Inspection on 19/01/07 for Beechcroft Residential Home

This inspection was carried out on 19th January 2007.

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

The inspector 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 Residential Home 08/03/06

Beechcroft Residential Home 22/02/05

Beechcroft Residential Home 18/11/04

Beechcroft Residential Home 16/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Beechcroft Residential Home Salop Drive Oldbury West Midlands B68 9AG Lead Inspector Linda Brown Key Unannounced Inspection 11:00 19th January 2007 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 Residential Home DS0000004776.V317153.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 Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechcroft Residential Home Address Salop Drive Oldbury West Midlands B68 9AG 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) 0121 429 2993 0121 429 6995 Mr Anthony Billingham Ms Carole Jenkins Jennifer Maisie Kelway Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user identified in the variation letter dated 5.1.2005 may be accommodated at the home in the category of SI(E). This will remain until such time that the service users placement is terminated or whilst the home is able to meet the service users needs. 8th March 2006 Date of last inspection Brief Description of the Service: Beechcroft is a purpose built residential care home, providing residential accommodation for fifty older people. The home is privately owned. Beechcroft is situated in a quiet cul-de-sac in a residential area of Oldbury, within close proximity of local shops and public transport. There is a car park adjacent to the home for visitors to the home. The home comprises of two lounge/dining rooms, 48 single bedrooms (11 of which have en-suite facilities), 1 shared bedroom, bathrooms and WCs. The home is of two-storey construction and built in a rectangle providing an inner sheltered courtyard, which has shrubs, garden furniture and has the benefit of a security light. The home is approached either by a sloping pathway or a flight of steps with handrails. The stated aim of Beechcroft is to provide an environment in which elderly people may lead as normal a life as they are able, maintaining individuality, dignity and retaining their status as independent adults. Beechcroft aims to promote good care, respect, and independence for every resident whilst responding to the needs and wishes of all. Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place on 19th January 2007 The purpose of this visit was to monitor the home’s performance against the key standards in the National Minimum Standards for Care homes for older people, and to assess improvements in line with the requirements made at the last inspection. Time was spent observing in the service users’ lounge, talking to residents and observing practice. Two members of staff were interviewed. Discussion took place with the manager and team manager, others were spoken to during the course of the inspection. The inspector case tracked three service users including files and medical files. The inspector examined records for the standards to be inspected along with assessing the progress from the requirements made at the last inspection. Three staff files were also examined, the manager completed a pre inspection questionnaire prior to the inspection and 17 comment cards were received from service users and 12 from families. The inspector would like to thank the service users, staff, manager and team manager for their cooperation and assistance during the inspection. The fees for this home range between £335 -£370 per week. What the service does well: Beechcroft is a large busy home, which despite its size has a warm, relaxed and friendly atmosphere. The home is clean, nicely decorated and well maintained. Bedrooms are personalised. As commented at the last inspection, the staff work well as a team and support each other. Staff interviewed informed the inspector “ it’s a nice environment to work in”. The inspector observed service users and staff joking with each other. Clearly good relationships have been developed between them. Comments received from service users stated “the staff are nice, they get us anything we need”.” I can always sit and talk to staff they are always available” The manager is active in investigating complaints and establishing satisfactory outcomes. The quality assurance system is very detailed and the manager monitors all aspects of the home on a monthly basis and evaluates the outcomes in order to make improvements. Pre-admission assessments and processes are very thorough and detailed. Both staff and service users commented on the information available at the time of admission to enable them to make an informed choice. Service users and families commented on the benefits of the visits to the home prior to Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 6 admission. Service users were able to meet staff and other service users and joining in with activities and meals before deciding on the home’s suitability. All service users that the inspector spoke to praised the meals provided by the home. Comment cards received also supported this. For example one person stated, “I enjoy all the meals, they are very nice. If we want anything different we just have to ask”. Records viewed by the inspector confirmed that service users are offered a variety of well-balanced and appealing meals. The cook also attends the residents’ meetings to ensure service users are happy with the meals. All staff that were interviewed demonstrated extensive knowledge of adult protection issues and their roles and responsibilities within this area, resulting in further protection for people living at the home. Staff confirmed that the manager actively promotes training. Generally the home is maintained to a very high standard, which results in a pleasant and safe environment for service users to live in. What has improved since the last inspection? What they could do better: Staff supervision takes place on a regular basis however records of the supervision are kept at supervisor’s homes. Staff were contacted during the inspection to bring records into work. These records must be retained on the premises and a secure place must be identified for their storage. Staff appraisals are taking place and in order to develop them further, the inspector recommends that training is identified for the following year and goals and targets are set for staff within time-scales. A recent pharmacy inspection has taken place and the inspector recommends the manager implements the recommendations made. Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 7 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 Residential Home DS0000004776.V317153.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 Residential Home DS0000004776.V317153.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): 1,23,4,5,6. Quality in this outcome area is good. Prospective service users have an informed choice about where to live. Each service user has a written contract, service users needs are assessed prior to admission and confirmation is given that their individual needs can be met. Visitors are made welcome at any time and families and prospective service users have the opportunity to visit the home prior to admission. The home does not provide intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Service User Guide gives information regarding the home and also includes contact details of other agencies and advocates. Staff also confirmed that people who are interested in moving into the home are given written information about services and facilities offered by the home, to enable them to make an informed choice about the suitability of the home. Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 10 In discussion with the manager and team manager work was taking place to review and develop the current Statement of Purpose and the service user guide. The manager explained that she completes all the initial assessments for potential service users. Other staff are able to complete them in her absence but the manager feels this is an integral part of her role. Evidence of detailed assessments were available on the files examined. Service users are then invited to visit and stay for lunch if they would like to. Comment cards received from service users and residents spoken to during the inspection confirmed that they had been given information about the home prior to moving in and that they had also visited to decide on its suitability. One service user stated, “I visited my friend here before I moved in so I knew what the home was like. I chose my room I like it because it is light and airy” Another service user wrote “ I came to view the home with my sister in law, I did not like the last care home and I could not wait to leave there” Three service users’ files were examined during the inspection and all three contained contracts and letters to the service users confirming the home is able to meet their needs The home does not offer intermediate care. Beechcroft Residential Home DS0000004776.V317153.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 good. Care planning is good within this home, ensuring staff have the information they need to satisfactorily meet service users’ needs. The health needs of service users are well met, with evidence of good multi disciplinary working taking place on a regular basis. The service users are protected by the home’s policies and procedures for dealing with medicines. All staff administering medication have received the appropriate training. Recommendations made at a recent pharmacy inspection should be implemented to develop and improve practice. Service users feel they are treated with respect and dignity. This judgement has been made using available evidence including a visit to this service. Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 12 EVIDENCE: Three service users’ files were examined and all contained care plans, which are regularly reviewed. The service user’s daughter signed one care plan, which had recently been reviewed; others were signed by the service users. All care plans that were sampled contained assessments for the prevention of falls, continence, pressure sore management and moving and handling. In addition to this records confirmed that the health needs of service users are monitored with the appropriate action taken and recorded. Nutritional assessments are completed as part of this process. Evidence was available on files examined that service users are being weighed on a monthly basis. Routine medical checks such as optician, dentist and chiropody appointments are regularly attended in addition to specialist services, which may be required. One relative wrote on her comment card “ my mother has been in Beechcroft for nearly three years and during this time she has become a more confident person and she is a great deal healthier than she was. They take wonderful care of her and meet all her needs, in particular my mother’s key worker, she knows my mum well and helps her. I was most grateful when she recently took mom for an eye test and helped choose some lovely glasses” Since the previous two inspections the manager has addressed many of the areas of concern regarding the safe administration of medication. Medication is stored appropriately and staff administering it have received the approved training. Three service users were case tracked, medication files contained photographs of residents and MAR sheets were completed. One gap was found for the morning of the inspection, the manager explained that she had given the medication and was distracted before she recorded it. The error was hers and she rectified it. A full pharmacy inspection was due on the 25/01/07 so the inspector requested a copy of the report to be forwarded to the Commission. The overall report was good with a few recommendations to further improve practice. The inspector recommends that the recommendations made by the pharmacy inspector are implemented. All seventeen service users’ comment cards talked positively about the care they received. Many commented on the weekly doctor’s visit “If I want to see the doctor I only have to say” another stated, “If I were not well I know I will get the medical help I need”. Others talked abut the support given if hospital appointments were required. “If I have an appointment, I just tell the seniors and they arrange the ambulance and escort to go with me “ Beechcroft Residential Home DS0000004776.V317153.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. Service users find the lifestyle experienced in the home matches their expectations and preferences. Service users maintain contact with their family and friends who are welcome to visit the home at any time. Service users are helped to exercise control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager is keen to promote activities, during the inspection a singer arrived to entertain the service users. This was enjoyed by residents. Pictures are displayed of the parties that took place over Christmas. Staff are very committed and attend the parties. There is a real community sprit with in the home. In addition to in-house entertainment residents go out on the minibus. Individual risk assessments are not completed for all activities that take place outside of the home. To ensure the safety of all service users and staff the manager must complete risk assessments on all outside activities. Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 14 Service users are supported to attend church. Some attend with their families, others feel they no longer want to go to church. The priest visits the Catholic residents and a vicar also visits the home. The manager has formed good links with the outside community and at Christmas a local school came to sing carols. At the previous inspection plans were well under way for the celebration of the home being open 10 yrs. One staff member and one service user had been at the home since it opened. Pictures were displayed of the party along with newspaper cuttings as the local MP also attended the event. Pictures were also seen of cheese and wine evenings and mince pie and sherry afternoons. Staff entertained the residents who named them the “Beechcroft babes” In addition to outside entertainment the staff organise in-house activities such as craft making and card games and quizzes. The library also attends and one service user commented that the audio stories were really good. Service users have regular meetings to discuss any changes or ideas for the future. The cook always attends this meeting to suggest menu changes and get feedback from residents about the meals. This is very good practice and clearly benefits the service users. Many service users prefer to talk to their link workers than speak in the residents’ meetings. All service users spoken to by the inspector feel they are able to have a say and be listened to. A lot of discussion was taking place with residents regarding the lounges; prior to Christmas they had two lounges and two dining rooms, during the Christmas festivities in order to be together they made one large dining room and one large lounge. Many service users prefer this, however consultation is taking place with all service users to decide which lounge to use. Service users are able to take their visitors to their rooms. Visitors are welcome at any time. Some service users have chosen to have a phone installed in their rooms. Others have access to a ’phone for private use. There is a system in place for the distribution of post. The cook takes an active role within the home, as previously stated she attends all service users’ meetings in order to accommodate their requirements. Special diets are catered for and service users are given a well balanced diet, which consists of a choice of hot meals. Lighter snacks are also available. Service users told the inspector the meals are good and drinks are available when ever they want one. All comment cards received made positive comments about the meals and one service user wrote, “I can always ask cooks or carers if there is something special I want.” Another wrote, “I asked for ‘fry up’ to go on the menu and she agreed”. Kitchen records are well maintained, fridge /freezer temperatures are recorded along with food temperatures. Records are also maintained of actual meals taken by service users. This assists the manager in the monitoring of residents weights and nutritional screening. Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 15 Service users are free to sit where that chooses in the dining room, however they always choose to sit in the same places. This only varies in a morning as service users get up at different times. Beechcroft Residential Home DS0000004776.V317153.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 good. The manager has developed a good system for recording and responding to complaints. Service users are confident their complaints will be listened to. Service users are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are policies and procedures are in place for staff to enable them to deal with complaints. Three complaints have been received since the last inspection. All have been responded to within the correct time scales and outcomes sent to the complainant. This was discussed at the last inspection and it is pleasing to see that areas discussed have now been implemented. To improve the recording systems further, discussion took place with the manager regarding the crossreferencing of where information is stored. For example, reference in the complaints book can be made to a service user’s file. It would not always be appropriate to store detailed information in the complaints book. 12 comment cards were received from relatives and visitors all twelve cards stated they had not needed to make a complaint and all were positive about the care received by their families. Seventeen comment cards were received from service users, all comments received stated service users felt confident in making a complaint and knew whom they would tell. Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 17 The manager actively promotes abuse awareness within the staff team. Thirtysix members of the staff team have completed adult abuse training. Six remaining care staff and six domestic staff are now awaiting training, which is booked for April 2007. Beechcroft Residential Home DS0000004776.V317153.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): 19,21,22,23,24,23,26. Quality in this outcome area is good. Service users live in a safe well maintained environment There are sufficient lavatories and toilet facilities. Service users have the specialist equipment they require to maximise their independence. Service users live in safe, comfortable surroundings. The home is clean and pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector toured the building with the manager and during the tour had the opportunity to talk to service users. Beechcroft is a large busy home, which despite its size has a warm, relaxed and friendly atmosphere. The home is clean, nicely decorated and wellmaintained. Bedrooms are personalised. One service user kindly invited the inspector into their room. They had recently moved into an ensuite room and were really pleased with it. The service users Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 19 told the inspector they were in the process of having satellite TV as they enjoyed watching sport in their room. The room identified in the last inspection report as having an unpleasant odour has had new carpet fitted and is now odour free. The manager explained the ongoing plans to improve the home, two bedrooms have been converted to ensuite and there are plans to convert more of the larger bedrooms. This manager is keen to develop the facilities in order to remain competitive with the current market and provide improved facilities for service users. The manager has plans to make another respite bed at the home, as they are unable to accommodate the current demand for respite. The manager is now keeping a separate booking in system for respite care. The reception area is welcoming and information is displayed in this area for example a sign to say “ we are here to help you”. This gives information about complaints and what to do if you are not happy. There is a suggestion box on the wall for the use of families and service users. The Investors in People certificate is also displayed. All visitors to the home sign in and out of the visitors’ book. New washable flooring has been fitted to the hairdressing salon within the home making it easier to clean and keep tidy. A large section of the roof was damaged during the bad weather. It has been made safe with a temporary cover and some service users had to be relocated Unfortunately due to the severe winds being experienced this has delayed the completion of the work. Work will be completed once it is safe to do so. The Commission was notified of this event. There are sufficient bathrooms and toilets for service users, which were clean and tidy. Hoists and adapted bathrooms are available for use. Beechcroft Residential Home DS0000004776.V317153.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): Quality in this outcome area is good. Service users are supported and protected by the home’s recruitment policies and procedures Management promotes training and courses are available and ongoing. There are sufficient staff on duty to meet the needs of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are adequate staff on duty to deal with the number of residents. In discussion with staff they confirmed that with the exception of unforeseen emergencies there are adequate staff. They explained that there is a very supportive staff team and at times of crisis everyone helps out and with cover shifts if required. There is a good team sprit and staff clearly support each other and work well together. Training is continuous and the manager keeps a training matrix to identify gaps. The training programme is ongoing; staff explained to the inspector that in addition to the mandatory training, courses are displayed on the notice board in the staff room. Staff are supported by the manager and encouraged to apply. Courses are available throughout the year. Since the previous inspection, staff have taken part in manual handling, fire training, first aid, food hygiene abuse infection control health and safety, medication and dementia. Senior staff has completed disciplinary procedure training. Staff interviewed stated “We can ask if we feel we need any particular training, there are often small courses advertised on the staff notice board and we are encouraged and supported to attend” Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 21 25 members of staff have attained their NVQ 2 award and five staff are currently completing the award. Two staff have completed their NVQ3. Three staff files were examined all contained the relevant paperwork to ensure the recruitment practices at the home are robust to protect service users. Evidence such as application forms, written references and Criminal Records Bureau checks were available on files. Evidence of induction was available on two files, the third member of staff was very recently appointed and another induction had begun. Staff now keep their own “skills for care” induction booklets to enable them to complete and record information. Samples of the booklets were shown to the inspector Staff work through the books with their supervisor, however evidence was seen at the previous inspection of completed books. Staff informed the inspector that the induction booklet had been very helpful. At first it had seemed a lot to digest but working through it with their supervisors had been beneficial. Staff confirmed they had regular supervision and they felt able to talk to their supervisors. All staff spoken to during the inspection stated how supportive the team was. They also felt Beechcroft was “a nice environment to work in” Three staff files were examined and evidence of training and certificates seen, along with yearly appraisals. Supervision takes place every two months unless the manager feels additional support is required. Beechcroft Residential Home DS0000004776.V317153.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): Quality in this outcome area is good. The home is run by a manager who is fit to be in charge and is currently undertaking her Registered Managers Award. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interest of the service users. There are systems in place to ensure service users’ financial interests are safeguarded. Staff are appropriately supervised, however records of these supervisions must be stored on the premises. Good recording systems are in place and overall the health and safety and welfare or service users are promoted and protected, however furniture must not be stored under the stairs. This judgement has been made using available evidence including a visit to this service. Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager is currently completing her Registered Managers Award (RMA) At the previous inspection the manager had reviewed the system for the safe storage of service users’ money and introduced a recording system to include signatures and receipts for expenditure. The manager explained the administration staff and she then check the monies weekly. Six service users’ monies were checked. Five were correct and one was found to be short. On further examination the manager explained the error was due to hairdressing charges not being recorded on the expenses sheet. The manager must ensure costs are deducted at the time of expenditure. This is a large residential home and the manager recognises the importance of good monitoring systems to enable her to effective manage the home. The inspector referred to the excellent, detailed in-house monthly monitoring system, which was in place at the previous inspection. It is pleasing to see that this system is still in place and continually under development and improvement. Health and safety issues identified from monthly audit are then discussed at manager’s supervision and regulation 26 visits. Copies of these regulation 26 reports are sent to the Commission on a regular basis. They are informative and highlight areas to be addressed as well as positive work being undertaken. Time is also spent talking with service users and staff. The manager also monitors care issues such as pressure sores where applicable, violent incidents, accident reports, dependency levels and staff training and supervision. The team manager undertakes occasional checks on the above, evaluates the findings and completes a yearly report. Questionnaires are sent out yearly to service users, family / friends and visiting professionals. These are also evaluated and a report is completed. Views are also gained from residents meetings, which take place regularly. Evidence was seen of regular detailed supervision taken place, however this information was not stored in the unit, with the exception of the manager’s. Staff were contacted at home and one supervisory member of staff arrived at the unit with her folder of staffs supervision notes. Discussion took place with the manager regarding this practice, she recognised this was unacceptable and had already started to clear a lockable cupboard for there storage. The manager must ensure that all staff records are stored at the home and a safe and secure place is identified to store them. Staff interviewed during the inspection confirmed the received regular supervision and in addition to this there is an open door policy and staff are encouraged to discuss concerns with their supervisors or managers at any time. Supervision takes place every two months unless the manager feels additional support is required. Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 24 Staff spoken to during the inspection felt supported and valued. The manager’s pre inspection questionnaire stated that all health and safety checks are in place. The information provided identifies that the yearly gas and central heating checks are now due. Fire alarm tests are weekly and an announcement is made prior to the test taking place. This took place during the inspection. Legionella risk assessments and water temperature checks take place. Equipment for example hoists, baths and the lift are also maintained. Fire officer last visited in September 2005 and any requirements made were implemented. At the last inspection a requirement was made regarding all the furniture being stored under the stairs. This has been removed however during the tour of the building the manager explained a bed had now been stored under the stairs whilst a bedroom was being refurbished. The inspector recognises the inconvenience caused when refurbishing bedrooms however the stairwell should not be used to store furniture as this poses a fire risk. Files are well maintained and there are good recording systems in place. The manager is constantly trying to develop the quality of the daily recording to ensure consistency between staff. Beechcroft Residential Home DS0000004776.V317153.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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 2 3 3 Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 26 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 OP36 2 OP38 13 Standard Regulation 18 Requirement The manager must ensure that supervision records are stored in a secure place on the premises. The manager must ensure the bed is removed from under the stair well. Timescale for action 01/03/07 01/03/07 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 OP36 Good Practice Recommendations Staff appraisals are taking place, in order to develop them further the inspector recommends that training is identified for the following year and goals and targets are set for staff within time scales. A recent pharmacy inspection has taken place and the inspector recommends the manager implements the recommendations made. 2 OP9 Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 27 3 OP16 It is recommended that reference is made in the complaints book of where relevant paper work has been filed in order to cross reference information. Beechcroft Residential Home DS0000004776.V317153.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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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