Inspection on 20/02/07 for Beechfield

This inspection was carried out on 20th February 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beechfield 02/12/08

Beechfield 08/12/05

Beechfield 03/05/05

Beechfield 23/12/04

Beechfield 13/10/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

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 Beechfield Beechfield 22 Hanger Hill Weybridge Surrey KT13 9XS Lead Inspector Vera Bulbeck Unannounced Inspection 20th February 2007 10:10 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 Beechfield DS0000013566.V327707.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. Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechfield Address Beechfield 22 Hanger Hill Weybridge Surrey KT13 9XS 01932 842380 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) Beechfield Trust Limited Mrs Audrey Claire Sentinella Care Home 16 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (10), of places Physical disability (1), Physical disability over 65 years of age (4), Sensory Impairment over 65 years of age (1) Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The number of persons for whom residential accommodation and personal care is provided at any one time shall not exceed SIXTEEN (16). The age range of the persons to be accommodated will be: 15 older persons (OP) 65 years and over up to 4 may be in the category PD (E), one in the category PD under the age of 64 years and one in the category SI (E). Accommodation may only be provided to one (1) resident with Dementia (DE) with prior written agreement of the CSCI. All staff is to receive ongoing training in the care of service users with dementia. 8th December 2005 3. 4. Date of last inspection Brief Description of the Service: Beechfield is a residential care home for active Christian Scientists. It opened in 1946 and was the first Christian Science care home in Britain. Resident’s rely on bible-based methods of spiritual healing rather than on conventional western medicine and care. The reliance of Christian Scientists on prayer alone for their health care is an integral part of their worship of God and practice of their religion. No medical processes, remedies or interventions are used at Beechfield. The home is registered as a care home not providing medicines or medical treatment. It is registered for up to 16 people. The age range of the persons to be accommodated is older persons aged 65 years and over. The home is situated in Weybridge opposite the cricket green and close to the local shops. The railway station and several bus routes are also in close proximity. The home stands in its own well established and maintained grounds. There is a lift serving the upper floor. There are sixteen single rooms; all but one has an en-suite toilet. Two have showers and two have baths. The major part of the home is wheelchair accessible. The Beechfield Trust members are actively involved with the home; several of the staff and management are active Christian Scientists themselves. There are ample parking facilities at the front of the building. The fees for the home are: £504.00 per week. Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and took place over five hours commencing at 10.10 am and ending at 15.10pm. Mrs V Bulbeck, Regulation Inspector carried out the visit. A full tour of the premises was undertaken. Three care plans were sampled and the care observed for the three individuals. A number of staff was spoken with during the visit. Five comment cards were received from residents and five comment cards from relatives/visitors. The registered manager Mrs Audrey Sentinella was on duty. There were twelve residents living in the home on the day of the site visit and there were four vacancies. However, the inspector was informed that two places have already been taken and the residents identified suitable for the home were currently in the moving in process. The inspector would like to thank the residents and staff for their co-operation and hospitality during the inspection. The residents living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report. What the service does well: Resident’s views are continually sought to improve the service the home provides. Regular meetings are held with residents. The inspector spoke to a number of residents; all were complimentary towards the staff, regarding the care provided and the staff team. Residents living in the home appeared to be happy; they were well dressed and some stated they enjoyed their lunch on the day of the site visit. Residents are able exercise their choice in the home. There is a servery on the ground floor in the home where residents are able to make their own drinks. However, the inspector was informed by two residents they prefer to be served drinks by the staff. The inspector spoke with a number of staff on duty on the day of inspection; staff commented they feel supported by the management of the home and work as a stable team. The home was homely and welcoming and all areas in the home were nicely decorated and furnished. Some residents had some items of furniture in their bedrooms, which they had brought into the home with them. Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 6 There were five comment cards received from residents and comments were complimentary towards the management and staff. One resident stated, she is “very happy living in the home and she had to wait some time before a vacancy was available in the home”. Another resident stated, “The staff are wonderful they are so caring and understanding”, and another resident commented, “Staff are so kind” and she is very grateful for all they do. Several residents commented the food served is very good. The chef has worked in the home for a number of years and knows all the resident’s likes and dislikes well. Five comment cards were received from relatives/visitors all were complimentary towards the staff and management, some stated the home is clean and well run. What has improved since the last inspection? What they could do better: The home’s management should ensure staff are aware of and use the National Minimum Standards for Older People and the Care Homes Regulations 2001 as a working tool. This will ensure that the quality outcomes for residents are being promoted. The registered manager must ensure CSCI are notified of any significant accidents or incidents at all times to ensure the safety and well being of residents. Recruitment practice needs to be improved to ensure the protection of residents and a review of the staffing numbers is advised in view of feedback from residents and relatives. For example a number of residents commented there are times when the home is short of staff and some relatives stated at times particuarly at weekends there are insufficient staff on duty. Further consideration should be given by the home management regarding the feedback from two relatives who stated that they were not aware of the homes Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 7 complaints procedure, and one who stated they did not have access to the inspection report. 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. Beechfield DS0000013566.V327707.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 Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each resident is only admitted to the home following a needs assessment to ensure that the home can meet the resident’s identified needs. The home does not offer intermediate care. EVIDENCE: At the time of the visit it was noted that a resident had recently been admitted to the home and the pre assessment for this resident was not available. The inspector was informed by the registered manager that the home is currently changing their filing system and the documents were somewhere in the administration office. However, the registered manager was able to show the inspector a pre inspection document which has been undertaken on a resident who is moving into the home within the next few days. The document had not been fully completed, but the registered manager explained that full details would be taken when the resident enters the home. The admission procedures Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 10 and criteria reflect the principles of admission and assessment appropriate to the home. The pre assessment document needs to be fully completed and residents need to be involved in the assessment to ensure the home is able to meet the resident’s needs, prior to admission to the home. The home has provided a service users guide to all residents and relatives. This was not checked on this visit, the inspector would advise the management of the home to ensure the statement of purpose and the service users guide is reviewed on a regular basis to include any changes, and a copy should be provided to all residents. Relatives need to be provided with a copy particuarly, if a resident is unable to be involved with the care provided in the home. It was identified at the time of the visit that the registered manager and all staff need to attend equality and diversity training. Beechfield is a Christian Scientists home that does not provide any medical services therefore medical screening, examination; diagnosis, prognosis treatment and administration of drugs are excluded. Intermediate care is not part of the ethos of the home. Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents health, personal and social care needs are set out in an individual plan of care, to demonstrate needs are met in accordance with the homes philosophy. Residents are treated in a respectful and sensitive manner. Residents in a Christian Science House will not have/receive medication. This is in accordance with the home’s philosophy. EVIDENCE: Three residents care plans were sampled and there was evidence that resident’s health, personal and social care needs had been identified and assessed. The Christian Science Practitioner and Christian Science Nurse supports resident’s to focus on spiritual ideas, healing and prayer. Care notes need to be more detailed to include residents daily routines, and consideration must be given to those residents who wish to be involved with their care plan. An action plan is in place to meet the physical care needs of the residents, to ensure the support, comfort and dignity of the residents is maintained. The Christian Scientist Nursing manager will review and respond to the resident’s Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 12 current care needs. The care plans are kept in the registered managers office and staff have access to the care plans to enable staff to use as a working tool. The residents living in the home are supported to enable them to focus on spiritual ideas and healing than on their affliction or injury. The Christian Scientist Practitioner and Nurse maintain this. The management of the home will liaise with support services to ensure appropriate equipment is received for example, hoists. The well being of the residents are managed in a spiritual approach to the attainment of health. In the event of a serious injury the resident has the choice of medical intervention. This would result in the resident being transferred to the facility of his or her choice. A number of risk assessments were seen and several need to be updated for all residents living in the home. Residents living in the home have chosen not to receive medication; this is also part of the ethos of the home. Individual circumstances and outcomes of this practice are set out in the residents care plan. A medication policy, which outlines action to be taken, when medication is brought into the home, will be available for staff and residents. The residents spoken to confirmed that staff are respectful and knock on resident’s bedroom doors before entering. Observation by the inspector was residents and staff have a good rapport, residents are able to discuss with the staff any worries they may have and staff reassure residents, by supporting, explaining, and helping to clarify any problems and to ensure residents have a clear understanding. A recommendation was made at the previous inspection 8th December 2005 for the manager to initiate contact with Social Services to review the residents placed by Social Services. Reviews need to be conducted yearly to ensure residents care needs are being met. The manager stated she had contacted Social services but no response had been made. However, the manager should continue to contact care management for this recommendation for good care practice to be met. Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported and encouraged to maintain contact with family and friends and have access to a range of activities. The majority of residents are able to take control over the planning of outings and their everyday routine. Meals are well balanced and varied with individual choices and preferences as well as special dietary needs catered for. EVIDENCE: The Majority of residents have contact with family and friends and those who do not have family or friends an advocate from the church is involved. A number of residents are able to go out with their family, and several residents are able to go out alone to the shops and town centre. All the residents attend the Christian Scientists Church in Weybridge on Sundays; transport to the church is by taxi. Every morning at 10.00 AM the residents hold a bible reading and prayer for one hour in the main lounge and all the residents are involved. There are planned activities these include visits to the garden centres, out to tea residents particuarly enjoy Garson’s Farm. Some of the church members Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 14 visit and take residents to out to various activities. Residents are able to make decisions with regards to the type of outings arranged and some are able to make their own travel arrangements for visiting friends and relatives. Every year in mid January the residents are invited to a play, a production by a local School, Claremont Fan Court. The majority of residents spoken too informed the inspector they enjoy the occasion. Residents attend music and movement in another residents home and the care staff sit and talk to the residents as well as play board games. A number of residents commented that the staff team are very good and they are always there to help. Meals are served in the dining room, the tables were nicely laid the food was plentiful and appeared appetising and nourishing and well balanced. The dining area was nicely presented and the residents are encouraged to eat meals in the dining room, this is also a social occasion. The chef is involved with the menu planning, and seeks the resident’s views and is aware of the resident’s likes and dislikes. The menu of the day is displayed in various areas around the home for residents to see and all residents are informed of the menu. The chef stated on the day of the visit, there is a choice of main meals every lunchtime, and suppertime there is a choice. However, the chef stated that residents enjoy whatever meals are provided for them, some days are more popular than others, for example all the residents like a roast. Fish and chips are on the menu for Fridays. Several resident’s confirmed the food is very good. The kitchen is well organised, records are well documented and the member of staff working in the kitchen appeared to be happy and contented working in the home. The kitchen was inspected by the Environmental Health Officer, (EHO) in November 2005 and the home was awarded a Silver Hygiene Award. Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 15 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure in place that includes timescales and action to be taken. Residents confirmed they have been provided with a copy. All staff have received the appropriate training to ensure residents are protected from potential risk of harm or abuse. EVIDENCE: There have been no recorded complaints in the home since the last inspection. The process for dealing with complaints was observed and found to be clear and any outcome or letters for the complaints were dealt with within the twenty-eight days timescale. All residents are provided with a copy of the complaints procedure, which, is documented in the homes brochure, all new residents are given a copy on arrival in the home. Resident’s confirmed they are able to discuss any problems or complaints with the manager or staff, residents stated they are listened to and appropriate action is always taken. The homes policies and procedures for the protection of vulnerable adults and a whistle blowing policy were in place and all staff has received the protection of vulnerable adults training. However, training needs to be updated. The staff on duty confirmed they had undertaken this training and were aware of the procedures. The home has a copy of Surrey Multi Agency procedures; this needs to be updated as the details within the document were dated 2001. Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 16 Residents are encouraged to vote and some have been registered for a postal vote. Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 17 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained comfortable, pleasant and has a homely atmosphere. It is safe and easily accessible to all areas in the home and garden. EVIDENCE: The home was found to be clean and tidy; on the day of the visit the housekeeper who is also a carer was able to confirm that the home’s cleaning routine is covered every day by a domestic, to maintain the cleanliness of the home. The housekeeper on duty also attends to the laundry. There are several areas around the home that have a nice homely touch and residents are able to enjoy, quiet seating areas situated around the home. All the bedrooms are different in character were nicely furnished and personalised by the residents. Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 18 Residents informed the inspector that they have a maintenance person who undertakes any little jobs requested by the residents, and all the residents spoke highly of this person. The maintenance person also looks after the grounds as well as the inside of the home. One resident who has recently moved into the home is very comfortable in her room and stated she is satisfied with the home. The resident informed the inspector that she had waited for some considerable time for a vacancy in the home. The grounds are spacious and nicely cared for. The inspector was informed that residents enjoy the garden during the summer months or good weather. A lot of the bedrooms lead directly into the garden and the residents stated they are really happy to have this facility, particuarly, as they like to feed and watch the birds. Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of the staff meets resident’s needs. The home has a comprehensive staff recruitment and training programme which, incorporates all areas needed to ensure, as far as reasonably possible, that residents are in safe hands at all times. However, staff recruitment procedures need to be improved. EVIDENCE: The staffing arrangements during each shift vary for example in the morning there are two care staff on duty, as well as the registered manager. In the afternoon there is only one member of care staff between the hours of 11.00 and 17.00. The inspector was informed that the housekeeper is also a carer in the event of an emergency she is available. There was some feedback from service users and two relatives that indicated the staffing numbers would benefit from a review. For example, a number of residents commented there are times when the home is short of staff and some relatives stated at times particuarly at weekends there are insufficient staff on duty. A recommendation has been made as a result of this feedback. Three staff files were sampled and the majority of documents required for each member of staff was found to be in place. However, details of all agency staff working in the home from an agency must be obtained from the agency to Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 20 ensure the safety of all residents. The records relating to Criminal Records Bureau (CRB) checks were not available on the day of the site visit. The registered manager stated and confirmed that all staff had received (CRB) checks except the hairdresser. The registered manager needs to ensure that evidence be available to the Commission for Social Care Inspection to confirm (CRB)’s are in place for all the staff. A training plan was observed by the inspector, which was kept up to date. The registered manager informed the inspector the majority of staff has received (POVA) protection of vulnerable adults training. The inspector discussed with staff on duty who confirmed they have received training in the past but several commented they need to be updated. The home has 62.5 of staff with NVQ Level 2 and above. The registered manager stated another member of staff is in the process of completing NVQ level 2. Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 21 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of residents by a person fit to do so and has a monitoring system in place that is based on seeking the views of the residents. The health, safety and welfare of residents is maintained at all times. EVIDENCE: The registered manager completed the Registered Managers Award in November 2004 and is competent and qualified to manage the home. Staff were complementary and stated they feel supported and the registered manager has an open door policy. Staff stated they are able to speak with the manager at anytime. One member of staff stated the manager is very flexible with staff and has a great understanding. Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 22 Regular visits are undertaken by a designated person to check the home is meeting the required standards. The management of the home need to ensure the Care Homes Regulations 2001 and the National Minimum Standards for Older People is available in the home at all times, and to ensure the staff follow the document and use as a working tool. The registered manager stated the home have regular meetings with residents and their relatives. Residents confirmed they have meetings, some also commented they hold their own meetings on discussion basis if an idea has been put to the residents perhaps for an outing resident’s discuss between themselves. Staff meetings are undertaken on a regular basis, to discuss a wide range of topics. The minutes of these meetings need to be recorded, and action that needs to be taken should be clearly documented. The registered manager informed the inspector, a questionnaire (Customer Care Satisfaction) is sent to all relatives on a yearly basis, and the last questionnaire sent out was some months ago. A number of comments were received from relatives and sampled by the inspector, all were complimentary regarding the home, and all commented the home provides the appropriate care. The administrator informed the inspector, relatives manage resident’s finances, and the home does not usually get involved. The majority of residents have family who are involved and those without family have a solicitor who has Power of Attorney. However, there is currently one resident who is not able to manage her finances who does not have any relatives, therefore the administrator manages the resident’s finances. Finance records were checked and found to be well documented, the money held by the home was found to be balancing with the records accordingly. A number of records were checked including the fire records, the inspector advised the home to implement an emergency contingency plan to ensure in the event of an emergency the staff and relevant emergency services would be clear on the action to be taken for the safety and wellbeing of the residents. The records were found to be well documented and details were filed appropriately, It was noted that a resident had gone missing from the home in June 2006. The police were called who found the resident close to the home. The homes policy and procedures were not followed at the time of the incident. However, the registered manager informed the inspector she has discussed and instructed the staff to ensure the correct procedures are followed at all times. It was also noted that the CSCI had not been notified of the incident. The Inspector discussed with the registered manager who was made aware of the requirement to notify the CSCI of such matters and the time scale of which the incident must be reported. The registered manager stated the home was aware and this was an oversight and had already been addressed with staff. Beechfield DS0000013566.V327707.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 3 Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19 Requirement Robust recruitment practices must be in place and appropriate records kept as detailed in the Care Homes Regulations and Schedule 2, to ensure the safety and protection of residents. The Commission for Social Care Inspection must have access to the staff records at all times. Timescale for action 23/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP27 Good Practice Recommendations That a review of the staffing numbers takes place in view of feedback from some of the residetns and their relatives. Beechfield DS0000013566.V327707.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Burgner House 4630 Kingsgate Cascade Way Oxford Business Park South Cowley Oxford, OX4 2SU 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 Beechfield DS0000013566.V327707.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. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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