Inspection on 14/08/06 for Beechey House

This inspection was carried out on 14th August 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beechey House 29/07/08

Beechey House 12/11/07

Beechey House 27/07/07

Beechey House 23/01/07

Similar services:

Trevaylor Manor

Stallcombe House

Stroud Lodge

The Woodmill

Woodland Vale

Bolealler House

Claremont Nursing Home

Althea Park House

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

CARE HOMES FOR OLDER PEOPLE Beechey House 14 Beechey Road Charminster Bournemouth Dorset BH8 8LL Lead Inspector Anne Weston Unannounced Inspection 14th August 2006 11:00 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 Beechey House DS0000064864.V308323.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. Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechey House Address 14 Beechey Road Charminster Bournemouth Dorset BH8 8LL 01202 290479 01202 290479 beecheyhouse@aol.com 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) Mr Dhanjaye Damhar Miss Nisha Devi Damhar, Mr Dhanjaye Ravi Damhar Miss Nisha Devi Damhar Care Home 16 Category(ies) of Dementia - over 65 years of age (16), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (16) Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Any residents accommodated on the second floor must not be dependent on staff to evacuate the building. The schedule of requirements must be completed within the agreed timescales. 07/03/2006 Date of last inspection Brief Description of the Service: Beechey House is a large detached property, situated in the Charminster area of Bournemouth. There has been a change of ownership since the last inspection. Beechey House is now registered under Mr Dhanjaye Damhar, his daughter Miss Nisha Devi Damhar and his son Mr Dhanjaye Ravi Damhar. Miss Damhar is the registered manager responsible for the day to day running of the home. The registration has increased from accommodating a maximum of 14 people to accommodating a maximum of 16 people. Three additional single bedrooms have been registered on the second floor, a shower room has also been installed on the second floor. The home is within walking distance of the local shopping area of Charminster, local buses are available close to the home to travel to nearby towns, including Poole and Bournemouth. The property is set back from the road and approached via a short driveway. On street parking is available for visitors. A secluded garden at the rear of the property is accessible to residents. Beechey House is registered to accommodate people over age 65 who have dementia or a mental disorder. The accommodation is arranged over three floors, with a passenger lift available to assist access between floors. There are 15 bedrooms, all bedrooms have a wash hand basin and 12 bedrooms have ensuite toilet facilities. A comfortable lounge/dining room is available to residents on the ground floor. Weekly fees (reviewed at least annually) range from £461.00 to £480.00. Fees include all care and accommodation costs, including meals, laundry and activities. Additional charges are made for hairdressing, dry cleaning and chiropody. People are expected to pay for their own personal items such as private telephone, toiletries and newspapers. Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out in the day time over two days on the 14th and 31st August 2006 by Anne Weston, the visits took a total of 7.5 hours. The pharmacy inspector also visited on 31st August 2006 to inspect the medication systems. Miss Damhar was present for most of the inspection process, Mr Damhar also made himself available. The purpose of this year’s first annual key unannounced inspection was to review the 9 requirements and 2 recommendations that had been previously made; to review all key National Minimum Standards and to check that the 16 people who were living there were safe and properly cared for. The premises were inspected and a range of records and related documentation were examined. Discussion was held with Miss Damhar and three care staff. All residents were observed as a group in the lounge and also having their lunch, residents were spoken with throughout the inspection. Interaction between staff and residents was observed throughout the day. Discussion was held with eight relatives who were visiting six of the residents. Seven relatives completed and returned CSCI comment cards. One GP completed and returned a CSCI comment card. The pre-inspection questionnaire sent before the inspection had not been returned before the inspection. This was completed and collected during the inspection process. What the service does well: Assessments of care needs were carried out with residents before they moved into the home. This meant residents were assured their care needs could be met. Care plans detailed the health and care needs of residents. This meant staff had information to meet people’s needs, including their health care needs. The home ensure access to health care services, there is good support from community health professionals. The home uses monitored dosage system blister packs with Medicine Administration Record (MAR) charts printed by the pharmacy and medicines can be taken round the home safely. Beechey House provides a homely, relaxed and friendly environment, visiting times are unrestricted. One relative said “I believe there to be a good standard of care in this home. The general atmosphere is friendly and X seems relaxed and happy in their own little world” (comment card). Visitors are made to feel welcome, comments from relatives included “We have always been delighted with the care given, the welcome we receive, and the progress our ‘loved one’ has made since X has been in the care home” (comment card) and “They look after X very well, they have to do everything for X” (discussion with a relative). Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 6 Staff treat residents in a friendly and kind manner and have an encouraging approach. A balanced and varied diet is provided. People felt confident about raising any complaints or concerns, one relative who was spoken with said “Nisha always addresses concerns”. The home is clean, comfortable, well maintained and set in pleasant grounds. What has improved since the last inspection? What they could do better: Storage of reserve medication and the recording of allergies and administration of prescribed creams and food supplements could be improved. The home should ensure that arrangements are facilitated for access to advocacy services for those residents who may like to have the advice of an independent person. Not all staff had received training in protecting residents from abuse. It is important that all care staff receive training in the protection of vulnerable adults so they do not commit unintentional abuse. There has not been an increase in staffing arrangements since the home increased their numbers from 14 people to 16 people. The home must review the staff rota and ensure sufficient care staff are on duty at all times. Some bedrooms do not contain all the items as listed in Standard 24 and as per the home’s Contract. The schedule of requirements set as a condition of Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 7 registration in respect of laundry facilities must be completed within the revised timescale. The induction programme must be formalised and revised to include the Skills for Care Common Induction Standards. Arrangements must be made for all staff, particularly the most recently recruited staff, to receive training appropriate to the work they carry out, including training in dementia. Staff must receive regular formal supervision. The poor recruitment practices are a matter of serious concern. Miss Damhar is advised to read the ‘Safe and Sound’ report on the CSCI website which highlights the importance of robust recruitment and vetting practices. A formal quality assurance system must be implemented to evaluate the quality of the services provided at Beechey House. 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. Beechey House DS0000064864.V308323.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 Beechey House DS0000064864.V308323.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Standard 6 is not applicable Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Beechey House. Residents have an assessment of their needs carried out before they move into Beechey House. This means their care needs are identified. EVIDENCE: The care records of two residents were examined. Assessments of care needs had been carried out with people before they moved into the home. Miss Damhar had visited one person in hospital and one person at home to carry out their assessments before admission to Beechey House. Miss Damhar was reminded that she should sign and date all assessments. Beechey House DS0000064864.V308323.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to Beechey House. Care plans contained relevant information so staff were able to provide residents with proper care. Health care needs were generally met. Records and audit trails indicated that most medicines were given as prescribed and recorded to meet their healthcare needs. Some aspects of the recording and monitoring of medicines in the home need improving to protect residents. Staff uphold the dignity of residents. EVIDENCE: The care records of two residents were examined. Care records were complex and were divided into separate sections with recorded information about care needs. Consideration should be given to making the care planning documentation available to staff in a more accessible format that is not too time consuming to read. Records demonstrated that residents have access to health care services such as dentist, GPs, chiropodists and community psychiatric nurses, and attend hospital appointments as necessary. Records showed that health care is Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 11 promoted. One relative said how helpful it was that a staff member (usually Miss Damhar) always accompanied a resident on their hospital appointment so that health care plans could be properly followed through. The CSCI comment card returned from a GP indicated satisfaction with overall care provision within the home. The manager showed the pharmacist inspector a draft medication policy and guidance was provided on some additions needed. No residents were selfmedicating. Medicines were stored and transported securely. Storage for reserve medication was not ideal because of the temperature of the room one cupboard was in and other products were stored with food. Some liquid feeds stored on the floor need to be moved to a shelf. There was a separate fridge for medicines that was not being used, as it needs a lock fitting, and a maximum and minimum thermometer to monitor the temperature. There was an overstock of some medicines that the manager was in the process of reducing. The date of opening eye drops was recorded so that they were not used beyond the expiry date. The home uses MAR charts printed by the pharmacy but some did not include medicine allergies, or “none known”, if applicable. Changes to medication were clearly recorded but handwritten medicine details were not countersigned as checked by a second carer. Staff recorded medicines received administered and returned for disposal and a sample of audit trails checked agreed with the records, indicating that medicines were given as prescribed. There were no records of administration of some topical creams or food supplements and the reason for this should be recorded on the MAR chart, or a separate record signed when they are given. There was no information on the MAR chart or in the care plan to indicate when one medicine prescribed, “when required” should be given. One medicine was being crushed and the manager was advised to ask the GP to prescribe a liquid preparation. The manager said that all but one carer, who give medicines, have done a medication course and the other had been trained “in house” and assessed as competent. There was a medicines reference book and patient information leaflets, but these should be organised so that staff can easily refer to them. Staff were observed throughout the inspection to be treating residents in a friendly and kind manner. Residents were properly dressed in their own clothes with appropriate footwear worn. One resident said “Staff are very nice”. One relative said “I am very pleased, as always, with the care X receives at Beechey House”. Beechey House DS0000064864.V308323.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to Beechey House. Development of the activities programme offered residents participation with recreational activities, further development is needed. Open visiting arrangements were in place, residents were able to maintain contact with visitors. Arrangements were not in place to access advocacy services. A balanced and varied diet was provided with choices offered, individual specialist diets and preferences were catered for. EVIDENCE: An activities programme is in the process of being developed and implemented. During the morning some residents were sat in the dining room with puzzles and other activities/materials in front of them. Most residents did not have the capacity to engage in these activities without assistance, although one resident was doing their knitting independently. Two staff are rostered during the day to carry out all the care and cooking duties, the manager is also available to assist, as necessary. This means there is not sufficient staff time to properly promote stimulation with individual activities. Residents were observed collectively enjoying an afternoon of musical entertainment. Regular communal musical and gentle exercise activities are provided. The home maintain an activities record. Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 13 Contact with residents and visiting relatives confirmed that residents maintained contact with friends and family. Relatives said that visiting was open and flexible and that they were always made to feel welcome into the home. One relative who was spoken with said “We can visit whenever we like”. Residents and people involved with residents were not informed how to contact people, such as advocates, who would act in residents’ best interests. Residents were observed enjoying their lunch in the dining room, all residents had the same meal of savoury mince and accompanying vegetables. Care staff duties included preparation and cooking of meals. A designated cook was not employed in the home. Residents have three meals a day. The main meal is provided at lunchtime, staff were aware of individual likes and dislikes so an alternative is provided if a resident does not like the dish of the day. There is no written menu informing of the main dish or alternative food choices. Examination of menus and observation confirmed a balanced and varied diet was provided. One visitor said they were impressed with the variety of food at supper time. Some residents needed assistance with their meal and help was given by staff. One staff member was observed giving assistance with feeding two people at the same time. This is because there are not enough staff members available to both serve the food and individually assist residents with their meals. The manager also helped residents with their meals. Beechey House DS0000064864.V308323.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to Beechey House. Residents and their representatives felt able to voice concerns over anything they were not happy with. Management dealt with any concerns promptly and effectively. Residents are not fully protected by the procedures for responding to suspicion or evidence of abuse as not all care staff had received training in the prevention of abuse. EVIDENCE: The home has a complaints policy. Miss Damhar confirmed there had been no written complaints since the last inspection. Any concerns are promptly dealt with day to day. People felt confident about raising any complaints or concerns with Miss Damhar. One relative said “I am very happy with Nisha and her staff, X is very happy in the home, at this time I have no complaints” (comment card). Another relative who was visiting with a family group said they felt able to raise concerns, and that concerns were always properly addressed. The home has an Adult Protection policy in place. Staff records showed that not all staff have received Adult Protection training so that they are enabled to identify different forms of abuse and know how to deal with any suspicion or allegation of abuse. Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to Beechey House. Residents live in a generally safe, clean, comfortable and well-maintained environment. Some rooms are not equipped with all furnishings as stated in the Contract. Some improvements need to be made with laundry facilities. EVIDENCE: Inspection of the premises demonstrated that routine maintenance and refurbishment work is consistently implemented. Miss Damhar said individual rooms will be redecorated as they become vacant. An additional three bedrooms and a shower room have been installed on the second floor. The three additional bedrooms were inspected, they were all safe and comfortable. A new nurse call system has been installed. New dining chairs have been purchased, Miss Damhar said she also planned to purchase new dining tables in the near future. The sun lounge area had been redecorated. Not all rooms had bedside lighting as stated in the home’s Contract. Pressure mats which alert staff to people getting out of bed are on the floor by beds to promote Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 16 safety of residents, particularly at night. There are plans to purchase new carpet for communal areas and new armchairs for the lounge. Inspection of the premises demonstrated the home was clean and hygienic. There is a laundry room with a domestic washing machine and tumble dryer. The home has a number of residents who are incontinent, an industrial washing machine with a sluice cycle is therefore recommended in line with Department of Health Infection Control Guidance for Care Homes (June 2006). Contact with residents, relatives and staff confirmed the home was routinely clean. A part-time cleaner is employed. The schedule of requirements set as a condition of registration included: 1 A suitable lock to be fitted to the laundry door to prevent access by vulnerable residents. A suitable lock had not been fitted on the laundry door. 2 Liquid soap and paper towels must be introduced for staff to use in the laundry and WC’s to aid infection control and help prevent any possible cross-contamination. Liquid soap and paper towels were not available for use in the laundry room. Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Overall quality in this outcome area is poor. This judgement has been made using available evidence including a visit to Beechey House. Sufficient numbers of staff were not always available to meet resident’s individual needs. Staff received training to deliver care, some aspects of training needed updating, some staff are trained in National Vocational Qualifications or equivalence. Induction training was not properly structured. Practices in relation to recruitment needed improvement as residents were placed at risk through lack of protection. EVIDENCE: There are a total of nine care staff. Examination of the staff rota and observation throughout the inspection demonstrated there were not always sufficient staff available to give individual care, as needed. There has been no increase in staffing arrangements since the change in registration from 14 to 16 people. The staff rota showed there were two care staff on duty at all times, during the night this consists of one waking night staff member and one staff member sleeping in and on call. Miss Damhar is also available through periods during the day to assist, as needed. Using the residential forum calculator as guidance indicates there is a shortfall of 23 care hours a week. This does not take account of the care staff carrying out all the meal preparation, this adds to the shortfall in care hours. Staff displayed a friendly approach and worked hard. Records of two members of staff were examined. Pre-employment checks had not been properly completed. On one file there was no application form so it Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 18 was not possible to ascertain the employment history; both references had been received after the start date of employment; the Criminal Records Bureau (CRB) clearance had been received six months after commencing employment and no PoVA First check had been carried out before receipt of the CRB clearance. Records showed that the member of staff had started work on the same day as the interview. On the other file, the member of staff had been transferred from another home under the same ownership. There was no evidence of an application form, CRB clearance or references. Discussion was held with Miss Damhar about the poor recruitment practices, she was aware that this is an area in which her management practices need significant improvement. Miss Damhar employs a number of staff from overseas, some with a nursing qualification, she states that these nursing qualifications are the equivalent of a National Vocational Qualification Level 3. Most staff had received training on fire safety, medication, health and safety, food hygiene, dementia and manual handling. Not all recently recruited staff (appointed in December 2005) had received training in dementia, infection control and first aid. Miss Damhar said further training on dementia and challenging behaviour was being planned and training in first aid had been booked for September 2006. Staff had induction training when they started work in the home but there was no structured induction programme linked to the Skills for Care induction standards. Miss Damhar said she is in the process of adapting the induction to incorporate the Skills for Care induction standards. The inspector advised that the Skills for Care website (www.skillsforcare.org.uk) should be accessed for guidance on training and induction. Further guidance on funding streams for training may be accessed from www.picbdp.co.uk and www.traintogain.gov.uk. Guidance for employers on training may be also accessed from www.lsc.gov.uk/bdp/employer/eggt_intro.htm. Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to Beechey House. Miss Damhar is working towards completing her management qualifications. The home does not have fully developed formal quality assurance systems to show that Beechey House is run in the best interests of residents. The home does not accept responsibility with residents financial affairs. Formal staff supervision remains outstanding. Working practices generally promoted the health, safety and welfare of residents and staff. EVIDENCE: Miss Damhar has gained the Registered Managers Award. She is working towards completion of the National Vocational Qualification Level 4 in Care. She has had to change to a different training provider as the training provider she was formerly using has ceased to operate. Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 20 Discussion with Miss Damhar contact with staff and residents demonstrated that Beechey House has informal quality assurance systems. Formal quality assurance systems are under development. Formal staff supervision remains outstanding. Miss Damhar confirmed that Beechey House do not have any involvement with residents financial transactions. She stated residents either have a relative or representative to assist in the management of their financial affairs. Fire records showed regular checks are carried out on emergency lighting and fire fighting equipment. Fire alarm testing was not up to date, this was rectified during the inspection. Not all staff had received training in infection control and first aid, arrangements have been made for staff to receive this training. Regulation 37 notifications were not always submitted to inform the Commission of deaths, illness and other events. Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 21 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 2 X 1 STAFFING Standard No Score 27 1 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 1 X 2 Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement The Registered Person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received in the care home including: a) Completing the medicines policy and making it available to staff. b) Recording details of any medicine sensitivity or ‘none known’ on or with the MAR chart. c) Recording the administration or reason for non-administration of all medicines, including creams etc. Monitoring the maximum temperature of the medicines cupboard to ensure that it does not exceed the recommended 25°C. The registered persons must ensure that residents are protected from possible abuse. All staff must receive Adult Protection training to ensure a proper response to any suspicion or allegation of abuse. Previous timescale of 30/06/06 not met. DS0000064864.V308323.R01.S.doc Timescale for action 1 OP9 13 31/10/06 2 OP18 13(6) 31/10/06 Beechey House Version 5.2 Page 23 3 OP24 23(2)(p) All residents must have an accessible bedside light in their room. A suitable lock must be fitted to the laundry door to prevent access by vulnerable residents. Liquid soap and paper towels must be introduced for staff to use in the laundry and WC’s to aid infection control and help prevent any possible crosscontamination. The previous timescales of 30/09/06 have been revised. The home must review the staff rota and provide evidence to demonstrate that sufficient care staff are on duty at all times. Miss Damhar must operate a thorough recruitment procedure in accordance with Schedule 2 to ensure the protection of residents. The registered person must ensure that all staff, particularly the most recently recruited staff receive training appropriate to the work they carry out, including training in dementia. The induction programme must be formalised and revised to include the Skills for Care Common Induction Standards. A formal quality assurance system must be implemented to evaluate the quality of the services provided at Beechey House. Staff must receive regular formal supervision. Previous timescale of 30/06/06 not met. Notifications must be submitted, without delay, to inform the Commission of death, illness and other events. DS0000064864.V308323.R01.S.doc 30/09/06 4 OP26 13(4) & 16 (2) (j) 31/12/06 5 OP27 18 30/09/06 6 OP29 19(1) 14/08/06 7 OP30 18(1) 31/12/06 8 OP33 24 31/03/07 9 OP36 18(2) 01/03/07 10 OP38 37 01/09/06 Beechey House Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The home should follow guidance from the Royal Pharmaceutical Society including: a) When a medicine is handwritten on the MAR chart a second competent person should check the details are accurate and countersign. b) Including the purpose of, and directions for, ‘when required’ medicines on the MAR chart and / or in the care plan. c) Written confirmation (e.g. copy of prescription, hospital discharge summary or fax of amended dose) should be kept with the MAR chart. Monitoring and recording the maximum and minimum temperature (normal range 2-8°C) of the refrigerator used to store medicines daily when in use. a. There should be an “in house” system for monitoring the audit trail and medication records to ensure that medicines are given as prescribed. Storage arrangements for reserve medicines should be reviewed so that they are not stored with food products and are stored off the floor, including liquid feeds. Arrangements should be made to ensure promotion of individual interests is supported so opportunities for stimulation are maximised. Residents and people involved with residents should be given information about opportunities to choose an external representative or advocate. Residents wishing to choose an external representative or advocate should be supported in doing so. An industrial washing machine with a sluice cycle is recommended in line with the Department of Health Infection Control Guidance for Care Homes (June 2006). The evidence obtained by the home that overseas nursing qualifications are the equivalent of National Vocational Qualification Level 3 (as stated in the Statement of Purpose) should be submitted to the Commission. Miss Damhar should complete her National Vocational Qualification Level 4 in Care. DS0000064864.V308323.R01.S.doc Version 5.2 Page 25 1 OP9 2 OP9 3 OP12 4 OP14 5 OP26 6 7 OP28 OP31 Beechey House Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF National Enquiry Line: 0845 015 0120 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 Beechey House DS0000064864.V308323.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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