CARE HOME ADULTS 18-65
Beechdale 302 Golden Hill Lane Leyland Lancashire PR5 1YH Lead Inspector
Mrs Marie Cordingley Unannounced Inspection 13th September 2007 10:00 Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Beechdale Address 302 Golden Hill Lane Leyland Lancashire PR5 1YH 01772 452924 F/P 01772 452924 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) Dalesview Partnership Mrs Hayley Elizabeth Stringfellow Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 7 service users of the category LD - (Learning Disability) including 1 named service user aged 17 years of age. 8th June 2006 Date of last inspection Brief Description of the Service: Beechdale is a detached bungalow situated on a main road approximately 1 mile from the town of Leyland, which can be accessed via a well-served bus route. Accommodation comprises 7 bedrooms, 4 with ensuite facilities, a separate bathroom, lounge, dining room, and kitchen. There is an enclosed paved patio area to the rear of the home, which contains an outbuilding, of which one room is a laundry room and the second has been converted into a ‘lifestyle’ (sensory) room. Beechdale provides care for service users who require short-term admission to a care home. Payment for periods of respite care is made through respite care vouchers provided by the local authority. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection of this home included an unannounced site visit which was carried out over 7 hours. During the visit we spoke with the person who was staying at the home, staff and the manager and examined a selection of documents including people’s individual care plans and staff personnel files. We also carried out a tour of the building looking at people’s communal living areas and private bedrooms. As part of the inspection we carried out a case tracking exercise which involved looking very closely at selected people’s care from the point that they started using the service. Prior to our visit, we asked the manager of the home to complete a comprehensive questionnaire which provided us with a lot of information about how the home is managed. The questionnaire also gave us information such as staff qualifications and some details about the needs of people using the service. We also sent some written questionnaires to people who use the service and their families, to ask them their opinions about standards within the home. What the service does well:
A number of people responded to our written survey and all expressed satisfaction with the service provided at Beechdale. People told us that carers always treated them well and listened and acted upon what they said. In addition, all the people who responded to the survey told us that they were aware of the complaints procedure and who they should speak to if they had any concerns. There was only one person using the service at the time of our visit. We spent some time with her and asked her if she enjoyed staying at Beechdale. She told us she liked being at Beechdale very much and said, ‘’I like all the staff. I like it when we go out.’’ Beechdale has a good approach to assessment and the manager ensures that a good deal of information is obtained about new people before they stay at the home for the first time. This means that a thorough individual plan can be developed and ensures that carers know exactly what they need to do to meet the person’s needs.
Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 6 There are individual plans in place for all people who stay at the home and those we viewed provided a good picture of people’s daily care needs and preferences. There is a person centred approach to care planning which means that every person is respected as an individual and their care is planned in line with their own wishes and views to as great an extent as possible. People who stay at Beechdale are given the opportunity to take part in a variety of activities both inside and outside the home. Each person’s individual plan describes their hobbies and the pastimes they enjoy. We were also able to confirm that people are supported to try out new activities and experiences when staying at the home. The person who was staying at the home at the time of our visit told us that she was looking forward to a holiday in Blackpool. In discussion, the manager confirmed that all the people who stay at Beechdale are offered the opportunity to have a holiday each year. The home is very well maintained and furnished and decorated to a good standard. During our visit we carried out a tour and found all areas to be warm, clean and comfortable. Beechdale is a spacious building with a variety of areas for people to access including a lounge, dining room, sensory room and safe outdoor area. Everyone who stays at the home is provided with a single bedroom. People are encouraged to express their views and opinions about their own care and the general running of the home. There are a number of ways that the manager tries to enable this, for instance by encouraging people to use the services of independent advocates. In addition, there is a Service User Council which meets on a regular basis to discuss ideas about the service. There is a good approach to staff training and carers are provided with a variety of courses to help them carry out their roles. As well as the mandatory courses in areas such as moving and handling, training is regularly available in additional areas such as person centred planning. There is a national standard for care homes that at least 50 of carers hold a National Vocational Qualification in care at level two or above. Beechdale has now exceeded this target and are actually on target to have 100 of their carers qualified at this level. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better:
Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 8 It was found during this visit that carers sometimes carry out certain health care tasks for some of the people who use the service. We also found that there was very detailed guidance in place for carers in relation to these tasks and that all carers had carried out relevant training. However, in these circumstances it is necessary for an agreement to be in place with the relevant NHS body in respect of each individual task. This arrangement is known as ‘clinical delegation.’ At the time of our visit the manager was unable to confirm that there was such an agreement in place. This matter needs to be addressed as soon as possible. We tracked the care of one person who had a bed rail in place. However, we couldn’t find a risk assessment in relation to this. A risk assessment must be carried out for any person who has a bed rail. Where appropriate, information relating to people’s religious or cultural needs is included in their individual plan. However, the information recorded in one plan we viewed was limited to the person’s dietary requirements. We talked to the manager about this who agreed that this information should be expanded upon to include details of her preferred dress code and dates of religious festivals, for example. We viewed the plan of one person whose rights had been restricted for her own safety and wellbeing. However, there was little information relating to these restrictions recorded. We advised the manager that any such restrictions must be clearly identified in the person’s individual plan. In addition, there must be agreement in place from the person themselves (where possible) and their representatives, which must also be recorded in their individual plan. Staff are sometimes required to assist people manage their finances while they are staying at the home. We viewed some records of people’s financial transactions which were found to be well maintained and in good order. However, we made two recommendations to the manager about how processes could be improved to protect people further. We advised the manager to carry out regular checks of these records herself. We also advised that receipts be obtained wherever possible and retained for the manager to check. There has been some work done to make various documents more accessible to people and there is now a pictorial Service User Guide and complaints procedure available. During our visit we talked with the manager about how this could be further developed and recommended that consideration be given to developing some information in a video format. We also recommended that the manager consider developing pictorial menus for people who do not read. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 9 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. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 11 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Carers have a good understanding of people’s needs before they start using the service. This means that people can be assured they will receive the help they need straight away. EVIDENCE: People who are considering using the service are given information to help them make their decision, including a pictorial Service User Guide. The manager of the home has also been involved in a project with the Local Authority to create a DVD which provides information about respite care and short breaks. In discussion with the manager we recommended that consideration be given to developing a video Service User Guide for Beechdale. We were able to confirm through viewing records and through discussion that people are encouraged to visit the home prior to staying there for the first time. This gives people the chance to look around the home, meet the staff and other people using the service. Usually people start with shorter visits, and progress to meal times and overnight stays. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 12 The manager has a thorough approach to the assessment of new service users which involves visiting people at their own home and talking to them and their families or people who know them well. The assessment process is carried out prior to the person using the service for the first time. This enables the manager to ensure that the service can meet the person’s needs. We saw evidence that steps are taken to ensure that each service user is as fully involved in their own assessment as possible. Wherever possible representatives of the service user will also be asked for their input. Recently, the home referred one prospective service user to an independent advocate to assist them throughout the assessment process and ensure that they had the chance to express their views and opinions. The home has a process in place to ensure that they keep up to date with any changes in a service user’s circumstances. This is particularly important in a respite service as there may be significant changes in a person’s care needs between their stays at the home. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 13 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a person centred approach to care planning which means that care is planned in line with people’s individual needs and preferences. EVIDENCE: There is an individual plan in place for every person using the service. These plans detail people’s care needs and provide guidance to staff in how to meet them. Areas covered in people’s individual plans include communication, relationships and activities. Most staff have been provided with training in person centred care which helps them to ensure that they take people’s individual needs and wishes into account when planning their care. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 14 The plans we viewed had been regularly updated to ensure that staff were always made aware of people’s changing needs. We looked at one person’s individual plan which contained some information about her religious and cultural needs, such as dietary requirements. However, the information was very basic and we made a recommendation that more details be included such as the person’s dress code and dates of religious festivals. When planning people’s care and support there is an emphasis on promoting independence and assisting people to gain new skills. As such, the manager and staff have a positive view of risk taking and an understanding of the benefits well managed risk taking can bring. We viewed a number of risk assessments that had been developed in relation to people trying new hobbies or activities. These were of a good standard clearly defining risk and detailing measures to be taken to address the risks without hampering people’s development. There are a number of ways in which people using the service can be involved in the running of the home, for instance by taking part in the Service User Council. This is a group of people from all five of the homes owned by The Dalesview Group who regularly meet to share opinions and discuss ideas. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 15 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People staying at Beechdale are given the opportunity to take part in a variety of activities inside and outside of the home. EVIDENCE: All the individual plans that we viewed contained a great deal of information about people’s preferred pastimes and hobbies. Each person has a community and in-house lifestyle plan detailing the support they require in both areas. Through discussion and through viewing records, we confirmed that people are regularly provided with the opportunity to take part in activities such as trips to the cinema, bowling and trips to the local pub.
Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 16 At the time of our visit one person was on her way out with a staff member to do the weekly grocery shopping. She told us that she often went shopping and enjoyed doing so very much. This person also told us that she was soon to go on a holiday and was very excited about this. In discussion with the manager it was confirmed that every service user is given the option to go on holiday each year with staff support provided from Beechdale. We saw evidence when tracking the care of one person that they had been provided with a great deal of support to maintain their valued relationships. In discussion, the manager stated that staff at the home had a very positive rapport with service users’ families. We noted that there had been a number of measures taken to further develop relationships with families including the introduction of coffee mornings and social events such as Christmas parties. We viewed a selection of menus and records of meals served to individual people. These records showed that people are provided with a varied and nutritious diet. We also noted that on some days, a number of different meals had been served demonstrating that there were a number of alternatives routinely available for people to choose from. We were advised by the manager that people using the service are encouraged to get involved with food preparation and grocery shopping. We saw evidence of this during our visit with one person going out on a grocery shopping trip with a staff member. In discussion with the manager we made a recommendation that pictorial menus be provided for people who do not read. Currently they are only made available in written format. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s health and well being is closely monitored by staff and there are procedures in place to ensure that medication is handled safely. Any clinical procedures which are carried out by care staff must be done so with the agreement of the relevant NHS body to ensure people’s safety and well-being is protected. EVIDENCE: Each person has a health action plan in place which details their health needs and the support they require in this area. It was found during this visit that carers sometimes carry out certain health care tasks for some of the people who use the service. We found that there was very detailed guidance in place for staff in relation to these tasks and that all carers had carried out relevant training. However, in these circumstances it is necessary for an agreement to be in place with the relevant NHS body in respect of each individual task, this is
Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 18 known as ‘clinical delegation.’ At the time of our visit the manager was unable to confirm such an agreement. This matter needs to be addressed as soon as possible. In viewing people’s individual plans we were able to determine that they are supported to access advice and treatment from health care professionals when they require it. In addition, people who stay at the home receive regular input from a privately employed physiotherapist and speech therapist. Each person’s individual plan contains in depth information about their communication. For people who do not communicate verbally, there is guidance in the ways they express themselves. This information assists staff greatly in getting to know people and understanding their needs. We viewed the home’s medication store and examined a number of medication administration records. These were all found to be in good order and medicines were stored safely and securely. All carers who handle medication have now been provided with training in the safe handling of medication. Some people who stay at the home are prescribed medication on a ‘prn’ basis which means they only need it in certain circumstances. There is very good guidance for staff as to when this medication should be administered for each person. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at this home are encouraged to express their concerns. There are systems in place to protect people from abuse. EVIDENCE: The home has a procedure in place which explains to people how to make a complaint and what will happen if they do so. There is also a complaints procedure available in pictorial format for people who do not read. During our visit we discussed the possibility of also making the complaints procedure available in audio and video formats. There is a record held within the home of any complaints made and subsequent action taken. We viewed these records which confirmed that the home had not received any complaints since their last inspection. The home has detailed guidance in place for staff who are concerned that an incident of abuse may have taken place. This guidance also assures staff that they will be protected from any reprisals in the event that they raise such a concern, and is provided to staff at the start of their employment. In discussion the manager and staff showed that they were well aware of this guidance. We were able to confirm that there had been no such concerns raised at Beechdale. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 20 Some people who use the service need support to manage their money during their stay. There are procedures in place to ensure that staff keep careful records in the event that they provide such support. We examined a sample of these records which were well maintained and in good order. However, to improve the system and protect people further we made some recommendations that receipts always be obtained when making purchases on behalf of people. We also recommended that the manager carries out regular checks of these records. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 21 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People staying at this home are provided with safe, comfortable accommodation which is decorated and furnished to a high standard. EVIDENCE: Beechdale is a spacious home and all accommodation is provided on a single room basis. There are a number of areas for people to access including a specially adapted sensory room and a safe outdoor area. During our visit we carried out a tour of the home and found all areas to be clean and comfortable. We looked at the bedroom of the person who was staying at the home during our visit. This was nicely personalised with pictures and ornaments. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 22 There is a well equipped laundry and procedures are in place to prevent the spread of infection within the home. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 23 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has thorough procedures in place to ensure that only suitable people are recruited. Staff are well trained to carry out their roles effectively. EVIDENCE: We viewed a sample of staff rotas which showed that there are always sufficient numbers of staff on duty to meet people’s needs. We also viewed a selection of staff personnel files and found evidence that appropriate background checks including Criminal Records Bureau checks and references are routinely carried out prior to offering a candidate employment. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 24 There are procedures in place to involve people who use the service in the recruitment of new staff. Currently people are asked to take part in setting interview questions for prospective staff members. Discussion took place as to how this could be developed further. We recommended that consideration be given to involving service users in interviews. There is a good approach to training at this home and all new staff are provided with a standard induction which is in line with Skills for Care Standards. Ongoing training includes all mandatory areas such as moving and handling and first aid as well as additional courses such as person centred planning. Training records confirmed that over 50 of care staff now hold National Vocational Qualifications in care at level 2 or above. This is a good achievement and means the home have met the national standard. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Beechdale is a well managed home and is run in the best interests of people who stay there. EVIDENCE: Throughout our inspection the registered manager demonstrated that she had a good understanding of her role and a commitment to people using the service. We were able to confirm that the manager holds the Registered Manager’s Award and regularly undertakes training in various areas to refresh her skills. In addition, the manager participates in a number of multi agency projects Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 26 such as the short breaks task group which is made up of professionals from the local area. The home has a good approach to quality assurance and there are a number of measures in place to monitor quality. People who use the service are involved in these processes in a number of ways for example, the Service Users Council. Each month a senior member of the Dalesview management team carries out an unannounced visit to the home and assesses standards in a number of areas. The Commission for Social Care Inspection are provided with reports of these visits which demonstrate that people using the service are consulted throughout them. The home has a number of measures in place to protect the safety and wellbeing of residents, staff and visitors. We viewed a selection of health and safety records including records of safety checks on equipment within the home. We were also able to confirm that all staff had been provided with appropriate health and safety training in areas such as moving and handling and food hygiene. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 28 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. 2. Standard YA42 Regulation 13 13 Requirement Risk assessments must be in place for every service user who has a bed rail. Any clinical task carried out by carers within the home must be agreed by the relevant NHS body. Timescale for action 20/09/07 31/10/07 YA19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA1 YA6 YA7 YA17 Good Practice Recommendations The home should consider making the Service User Guide available in video format. Increased information relating to people’s religious and cultural needs should be included in their individual plans. Any restrictions to a service user’s rights should be included in their care plan. Consideration should be given to providing pictorial menus.
DS0000005928.V340338.R01.S.doc Version 5.2 Page 29 Beechdale 5. 6. 7. 8. YA22 YA24 YA24 YA8 Consideration should be given to producing a video complaints procedure. The manager should make regular checks of records relating to service users’ finances. Receipts should be obtained wherever possible when making purchases on behalf of service users. Consideration should be given to enabling service users to become more involved in the recruitment process. Beechdale DS0000005928.V340338.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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
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