Inspection on 31/10/07 for Beeches Retirement Home

This inspection was carried out on 31st October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beeches Retirement Home 31/07/08

Beeches Retirement Home 17/07/06

Beeches Retirement Home 03/11/05

Beeches Retirement Home 28/04/05

Beeches Retirement Home 22/10/04

Beeches Retirement Home 26/04/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Beeches Retirement Home 4 De Roos Road Eastbourne East Sussex BN21 2QA Lead Inspector Jane Jewell Key Unannounced Inspection 31st October 2007 11:30 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 Beeches Retirement Home DS0000021045.V348640.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. Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beeches Retirement Home Address 4 De Roos Road Eastbourne East Sussex BN21 2QA 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) 01323 731307 beechesretirementhome@aol.com Mrs Joan Sinclair Mr Darren Sinclair Mr Darren Sinclair Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty (20) Service users must be older people aged sixty-five (65) years or over on admission. 17th July 2006 Date of last inspection Brief Description of the Service: Beeches retirement home is a detached two-storey Victorian property set in its own grounds in a residential area near to Eastbourne town centre. The home is registered to provide care and accommodation for up to twenty older people. Accommodation is presented across two floors with a shaft lift providing level access to most parts of the first floor and additional chair lifts fitted to small flights of stairs. Communal facilities include a dinning room, lounge and conservatory. There is a rear secure garden, which has seating areas and a barbeque area. Resident’s private accommodation consists of fourteen single and three double bedrooms with all providing toilet en-suite facilities. The home aims to provide a homely and friendly service with the emphasis on comfort and care. The range of fees charged as from 1 April 2007 is from £350 to £470 which include personal toiletries and in-house activities. Additional charges are made for hairdressing, chiropody, newspapers and dry cleaning. Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The information contained in this report has been comprised from an unannounced inspection undertaken over six hours and information gathered about the home. This includes discussion with relatives and health care professionals involved in resident’s care. The manager had completed an Annual Quality Assurance Assessment form prior to the inspection and the information contained in this document has been used to inform the inspection of the home. The inspection was facilitated by the Deputy Manager. The inspection involved a tour of the premises, observation, examination of records and discussion with residents and staff. The focus of the inspection was to look at the experiences of life at the home for people living there, this involved observing residents and their interactions with staff and examination of the homes facilities and documentation. There were seventeen residents residing at the home at the time of the inspection. In order that a balanced and thorough view of the home is obtained, this inspection report should be read in conjunction with the previous inspection reports. The Inspector would like to thank the residents and staff for their assistance and hospitality during the visit. What the service does well: Residents spoke positively about their experiences at the home and a sample of their comments include: “happy enough”; “Really like it here”; “everything is done for the good of the residents” and “Best bit about the home is being able to have my cat live with me”. Links with families and friends are valued and supported by the home. A relative commented: “Very happy with the home”. Flexible in the daily routines, helps to promote resident’s choices, with residents commenting: “free to get up and go to bed whenever I want” and “I can do what I want to do”. The meals are good offering both choice and variety. Residents live in a clean and homely environment, which is gradually undergoing refurbishment with their private accommodation personalised to suit their taste. Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 6 The health needs of residents are being met with regular input from health care professionals. The system for the administration of medications are good with clear and comprehensive arrangement in place to ensure residents safety. Residents’ benefit from an enthusiastic staff team that know them and who are deployed in sufficient numbers as is necessary to meet their needs What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 7 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 Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 4 and 5 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents do not have access to a range of up to date information about the home to help them make informed choices about whether to live at the home. The admission procedure does not ensure residents are fully assessed prior to moving into the home and therefore their needs can be met by the home. EVIDENCE: There was a range of information about the home and the services it provides, this included a statement of purpose and service user guide. These documents were not however readily available to help inform residents and their representatives about the homes services and facilities. A newly admitted resident and their relative said that they were not aware of these documents. Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 9 Not all residents had been provided with a written statement of their terms and conditions of residency with the home. This is necessary in order that residents and their representatives are aware of any additional charges and their rights and responsibilities whilst staying at the home. Assessment documentation relating to a newly admitted resident showed that their assessment process was not sufficiently robust for the home to be able to identity whether their needs can be safely met at the home. There is a range of residents needs accommodated at the home with the majority of residents assessed as low needs. The evidence seen indicates that most needs of residents are being met. However further work is needed to the care planning process to ensure that the range of resident’s assessed needs can be identified and addressed. Residents spoke positively about their experiences at the home and a sample of their comments include: “happy enough”; “Really like it here”; “everything is done for the good of the residents” and “Best bit about the home is being able to have my cat live with me”. A relative commented: “Very happy with the home” Residents and their representatives consulted with spoke of being provided with the opportunity to visit the home in advance to assess the quality, facilities and suitability of the home. Most residents consulted said that it was their families that looked around the home on their behalf. A friend of a resident said that they were particularly impressed with the warm welcome they received when looking around the home and how helpful and knowledgeable staff were. Intermediate care is not offered at the home therefore this standard is not assessed. Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 10 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 and 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans do not provide adequate and accurate guidance for staff on the assessed needs of residents in order that their needs can be identified and met. The health needs of residents are being met with regular input from health care professionals. The system for the administration of medications are good with clear and comprehensive arrangement in place to ensure residents safety. EVIDENCE: Information about each resident is complied into a care plan. The six care plans inspected did not provide adequate and accurate guidance for staff on the assessed needs of residents. Not all care plans had been regularly updated to reflect changes in residents needs. The deputy manager said that they were aware of the shortfalls in the current care planning process, as they had Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 11 recently not had time to keep them updated. The home manages well the personal risk faced and posed by residents with guidance provided for staff on how to reduce or manage any risks identified. Residents consulted expressed little or no interest in the development and review of their care plans, but felt that they could ask to see what is recorded about them at any time. Some care plans had been signed by the residents when it had been first written. An agency staff member spoke of being provided with written details of the basic needs of each resident. This they felt was extremely useful in helping them identify the support needs of residents. Staff spoke knowledgeable on the needs and preferences of each resident. It was discussed that staff’s knowledge of residents needs must be underpinned by an effective care planning process in order to ensure consistency in the support provided to residents. Records of medical intervention showed that the home works closely with health care professionals including GP’s, district and specialist nurses to ensure residents receive a range of health care intervention. Health care professionals consultants with all felt that staff were prompt to seek medical support and followed any guidance given. A resident consulted with also felt that staff acted promptly to their requests to see their GP also stating “staff do accompany me to hospital and I pay for the taxi there”. The deputy manager said that the home is part of the “sloppy slipper campaign” which has helped to reduce the number of residents falls. The medicine administration practices observed were seen to be safe and the records demonstrated that systems have been established to ensure staff are appropriately trained and records are accurate and provide a history of what was given by who and when. Good practices were noted in the innovative way of supporting a resident to self medicate by providing a colour-coded chart for ease of understanding. During the inspection staff were seen to be respectful and considerate to residents and visitors. Staff were observed using residents preferred forms of address and knocking on bedroom doors prior to entering. A resident said: “staff always shut the door and knock on the door before entering” Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 12 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 and 15 People who use the service experience good, quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Flexible in the daily routines, helps to promote resident’s choices. There is evidence that residents are treated as individuals. The meals are good offering both choice and variety. Links with families continued to be valued and supported by the home. EVIDENCE: Many residents consulted with said that they preferred to occupy their own time. While other residents said that the home provides some activities such as crafts, board games and external entertainers. The deputy manager said that all residents are provided with the opportunity to go out. Visitors commented upon how welcomed they are made to feel during their stay, this included being offered beverages or meals and staff being friendly and approachable. A resident said “friends can visit whenever I want them to”. A resident spoke of the importance of keeping in touch with family and friends through their mobile phone. Relatives consulted with all said that the home Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 13 was good at keeping in touch with them and informing them of any changes in their relatives needs. Observation of the daily routines and discussion with residents confirm that staff accommodate resident’s personal wishes with regard to meal times, going to bed, rising and bathing. Staff were knowledgeable about the cultural, religious needs of residents. During the inspection residents were observed to move around the home choosing which room to be in and what level of company they wanted to enjoy with a residents saying: “free to get up and go to bed whenever I want”; “I can do what I want to do” and “let me do what I like”. The meal served at inspection was presented well with resident’s individual preferences respected and specialist diets begin catered for. The atmosphere was relaxed with residents who needed assistance being supported in a discreet and sensitive manor. The majority of residents eat their meals in the dinning room with one resident saying that they preferred to eat in their bedroom, which was respected by staff. A sample of comments made regarding the food served includes: “choice of meals if you don’t like something”; “usually a choice”; “good” “there is a choice as I am a vegetarian” and “Pretty good” and good however not very much fruit”. Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 14 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 and 18 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a complaints system with residents and their representatives feeling that their views are listened to and acted upon. Not all of the home’s processes and procedures provide adequate safeguards for residents. EVIDENCE: There is a complaints procedure for residents, their representatives, and staff to follow should they be unhappy with any aspect of the service. Residents and relatives consulted with said that they felt able to share any concerns they had with staff or the manager and where they have had to raise minor concerns then this has been addressed promptly. The Deputy manager stated that the home has not received any complaints about the service in the last twelve months. Although there was guidance for staff to follow on safeguarding vulnerable adults this needed to be updated with the significant changes in safeguarding adults procedures. The permanent member of staff on duty at the time of the inspection although not yet undertaken safeguarding adults training knew what their immediate responsibilities were if they suspected abuse had occurred. It Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 15 is recommended that the homes safeguarding adult’s policy be reviewed and updated in accordance with East Sussex Multi Agency guidelines on the safeguarding adults. This is to ensure that the staff team are fully aware of their roles and responsibilities under this guidance. Of particular concern is that it has been required for some time that staff do not work unsupervised unless they have an up to date Criminal Records Bureau and POVA first check. As discussed under standard twenty-nine of this report this has not yet been complied with and as a result this practice does not safeguard residents, as staff are not being fully vetted before working at the home. Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 16 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 20 21 22 24 25 and 26 People who use the service experience good, quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and homely environment with parts of it decorated and furnished to a good standard. The home ensures that residents private accommodation is equipped to provide comfort and privacy and to meet the assessed needs of those people residing in the room. EVIDENCE: The home comprises of a detached domestic converted dwelling, located on the outskirts of Eastbourne. Standards of maintenance and decoration were in the main good. Parts of the home that have undergone redecoration as part of the homes gradual refurbishment plan have been completed to a good standard. Comments from residents and relatives regarding the environment include: “adequate bits of it are decorated well but it is always clean”; “environment on the whole good but I suppose it could do with a lick of paint”; Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 17 “very homely”; “not posh but clean and homely” and “quite happy with my room but it is now getting a bit tatty but I am told its just about to be refurbished”. At inspection there were building works underway to create an additional en-suite and shower room. Although these works were noisy at the time, all of the residents consulted with said that it was not too disturbing and it would not be lasting for much long. Communal space consists of a lounge, conservatory and dinning room. There is a small rear well maintained garden, which has a patio, barbeque and seating areas, making this an attractive area to use and overlook. The deputy manager reported that all double rooms are currently used for single occupancy. Bedrooms seen had been individualized with personal belongings and in some cases items of small furniture. All residents consulted with said that they liked their bedroom and that they provided everything they needed. A resident commented about their bedroom, “although not very big it has everything I need and is nicely decorated”. None of the residents consulted with said that they had a lockable facility in their bedroom in order to secure any valuables. They felt that this was not currently a problem as there was a safe in the office that they could request to use. Bedroom doors are fitted with locks with residents saying that they could request a key if they wanted. There is sufficient number of toilets and bathrooms located around the home, including all bedrooms providing ensuite facilities. There was a range of individual aids and adaptations to assist resident’s mobility and independence, including a shaft and chair lifts, raised toilet seats, walking aids, assisted baths and grab rails. Fitted throughout the home are call points, which enable assistance to be summoned when pressed. Residents who had used this said that the staff: “Always respond quickly” and “come quickly day or night like lightening”. The deputy manager reported that a digital telephone system has recently been installed which allows residents to make and receive calls anywhere in the home. All parts of the home visited were observed to be clean with a good standard of hygiene maintained. A sample of comments made about the cleanliness of the home includes: “ No odours”; “always kept clean” and “my bedroom always kept clean”. Variable comments were received about the standard of laundry. The deputy manager had already identified quality issues regarding laundry and spoke of the plans to improve the laundry facilities. Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 18 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 and 30 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Despite recent staffing difficulties residents’ benefit from an enthusiastic staff team that know them and who are deployed in sufficient numbers as is necessary to meet their needs. However, the procedures for the recruitment of staff remain insufficiently robust to safeguards residents. EVIDENCE: Staff, relatives and residents felt that there was sufficient numbers of staff on duty for staff to undertake their roles in a timely manner and for residents to receive the support they needed, when they wanted it. All staff were found to have a good rapport with residents and visitors which promoted a relaxed atmosphere in the home. A sample of comments made about staff include: “Staff very welcoming really pleasant atmosphere to work in”; “very nice but hey seem to come and go”; “they will do anything you want they are all very kind”; “not many staff around often difficult to find staff to let you out”; “alright” and “marvellous”. There has been a significant turnover of staff since the last inspection with the deputy manager reporting difficulties in sometimes covering shifts. There has been some use of agency staff to cover shifts and it was reported that where possible the same agency staff are used in order to promote consistency. Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 19 There was no evidence to suggest that the quality of care had been affected by the staffing situation. A resident commented: “there has been a lot of new faces which can be frustrating at times but they do there best”. In information submitted to the Commission as part of the inspection process, the Manager stated that currently over half of the staff team have completed National Vocational Qualifications to at least NVQ Level 2. New staff confirmed that they have undertaken a local induction process. It was discussed that all new staff should undertake “skills for care” induction, which is the industry recommended minimum induction standards. This is designed to help ensure that all new staff entering into the care industry has a minimum level of initial training. Following a significant staff turnover at the home the deputy manager reported that they are in the process of appointing a number of new staff. The staff files of some newly appointed staff members were examined and these showed that the home had not undertaken all the necessary recruitment checks to ensure residents protection. Criminal Records Bureau (CRB) checks had not been requested for a staff member and not all references could be located. This is a matter of concern as it has been required for some time that CRB checks must be undertaken on staff working unsupervised. Following the inspection the manager confirmed that they had put into place steps to ensure that all of the necessary checks were undertaken and measures to ensure residents would be safeguarded in the interim. The majority of training is undertaken in house by the management team using a training guide, which involves videos, questionnaires and competency tests. The deputy manager was aware of the need to ensure that the new staff would complete mandatory training within reasonable timescales of commencing employment. Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 20 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 36 and 38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management team provides a sense of leadership and direction and run the home in the best interest of residents however shortfalls in some key management responsibilities means some practices do not promote and safeguard the health, safety and welfare of residents. The health, safety and welfare of residents and staff are generally promoted and protected. EVIDENCE: Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 21 The management team consists of the deputy and manager, with each one taking a lead on key management tasks. The deputy manager reported that they and the manager are in the process of completing the recommended management qualification. The deputy manager was knowledgeable on the daily running of a service for older people and showed much commitment to ensuring good standards of care were maintained. However due to the recent staffing difficulties in order to ensure continuity of care the deputy manager reported that they had undertaken a significant number of care shifts. This has clearly impacted on their ability to fulfil some of their key management tasks such as care planning. A sample of comments received about the manager include: “very approachable”; “so cheerful helpful speaks to the staff nicely there is no unpleasantness”; “see very little off but I think he is around most days”; “Genuine anything you need will go and get it he is in most days”; “deputy makes sure things get done” and “easy to talk to, don’t see him very often as always seems to have gone shopping but he is very approachable.” Residents are encouraged to retain control of their own finances for as long as they are able to do so and if unable then this responsibility is taken on by a relative or another responsible persons external to the home. The deputy manager reported that they do hold small amounts of money for a few residents with records showing when money has been spend on a resident’s behalf. A resident commented: “The home looks after my money for me so all I have to do is ask for some when I want and I don’t have to worry about anything”. Six weekly residents meetings are used to obtain feedback on the quality of the services provided and whether it is achieving its aims and objectives. It is necessary that feedback is also obtained from other stakeholders involved in resident’s lives, this includes health care professionals, staff and relatives. This is to enable the home to effectively self-monitoring and review of its own practices through a range of feedback. The home had completed a qualitymentoring audit in July 07 of some of its processes. This highlighted areas for service improvement. Care staff supervision is informal and takes the form of the deputy manager generally overseeing staff within the work place by directly working alongside them. Care staff consulted with spoke of feeling supported to undertaken their roles and could approach the deputy manager with any concerns that they had. The deputy manager reported that systems were in place to support fire safety, which included: regular fire alarms and emergency lighting checks, staff training and maintenance of fire equipment and fire drills. The deputy manager reported that a fire risk assessment had been undertaken by a fire Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 22 safety expert, which recorded significant findings and the actions taken to ensure adequate fire safety precautions in the home Records submitted by the Provider stated that the necessary servicing and testing of health and safety equipment has been undertaken. Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 2 2 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 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 2 3 3 3 3 x 3 3 3 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 2 x 2 x 3 3 x 3 Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 24 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 OP2 Regulation 5(1)(b) Requirement Timescale for action 30/01/08 2 OP3 3 OP7 4 OP29 That service users or their representatives are provided with a copy of the terms and conditions of residency, in order that they are aware of charges and their rights and responsibilities whilst residing at the home. 14(1)(a) That the needs of prospective services users have been assessed by suitably qualified persons prior to admission in order that their needs are identified and can be met safely at the home. 15(1) That each service user has a plan of care which records their health, personal and social care needs and the actions needed to meet these needs, which is reviewed regularly to reflect any changes in needs and preferences. 19(1)(a-c) That staff do not work (2-7) unsupervised unless they have an up to date Criminal Records Bureau and POVA first check as required under Schedule 2. (timescale of 03/12/05 & DS0000021045.V348640.R01.S.doc 30/12/07 30/12/07 30/12/07 Beeches Retirement Home Version 5.2 Page 25 17/08/06 not met) 5 OP33 24(1) That a system be established and maintained for monitoring the quality of the care provided, which includes a system for obtaining feedback from service users their representatives and other stakeholders on the services provided and the performance of the home. 30/01/08 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 OP19 Good Practice Recommendations That a policy on safeguarding adults is reviewed and updated in accordance with East Sussex Multi Agency guidelines on safeguarding adults, to include the reporting procedures and the responsibilities of the home. That all new staff receive “skills for care” induction training. 2 OP30 Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. Extracts may not be used or reproduced without the express permission of CSCI Beeches Retirement Home DS0000021045.V348640.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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