Inspection on 28/08/07 for Beechcroft House

This inspection was carried out on 28th 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 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 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Beechcroft House St Johns Road Rowley Park Stafford Staffordshire ST17 9BA Lead Inspector Mandy Beck Unannounced Inspection 10:00 28 and 29th July 2008 th 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.V368282.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.V368282.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 Manager post vacant 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.V368282.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD(E) – Registered for 25, 6 PD(E) 2 of whom may be 50 on admission. 22nd August 2007 Date of last inspection 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. 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 not 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 not available in the reception area but is available to people upon request. Beechcroft House DS0000004916.V368282.R01.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 0 star. This means that people who use this service experience poor 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 service. 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 service. • Information we have about how the service has managed any complaints. • What the service has told us about things that have happened in the service, these are called ‘notifications’ 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 looked at the care of two people who use this service in depth. This is part of our case tracking process and helps us makes judgements about the home’s abilities to meet people’s needs. What the service does well: What has improved since the last inspection? The service has continued with the redecoration programme and there have been improvements made to other areas of the premises; some people’s bedrooms have been decorated and also hallways and corridors. Beechcroft House DS0000004916.V368282.R01.S.doc Version 5.2 Page 6 The shower room on the ground floor has also been totally refurbished and offers a pleasant place for people to bathe. What they could do better: The service could improve upon the care planning systems it has. This would ensure that each person’s care needs are identified and clearly detailed in a plan of care. Every person must have care plans upon their admission to the service. There could be more activities on offer for people to take part in. We were told “I am bored sometimes, I feel there could be more to do”. Staff also told us “we would like to take people out more but there isn’t enough staff”. The menu needs to reflect more choices from the people who live within the service. People have said “I would like to see more fresh fruit on the menu”. Another person said, “the food is very average”. Staff working at the service needs to have training in safeguarding vulnerable adults. This needs to happen so that all staff are sure about the actions they need to take in order to protect and keep safe people living within the service. Staff training in other areas such as infection control, food hygiene, first aid and fire safety must be improved. Recruitment procedures need to be improved to make sure the service is not recruiting people who are unsuitable The management team need to improve the quality assurance system within the service if people are to be assured the service is being run in their best interests. The policies and procedures need to be updated in order to make sure that staff are using policies that reflect current best practice and changes legislation. There has not been a registered manager in post for over 12 months and this must now be addressed. Please contact the provider for advice of actions taken in response to this Beechcroft House DS0000004916.V368282.R01.S.doc Version 5.2 Page 7 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.V368282.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.V368282.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): 3,6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People choosing to live in this service will have most of the information they need to help them make choices. They can feel confident that their needs will be assessed prior to moving in. EVIDENCE: The service does have a Statement of Purpose and a Service User Guide. The person in charge told us that at present both documents are in the process of being updated. People are not given an individual copy of the service user guide when they move in but they are able to access one upon request. We have recommended that the current range of fees the home charges be included in the review of these documents. We looked at the care of two people as part of our case tracking. This enables us to make decisions about the quality of care people are receiving in the home. We saw that in both cases the home had obtained a needs assessment Beechcroft House DS0000004916.V368282.R01.S.doc Version 5.2 Page 10 from the placing authorities. The service’s own assessment had been completed for one person but not the other. The acting manager told us this was because one person had been admitted for a short period of respite and a visit to the service had not taken place. The service had used information from their prior admission to inform this one. We have recommended that people’s needs are assessed for each admission they have this will ensure that assessments are up to date and reflect people’s current situation. This service does not provide intermediate care facilities. Beechcroft House DS0000004916.V368282.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. People living in this service do have their healthcare needs met but improvements are needed to record keeping so that each person’s needs are individually recorded. EVIDENCE: Each person living at the service has their own individual care plan. We saw that in some cases however, these care plans were not always completed. We looked at the care plans for one person who was using the home for a short stay, they had written care plans at all. The acting manager told us she thought it was “ok to use the social workers assessment”. The other person’s care plans we looked at were not completed. There were gaps in all areas of documentation. The service has told us in their Annual Quality Assurance Assessment (AQAA) “our staff always assist service users to maintain their health and personal care by helping them to maintain as much of their independence as possible” and “service users have a choice over their personal care and are encouraged to be independent and responsible for their own Beechcroft House DS0000004916.V368282.R01.S.doc Version 5.2 Page 12 personal hygiene where possible”. If care plans are incomplete and do not hold information on people’s wishes staff are going to find it difficult to provide person centred care. We found other omissions in record keeping such as the recording of people’s weight as part of ongoing concerns about weight loss. One care plan said that a person’s weight should have been recorded weekly, we found that this had be done twice since June 2008. We also noted that a “foot care checklist” had not been completed for one person, this was particularly important as the district nurses were visiting the home regularly to see this person because of specific problems with their feet. Risk assessments for moving and handling of people had not been completed for the two people we looked at. This means that any specific risks associated with mobility may not have been recorded. In both cases we saw that the care plan agreement had not been completed by either person living within the service. This means the service cannot successfully demonstrate how it has involved people in the planning of their own care. We asked people if they felt there needs were being met by the service. They told us “yes they are, sometimes you have to tell them a few times what you want them to do though”, and “it is perfect the staff are very kind”. We also spoke to staff, we asked them how they knew what care to give the people they look after, they said “we ask them, or they tell us”. We also asked them about the care of the two people we case tracked and despite the lack of written information available to them they were all able to give a clear explanation of each person’s needs. Medication systems have improved since our last visit. The service now has suitable storage for controlled drugs. The service records the temperature of the medication fridge. This means that medicines are being stored safely. There are good systems in place for the administration and receipt of medication. At present none of the people living at this service administers their own medication but the service does have risk assessments and consent forms for people to use should they choose to do this. The service has not met one of the previous requirements from the last inspection visits. We required the service to complete competency assessments for all of the staff that administer medication. The acting manager told us this has not been done. We will be considering further action as part of our management review process and enforcement pathway. We observed throughout the inspection that people were spoken to politely and staff took time to knock people’s doors before entering. People living at the service said that they felt they were treated with respect and dignity at all times. Beechcroft House DS0000004916.V368282.R01.S.doc Version 5.2 Page 13 Beechcroft House DS0000004916.V368282.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 service offers some activities for people to take part in but more could be done. Meals are provided on a regular basis and people are generally happy with them EVIDENCE: People do have the opportunity to take part in activity. There are weekly chair exercises for people to do, there are also visiting entertainers. People who responded to our surveys said “more activity would be nice, especially for those in bed who can’t take part”. People we spoke to said “the staff try to keep us entertained but I don’t think they have enough time”. Staff said “we could do more for the residents but the staffing levels don’t allow it”, “there is time to get the basics done but I don’t think enough thought is given to activities”. The service told us in their AQAA they would like staff to “join in the activities alongside the service users” in order for them to do this the service may need to review the staffing levels to make sure this can happen. The service has already one worker who is responsible for activity provision and some improvements are being planned. Beechcroft House DS0000004916.V368282.R01.S.doc Version 5.2 Page 15 Visitors are welcomed to the service at any time. We saw a steady stream of people visiting throughout the day. People are encouraged to decorate and furnish their own rooms with personal possessions. Rooms we saw had been decorated in this way. The service has said that it intends to give staff training in the principles of the Mental Capacity Act 2005. This will give staff an understanding of their role and responsibility in supporting people who may not be able to make decisions about their lives because of a lack of mental capacity. The service should also look at ways in which they can support people in looking after their own money rather than having the home do it for them. Meals are provided three times a day and for those people who want supper there is an option of milky drinks and sandwiches available. People gave us mixed reviews about the food. They said “it’s very average the food, I would like to see different things on the menu but I think it’s the price”, others said “the food is very nice we have a choice of different sandwiches at tea time the cook always comes round to ask us”. “I do get fed up with sandwiches every night”. Staff told us “the food is ok but there is no variety for people”. We spent time talking to the cook who told us that some changes have been made to the menu. There are now five varieties of sandwiches on offer for teatime along with choices of crisps, pork pies and sausage rolls. There is no choice available for lunchtime everyone has the same meal. People are offered an alternative if they do not like the main meal of the day. It is recommended that a choice be offered for everyone at lunchtime this may add more variety to the menu for people to enjoy. Beechcroft House DS0000004916.V368282.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. People are aware of how to make a complaint but not everyone is confident their views will be listened to and acted upon. Staff need further training in protecting vulnerable adults because they are likely to take matters into their own hands rather than refer to appropriate agencies. EVIDENCE: The service tells us that it has received no complaints since our last visit. The complaints policy is on display in the reception area of the home for people to access. We saw from responses to our questionnaires that people are aware of who to make complaints to. They also told us “I have no complaints at present but I would talk to a senior on duty if I was unhappy”, another person said “Making any complaint is very difficult. It creates an atmosphere and staff hate it”. During our last visit the home told us they intended to introduce a “grumbles” book to record issues that they considered not to be formal complaints. The acting manager told us this had not been done. She told us “we haven’t had any to deal with”. The service’s AQAA tells us the home has updated the Safeguarding vulnerable adults policies. We spoke to staff about safeguarding and their role in keeping people safe from harm. None of the staff we spoke to or who responded to our Beechcroft House DS0000004916.V368282.R01.S.doc Version 5.2 Page 17 questionnaire said they had received training in this area. They were unable to recall the different types of abuse or had any knowledge of the local council guidance for safeguarding adults. We have recommended that training be sought promptly for all staff, including night staff. This will mean that people are being protected by staff that are aware of the signs of abuse, the different types of abuse and how to respond should an allegation be made to them or they witness an incident. We have also recommended the home obtains a copy of the local council guidance and updates their own policies to give staff very clear guidance should an incident occur. We saw in one person’s notes they had sustained bruising in a fall but this had not been reported on an accident form. There were different explanations from staff and the acting manager about how the bruising had occurred. A referral to the safeguarding team should have been made in respect of these injuries but was not done. The acting manager was not aware of her responsibility in reporting incidents to the safeguarding team. At present there is no restraint being used in the home. Bed rails are no longer in use and there are no wheelchair lapbelts. Staff confirmed that they do not use restraint of any kind in the course of their duties. We looked at the recruitment files for three new workers since the last inspection. We did this to see if the home is fulfilling its obligation in completing safety checks against the Protection of Vulnerable Adults (PoVA) list and Criminal Records Bureau disclosures (CRB). The service must do this to prevent unsuitable people from working with vulnerable adults. We found that checks against the PoVA list were confirmed but we did not see CRB’s for two new workers. The provider told us that they had been destroyed once he had seen them. We must be able to see CRB’s as part of our inspection process to enable us to make judgments about safe practice. The service must keep new workers CRB’s for us to inspect once we have done this they can then be destroyed. Beechcroft House DS0000004916.V368282.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. The service provides a clean environment and has a welcoming atmosphere. EVIDENCE: There have been some improvements in the service since our last visit. The planned refit of the bathroom has taken place. It is now a wet room with assisted facilities for people to use. There is continued redecoration of the home. People told us “it’s perfect here”, “the home is very nice and well presented”, “nobody would choose to live in a home but this one is very nice”. We did notice the carpet in one of the lounges is quite heavily stained and in need of cleaning or replacing. The acting manager told us this was on the plan for the coming year. As the result of a fire risk assessment being completed by an external company, the owners are presently updating and improving their fire safety Beechcroft House DS0000004916.V368282.R01.S.doc Version 5.2 Page 19 arrangements. Staff are being regularly trained and but more fire drills are needed. Thorough and more regular systems have been 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. Infection control procedures have been updated throughout the service. There are paper towels and liquid soap available for people to use for hand washing purposes in all toilets and bathrooms. Beechcroft House DS0000004916.V368282.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. There are staff available to meet people’s needs. staff are recruited and trained satisfactorily but improvements could be made. EVIDENCE: The staffing levels in this service are sufficient for meeting people’s basic needs. More consideration should be given to increasing numbers that allows staff to spend more time with people doing activities. The service is using agency staff at present to make up staff numbers. We spoke to staff about staffing levels, they told us “some of the staff here work crazy hours”, “we have enough staff to do the basics but we never get chance to sit and talk to people or do activities”, “there are no incentives to want to work more hours”. Staff are being encouraged to undertake their National Vocational Qualification (NVQ) and at present the home has 71 of care staff who have achieved this. There are plans to support the remaining staff through this process to. We looked at the staff files of three people who have been employed since our last inspection. We found that most of the required information was available. The home has taken steps to make sure people have two written references, proof of identity and in some cases a photograph. The had also made sure that a check against the Protection of Vulnerable Adults (PoVA) list had been Beechcroft House DS0000004916.V368282.R01.S.doc Version 5.2 Page 21 completed but the provider had told us that he was not in possession of people’s CRB’s. We must be able to see these in order to satisfy ourselves recruitment processes are being followed and that the home is taking steps to prevent unsuitable people from working with vulnerable adults. There are good systems in place to support people through the induction process. Records were seen and staff confirmed the service had supported them when they started employment. Beechcroft House DS0000004916.V368282.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): 31,33,35,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are systems is in place to protect the health and safety of the people living there. Management of the home is disjointed and must be improved if the service is to move forward. EVIDENCE: This service has not had a registered manager for over 12 months. There is currently an acting care manager in post but we have not received any application to register this person. The service must take action to resolve this situation. This is an outstanding requirement from their last inspection and we will be considering what further action to take with the service as part of our enforcement pathway. Beechcroft House DS0000004916.V368282.R01.S.doc Version 5.2 Page 23 The quality assurance system was discussed with the acting manager; she told us that she is not responsible for completing this. She also told us that no new surveys have been sent out to the people living in the home since the last inspection. We, the commission also sent individually addressed surveys to people living in the home but we have received a limited response. The Annual Quality Assurance Assessment (AQAA) we received gave us limited information about the home and the service it provides. The service has not told us of its plans to register their manager, or how it plans to improve the service for people living there. It has told us “the home owners work continuously to improve the services and provide an increased quality of life for service users” but not how it does this. The service does provide safe storage for people’s money. There are not many of the people living in this home that keep and manage their own money. It is recommended the home should look at ways of supporting people to do this. We checked the money for some of the people living here, we found that records of all transactions are kept and that monies did balance. We also looked at fire equipment checks such as the emergency lighting and fire alarms. They were up to date but there were no records of staff undertaking a fire drill. We also asked the manager about the recommendations from the recent fire officer’s visit. She was unable to tell us if these recommendations have been met. This will need to be done promptly so that we can feel assured people living in this home are not being place at increased risk. We also asked to see other maintenance records for the home but these were not made available to us during this inspection. We did not see certificates that show the home has a current five year electrical check, gas landlords check or if the home is monitoring the hot water temperatures for the people living there. Staff training continues to be completed although there are gaps that the home will need to address. Staff must have the mandatory training they need to keep their knowledge and skills up to date. The acting manager told us “we are trying to arrange dates so that all staff are due for training at the same time to make it easier for them to attend”. Beechcroft House DS0000004916.V368282.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 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 X X 1 Beechcroft House DS0000004916.V368282.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement People must have care plans in place at the point of admission to the home. This must also include those people who are admitted for short stay respite periods. People’s care plan must include clear guidelines for staff so that people’s needs are known, understood and carried out by staff. People’s plans must be kept under regular review. People’s weight must be kept under regular review with clear records kept. Care plans should clearly indicate the frequency with which this should happen. i.e. monthly or weekly The home must develop an effective programme to assess and monitor the care staffs’ competency in handling and administering medication to the residents. (previous timescale of 01/10/07 not met) Timescale for action 30/10/08 2 OP7 15 30/10/08 3 OP8 15 30/10/08 4 OP9 13(2) 17/07/08 Beechcroft House DS0000004916.V368282.R01.S.doc Version 5.2 Page 26 5 OP18 13(6) 6 7 OP18 OP29 13(6) 19 8 OP31 9 Care Standards Act (CSA) 2000 11(1). 17 9 OP38 The home must make sure that referrals are appropriately made to the safeguarding team. In order to protect people from harm. The home must arrange for all staff to have training in safeguarding vulnerable adults. The home must ensure that when recruiting staff the recruitment process is followed. This must include those staff who are being re employed by the home. The registered person must submit an application to register the acting manager to the Commission for Social Care Inspection. (previous timescale of 01/10/07 not met) The home must be able to demonstrate that it is a safe place for people to live and that safety records are kept up to date. This includes fire fighting equipment, fire drills, 5yr electrical certificate and gas landlords. The home must also make sure that these documents are available for inspection. 30/10/08 30/10/08 30/10/08 17/07/08 30/09/08 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 OP1 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. DS0000004916.V368282.R01.S.doc Version 5.2 Page 27 Beechcroft House 2 3 4 5 OP7 OP9 OP12 OP14 6 7 8 9 OP15 OP18 OP27 OP33 10 11 OP35 OP36 This should also include the range of fees that people would be expected to pay. 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. Two staff should sign all handwritten entries on to the MAR sheet. This should reduce the risk of errors being made. The home 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 The home should consider training for staff that underlines the principles of the Mental Capacity Act 2005. this should give staff guidance on their role and responsibility in supporting people who may not be able to make choices about their care because of a lack of mental capacity. The home should consider giving a choice to two meals to people for their main meal of the day. This may help to improve the variety and choice for people CRB’s for new workers must be retained for CSCI inspection purposes Staffing levels should be reviewed so that staff have more time to spend with people living in the home doing activities and outings. The management team need to continue to develop the quality assurance systems. The analysis of the completed residents surveys should be completed and made available for people to read. The home should consider ways in which to support people to manage their own money. Staff should have regular supervision, this should give them the opportunity to discuss issues arising from practice and further training needs. Beechcroft House DS0000004916.V368282.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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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