a well-maintained and comfortable environment for the residents, which is continually redecorated and refurbished. Throughout a difficult time of change the staff team have remained loyal to Beechcroft and the residents. What has improved since the last inspection? The care plans have been reorganised and are being kept under review. The staff are more careful in their recording to ensure that the information is accurate and reflects the resident’s needs. The medication practices have improved dramatically and all but one of the requirements regarding this area have now been met. The residents can be confident in the procedures used. More emphasis is being placed on daily activities and work is being carried out to improve this area further. There are plans to arrange more trips and entertainers. The staff are encouraged to spend time chatting to the residents. Staff recruitment procedures are now robust and not only comply with legal requirements but are also based on good practice guidelines. The Home does not employ staff unless they are satisfied that they are suitable and have received the results of the required checks. The owners are monitoring the service to ensure that the residents and relatives are happy with the care provided at Beechcroft. The atmosphere in the Home is more relaxed and the staff and residents say that they find the owners and acting manager approachable. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 7 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 House DS0000004916.V342870.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 House DS0000004916.V342870.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): 1, 2, 3, 4, 5, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Pre-admission information is available to prospective residents in a standard format. The service consults the assessment information to see if they can meet the prospective individual’s needs before they make the decision to accept the application for admission. EVIDENCE: A Statement of Purpose and Service Users Guide are available in a standard format, in the lobby area of the Home, although the owner is aware that they need updating to reflect the changes at Beechcroft and the Commission for Social Care Inspection. This will ensure that the people using the service have Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 10 access to current information. Five surveys were completed by people using the service and/or their families and they all confirmed that they had had enough information about the Home before deciding whether to move in. They also confirmed that they had received a contract. The acting manager makes sure that she always receives an up to date Local Authority assessment and care plan before deciding whether the Home can meet a prospective resident’s needs. She also undertakes an ‘in-house’ assessment, which covers the crucial areas of need. The management are aware of their registration categories and only admit people for whom they are registered to provide care. The acting manager has had instruction from one of the owners regarding assessment, but as yet has not embarked on any formal training. Where possible prospective residents and/or their families are encouraged to visit the Home before making a final decision. Training is being arranged and provided in a number of specialist areas, which will support the staff to care for individual resident’s needs. The Home has developed an ‘Equality and Diversity’ policy and is aware that this is a subject which requires some staff guidance and training. The staff respect the individual and this was evident during observations of interaction between them. The residents are supported to maintain their religious beliefs. Beechcroft House does not provide intermediate care. Beechcroft House DS0000004916.V342870.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): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and well being of the residents is monitored and medical assistance and guidance sought, when needed. Care planning and medication systems have improved ensuring that the residents are safeguarded and that the staff know what support is required and any risks involved. EVIDENCE: Major improvements were noted in the care records. The files have been reorganised and the care plans are being reviewed monthly. The information is being recorded in the care plans as soon as possible following admission, ensuring that the staff have the guidance required to support the residents. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 12 There is evidence that some of the residents and/or their families have signed to say that they are aware of their care plans. The owner indicated in the preinspection assessment that she wants to make the care planning process ‘more interesting and worthwhile’. A district nurse visiting the Home during the inspection commented on the improved paperwork. There is ample evidence that the staff monitor the health of the people using the service and access medical advice and assistance when needed. The records seen indicated that people are being weighed regularly and the results documented. The district nurse team are presently providing staff with some additional training, including catheter care, incontinence and tissue viability. Four of the five surveys received indicated that the residents feel they get the medical support they need. Concerns were raised at the last inspection about the use of bed guards without appropriate covering or consultation with appropriate professionals. The safety aspects and concerns around the use of bed guards were discussed. As a result, the Home has decided that those residents previously using them do not now require them. The owner reported difficulties in accessing occupational therapy or physiotherapy guidance, but has found a private resource if needed in the future. A number of requirements were outstanding regarding the medication procedures and these were all checked: • The acting manager has been liaising with general practitioners and pharmacists to make sure that the medication labels give clear instructions to staff as to when and how drugs are to be administered. Vague instructions such as ‘as required’ or ‘as directed’ are being removed to ensure that the staff do not have to take responsibility for such decisions. Where possible, the staff ask the general practitioner to sign the medication administration sheets when there have been changes. This provides evidence that the staff are acting according to the prescriber’s instructions. None of the residents administer their own medication at present. The acting manager is aware that in such cases a risk assessment must be undertaken to support the person, and that a monitoring programme must be put in place to ensure that the person continues to follow the prescriber’s instructions, staying safe and well. • • Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 13 • The management team, including the senior care workers administer medication. A number of them have already received training, but more is being planned for other staff and to check on-going competency. One of the owners is presently developing a competency checklist, which can be used in the future. It is recommended that the staff be assessed at least six monthly. The acting manager said that she has observed and supervised staff administering medication, but was advised to record such events. Medication is now being stored securely and in accordance with the manufacturers instructions. The temperature of the medication fridge is checked twice daily and it is kept locked. • • The lunchtime administration was observed and no problems or errors were identified. The staff were observed treating the residents with respect and dignity and during this inspection a friendly, relaxed atmosphere was noted. All of the residents spoken to praised the staff at Beechcroft and the care received. People were seen to be able to go to their room if they wished during the day and there are areas in the Home where others can have privacy. All of the present residents have their own bedroom and a few have en-suite facilities. Staff induction and National Vocational Qualification training covers the area of privacy and dignity and no issues were identified during this visit. Beechcroft House DS0000004916.V342870.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): 12, 13, 14, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents are being offered more opportunities to take part in activities. There is a relaxed atmosphere in the Home and staff are encouraged to spend time with the residents. The residents are provided with a varied and balanced diet and are able to choose their favourite food. EVIDENCE: Beechcroft continues to try and improve its provision of daily activities. They are listed in advance and the staff delegated per shift. A list is available for the residents to see. Most of the activities such as board games and crafts take place in the dining room and some residents choose not to participate. A new ‘chair aerobics’ provider has been found who goes to all of the residents wherever they are sitting to encourage them to join in. It was reported that Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 15 this was successful, with more people joining in than before. The Home could consider this approach when arranging their own activities. The staff were observed spending time with residents chatting and this is now openly encouraged. The cook has some previous experience of organising activities, trips and entertainment in a similar setting and therefore she has been asked to take on this role. She is also to attend some training in this area. Of the five surveys received by residents and/or their relatives, one said that there were ‘usually’ activities planned by the Home, three said ‘sometimes’ and one declined to answer. This is an area of on-going improvement, which the Home is committed to address. Visitors are made welcome in the Home and there are places where they can visit in private. The new cook has introduced some variety to the menus and the residents are able to have alternatives if they wish. A summer menu is presently being followed. Four of the residents asked for an alternative to the braised steak lunch on offer during this inspection and these included curry and rice, jacket potato, fish cakes and omelette. There was a choice of three deserts. The Home is able to cater for diabetics and those people requiring a soft diet. Mealtimes are a pleasant experience; the tables are nicely set and decorated and the staff sit with the residents. This means that they can have a chat or assist them with their food, if required. Of the five surveys received, one said they ‘always’ enjoyed the food, three said usually and one said sometimes. All of the residents spoken to during the inspection said that they liked the food. Food and hygiene training is being planned for all staff. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 16 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): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A stable management team should afford the residents and staff more consistency and therefore confidence to express their concerns. The recruitment procedures protect the people using the service and the staff are being trained to understand adult abuse and what to do in such an event or allegation. EVIDENCE: There have been no formal complaints made to the Commission for Social Care Inspection since the last Key Inspection in March 2007. An informal, anonymous complaint was passed back to the proprietors who made their own investigations. This was unsubstantiated. A complaint was received by the Home just prior to this inspection, which the owners are committed to address. The owners are trying to create a more open culture in the Home. They are regular visitors to the Home and are available to the people using the service and the staff. They also hold regular meetings with the staff and have sent out their own questionnaires to ensure that everybody is happy with the service. They are supporting and encouraging the acting manager. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 17 The five people completing Commission for Social Care Inspection surveys said that they knew how to make a complaint. Two people said that they ‘always’ know who to speak to if they’re unhappy and three people said that they ‘usually’ do. The last twelve months has been unsettling for the people living at Beechcroft and the staff; the previous manager has left the home and a lot of changes, albeit positive, have been made. At the present time, a senior care worker is acting in the manager’s role and she is intending to apply to the Commission for Social Care Inspection for registration. A stable management team should afford the residents and staff more consistency and therefore confidence to express their concerns. Staff said that they find the acting manager very approachable. Most of the staff team have received training in adult abuse, what to look for and how to respond. The basic principles are covered in National Vocational Qualification training. One of the owners is trained to provide this training and is planning to deliver it during staff meetings in the very near future. The Home has included this course on their list of mandatory training to be provided regularly to staff. Prospective staff undergo rigorous checks before they are able to work with the people using the service. The owners have studied the new ‘Mental Capacity Act’ and are planning to cascade their knowledge to staff, together with the implications for the residents. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 18 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): 19, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Beechcroft provides its residents with a comfortable, clean environment. EVIDENCE: Beechcroft is well presented, homely and provides a pleasant clean environment for the residents. Maintenance, redecoration and refurbishment are continuous. Since the last inspection a number of bedrooms have been redecorated and new bedding provided. One of the residents said that she was really pleased with her bedroom. New flooring has been provided in the lounge and conservatory. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 19 There are imminent plans to refit the downstairs bathroom. This is used by the majority of the residents and is in desperate need of refurbishment. As the result of a fire risk assessment being completed by an external company, the owners are presently updating and improving their fire safety arrangements. Staff are being regularly trained and more fire drills are being undertaken. Thorough and more regular systems are to be introduced for checking the fire safety equipment. New fire extinguishers have been provided. Individual fire risk assessments for the residents still need to be completed, so that their individual needs, in particular mobility, are taken into account to ensure their safe evacuation. The Home is kept clean and there are no unpleasant odours. The owners are presently implementing new infection control procedures to reduce the risk of cross infection. These will include providing staff with paper towels in the communal toilets and a member of staff suggested a cupboard where staff can keep gloves and aprons. Obstacles need to be removed from the sink area in the laundry so that the staff can wash their hands. Infection control training is to be added to the list of mandatory training. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 20 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): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home has a consistent staff team dedicated to the residents. Training provision continues to improve, with more regular courses being planned and attended, ensuring that the staff have the knowledge and skills required to care for the residents. A safe recruitment system is being maintained for all staff employed so that the residents can be fully confident in the people that support them. EVIDENCE: Adequate staffing ratios are maintained and there are no staff vacancies at the Home. There are presently seventeen people living in Beechcroft and there were one senior care worker, two care workers, the acting manager, a cook and a domestic working during this inspection. Throughout a very difficult period of change, the staff have remained loyal to the Home and committed to the residents. A person completing a survey said, “A really nice Home, the staff are great”. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 21 The Home is showing a commitment to National Vocational Qualification training. Most staff are now registered and/or completing this training. Some are to do level two and some level three dependent on their job role. New staff undergo the Skills for Care Induction. Staff training has also improved and although there are gaps, training is being regularly planned and delivered. Most staff are enthusiastic about training and this is evident from the records and from discussions with them. However, some staff are not attending training as regularly as they should, even when they are offered alternative dates. The owners and acting manager are to address this situation, as staff must be trained appropriate to the work they are to perform. There are plans to develop a personal training plan for each member of staff and Beechcroft has extended it’s list of mandatory training to ensure that the needs of the residents are fully met, by trained and competent staff. The recruitment files were checked of two staff employed since the last inspection. The procedures continue to have improved and the files provide evidence of thorough vetting of prospective staff. The files contain all the elements legally required and also contain additional information for example evidence of telephone calls to referees to support written references and interview notes. Staff do not work with the residents until the Home is satisfied that they are suitable and they have received the results of all the required checks. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 22 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): 31, 33, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management systems have improved, which have had a positive effect on the residents and staff. The manager role must be formalised with permanent employment and registration with the Commission for Social Care Inspection. This will ensure that the improvements made are sustained and further developed to afford the residents consistency, stability and confidence in the service provided. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager resigned on 12/03/07. Since that time one of the existing senior care workers has taken on the acting manager role, with the support of the owners and staff team. There are plans for her to apply to the Commission for Social Care Inspection to be registered. This now needs to be done as soon as possible, so that the Home can settle into period of stability. The manager will need to undertake appropriate training and obtain the Registered Managers Award and National Vocational Qualification 4. She is aware that she has a lot to learn but shows a willingness to build on her experience. The acting manager has sustained the improvements made at Beechcroft in the last six months. Her efficiency and approachability was praised by the staff and a visiting district nurse. The owners are able to demonstrate their plans to continuous improvement of the service provided at Beechcroft, these include continuing to maintain the environment, progressing further with the staff training programme, new fire safety systems, Quality Assurance, regular staff meetings, establishing structured staff supervision, maintaining robust recruitment procedures and further developing activities and care planning, with the involvement of the residents and/or their families. Of the eighteen requirements left at the end of the last Key Inspection fifteen have now been met and major improvements were again noted at this inspection. This has had a positive effect on the residents and staff and there is an open, relaxed atmosphere in the Home. Questionnaires have been sent to the residents and their next of kin and the owner is presently collating the results. The owner and the acting manager have started to formally supervise staff, although this is in its infancy and needs to further developed. This will ensure that all staff are up to date with their training, the new expectations of the management team and the procedures in the Home. The residents will benefit from this consistent approach. Regular staff meetings are being held and there is a more transparent approach in the operations in the Home. Staff are able to contribute and make suggestions for improvement. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 24 The financial procedures were thoroughly checked at previous inspections and many improvements had been made to protect both residents and staff. They were not checked at this inspection, although the Home wants to try and encourage the residents to look after their own finances if possible. Mandatory training is being planned to cover all of the Health and Safety requirements. The owner is yet to address the Control of Substances Hazardous to Health procedures to ensure that they fully comply. Steps are being taken to strengthen Fire Safety and Infection Control procedures. Individual fire evacuation assessments must be undertaken. Beechcroft House DS0000004916.V342870.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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X X 2 X 2 Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 26 Yes 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 OP9 Regulation 13(2) Requirement The home must develop an effective programme to assess and monitor the care staffs’ competency in handling and administering medication to the residents. Timescale for action 01/10/07 2. OP30 3. OP31 4. 5. OP36 OP38 Previous Requirement 18 (1a, ci) All staff must be included in the training and development programme to ensure that a consistent, well-qualified team supports the residents. 9 The registered person must submit an application to register the acting manager to the Commission for Social Care Inspection. 18 (2) All staff must be supervised to 12 ensure a consistent approach, which safeguards the residents. 12 (1a) The registered person must 13 (4) complete the Health and Safety improvements and ensure that robust systems support and protect the residents. These include Fire Safety, Control of Substances Hazardous to Health and Infection Control procedures DS0000004916.V342870.R01.S.doc 01/10/07 01/10/07 01/10/07 01/10/07 Beechcroft House Version 5.2 Page 27 and mandatory training to all staff. 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. Refer to Standard OP1 OP9 OP30 Good Practice Recommendations The Statement of Purpose and Service Users Guide must be updated to ensure that the residents have access to current information about the service they can expect. It is recommended that the home obtain a Controlled Drugs cabinet and attach it to a solid wall using rag bolts. It is recommended that new staff receive documented manual handling training prior to working with the residents, ensuring a safe system of work. Beechcroft House DS0000004916.V342870.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Local Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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