Inspection on 21/01/05 for Beechfields

Care Home For Older PeopleBeechfieldsConyer Road Teynham Sittingbourne Kent ME9 9ETAnnounced Inspection21st January 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Beechfields Address Beechfields, Conyer Road, Teynham, Sittingbourne, Kent, ME9 9ET Email address Name of registered provider(s)/company (if applicable) Mr Clifford Lewis Saffrey Mrs Dorothy Elizabeth Saffrey Name of registered manager (if applicable) Type of registration Care Home Tel No: 01795 520580 Fax No:No. of places registered (if applicable) 9Category (ies) of registration, with (number of places) Old age, not falling within any other category (9) Registration number H060000092 Date first registered 29th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply? Date of last inspectionDate of latest registration certificate 29th July 2002 NO NO 25/5/04 If Yes refer to Part CBeechfieldsPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 321st January 2005 09:30 am Sarah MontgomeryID Code096286Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMrs Saffrey.BeechfieldsPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementBeechfieldsPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Beechfields. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.BeechfieldsPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Beechfields is a privately owned residential home. It has registration for up to 9 adults over the age of 65. The premises have been designed and built with reference to the National Minimum Standards for Care Homes for Older People.BeechfieldsPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection took place on 21st January 2004. It found that many of the National Minimum Standards had been met or partially met and that the overall quality of care provided was good. Comment cards were received from a number of service users at the home, and others were spoken with on the visit. Choice of Home (Standards 1-6) 3 of the 4 standards assessed were met. Standard 6 does not apply. Standard 3 was not assessed. Standard 1 was assessed as having minor shortfalls. The home is required to update the statement of purpose and service user guide, ensuring both documents comply with Regulations 4 and 5, and Schedule 1. Documents viewed during the inspection evidenced that service users needs are regularly assessed, and this is followed through in individual care planning. Health and Personal Care (Standards 7-11) 4 of the 4 standards assessed were met. Standard 9 was not assessed. Care plans detail all healthcare needs. Risk assessments were inspected and found to adequately address all assessed areas. Documents viewed evidenced an individual and sensitive approach towards service users personal care needs. Daily Life and Social Activities (Standards 12-15) 2 of the 2 standards assessed were met. Standards 14 and 15 were not assessed. Service users confirmed that the homes routines were flexible and individual preferences were respected. The owner stated that there are visiting entertainers throughout the year and various musicians etc. Service users have access to television, radio, newspapers and books. Complaints and Protection (Standards 16-18) 2 of the 2 standards assessed were met. Standard 17 was not assessed. The homes complaints policy and procedure were viewed and was found to contain all the information required by this standard. The owner stated that there have not been any complaints in the past year. The home has an adult protection policy. This complies with the standard required.Environment (Standards 19-26) 4 of the 5 standards assessed were met. Standard 25 was assessed as having a Beechfields Page 6 minor shortfall. Standards 20, 22 and 23 were not assessed. Beechfields has a homely welcoming feel to it. The Inspector undertook a tour of the home, including service users bedrooms, bathroom and toilet facilities, and communal areas. Accommodation is provided on one floor with all bedrooms and communal areas accessible to all service users. The home was safe and well maintained it was in good decorative order throughout and was comfortably furnished with furniture and fittings of good quality. The inspector requires the homeowners to assess whether individual service users are able to manage controlling the temperature in their rooms, and to override the system if they cannot. Staffing (Standards 27-30) 2 of the 2 standards assessed were met. Standards 28 and 30 were not assessed. Staffing numbers were assessed to be adequate for the needs of the home. Inspection of staff files evidenced the home operates a thorough recruitment procedure. Management and Administration (Standards 31-38) 2 of the 2 standards assessed were met. Standards 31, 33, 34, 35, 36 and 37 were not assessed. The inspector observed a good working relationship between the staff and owner. The home has a relaxed and informal atmosphere and many of the staff have worked there for a number of years. The owner is available in the home and works alongside staff on a daily basis.BeechfieldsPage 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)BeechfieldsPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 4(1)(c) OP1 The registered person produces a statement of purpose to include all items in Schedule 1, ensuring that all language used is accessible and can be understood. March 31st 2005.5(1)(a) 2 5(1)(b) 5(1)(c) 5(1)(e) The registered person ensures all rooms are heated appropriately, and for service users unable to control their own heating, the system is set by the homeowners. Immediate. From the date of inspection. OP1 The registered person produces a service user guide to include all items listed in Regulation 5. March 31st 2005.323(2)(p)OP25RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues, which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * Beechfields Page 9 * Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.BeechfieldsPage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES YES NO NO YES NO YES NO YES YES YES YES YES YES NO YES 6 0 0 NO NO YES YES 3 X 21/1/05 09.30 4.5BeechfieldsPage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.BeechfieldsPage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extrasYESIf yes, please state what the extras are: 2 Key findings/Evidence Standard met? The homes statement of purpose and service user guide was inspected. Both documents have minor shortfalls and do not meet the required standard. The inspector found some of the language confusing in the statement of purpose, and recommended that sections are rewritten. The service user guide does not include all information as specified in Standard 1.2. The owners are required to re write the service user guide following guidance from Standard 1, Schedule 1, and Regulations 4 and 5 of the Care Standards Act.BeechfieldsPage 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? The inspector examined service users statement of terms and conditions. All performance indicators in this standard are met, in that, the terms and conditions state all items as listed in 2.2. All service users have a copy of their terms and conditions on file. Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? Not inspected.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? All care plans were read. Evidence of regular assessment and review of assessments was documented on the care plan. Discussion with service users, staff and management evidenced that individual assessed needs are met on a daily basis through following care plans.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Evidence for this Standard was gained through discussion with the home manager, staff and service users. Prospective service users and their families visit the home prior to admission. Service users are encouraged to bring personal items with them. In discussion, one service user spoke of her admission, and stated that she had no knowledge she was moving to the home until she arrived on the day. This was substantiated by the owners, who, although felt uncomfortable about admitting the service user under such circumstances, did so because they were informed by care managers and relatives that the service user was at risk of harm in her previous placement.BeechfieldsPage 14 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? This standard does not apply.BeechfieldsPage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The inspector viewed service users Care Plans that included details of the service users physical care needs, mobility, medical needs, diet and personal lifestyle preferences and personal care to be given in relation to hygiene. Risk assessments were in place and those viewed indicated that these were regularly reviewed.Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 0 03 Key findings/Evidence Standard met? Evidence in respect of this Standard was gathered from service user care plans, discussions with service users, staff and management. All service user files inspected contained detailed notes on individual health care needs, including prevention of pressure sores, risk assessment of falls, nutritional screening, and community health services. Discussion with service users, staff and management evidenced an individual and holistic approach to meeting needs, with service users expressing satisfaction regarding how their individual needs are met.BeechfieldsPage 16 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 0 Key findings/Evidence Standard Met? Not inspected.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Discussion with service users, staff and management evidenced a sensitive and dignified approach to personal care giving; All individual needs regarding personal care are detailed on care plans. Inspection of bedrooms evidenced that the majority of service users have their own telephone within the room. Discussion with service users indicated that all personal post is delivered to them, that staff use the term of address preferred by the service user. Observations made on the day of inspection evidenced that service users are treated with respect. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Inspection of this Standard evidenced that care and comfort is given to service users who are dying, and their death is handled with dignity and propriety. Discussion with the owner indicated that the home and staff group are responsive to the needs and wishes of the service users and their families. Families are welcome at any time, and can stay as long as they wish. The home recognises its limitations with regard to specialist nursing care, and will, if necessary, obtain a re assessment of the service user.BeechfieldsPage 17 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? Service users confirmed that the homes routines were flexible and individual preferences were respected. The owner stated that there are visiting entertainers throughout the year and various musicians etc. Service users have access to television, radio, newspapers and books.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? Evidence for this Standard was gained through document reading, discussion with the homeowner and service users. The home has an `open door policy regarding visitors. Discussion with service users evidenced that they are able to receive visitors, and can choose whether to entertain them in the communal areas or in private. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? Not inspected.BeechfieldsPage 18 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Not inspected.BeechfieldsPage 19 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 1 100 3 Key findings/Evidence Standard met? The homes complaints policy and procedure were viewed and was found to contain all the information required by this standard. The owner stated that there have not been any complaints in the past year.Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? Not inspected.BeechfieldsPage 20 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? The home has an adult protection policy. This complies with the standard required. Both owners displayed acceptable knowledge of adult protection protocols.BeechfieldsPage 21 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Beechfields has a homely welcoming feel to it. The Inspector undertook a tour of the home, including service users bedrooms, bathroom and toilet facilities, and communal areas. Accommodation is provided on one floor with all bedrooms and communal areas accessible to all service users. The home was safe and well maintained it was in good decorative order throughout and was comfortably furnished with furniture and fittings of good quality. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? Not inspected.BeechfieldsPage 22 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? Apart from the shared room, all service users have an ensuite toilet, hand basin and shower in their bedrooms. A selection of these were inspected and found to meet the standard. The communal bathroom was inspected. It has an assisted bath and suitable adaptations for the toilet.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? Not inspected.BeechfieldsPage 23 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence Not inspected. NO YES NO 7 7 1 0 Standard met? 0 7 0X X 1 0BeechfieldsPage 24 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? 4 bedrooms were inspected. Bedrooms were attractively and individually decorated with comfortable furnishings appropriate to individual requirements. The bedrooms were personalised with pictures and ornaments and the owner stated that many service users had brought their own pieces of furniture. Service users spoken to said they were happy with their rooms. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? The home is heated with an under floor heating system. All rooms have individual thermostats, which can be controlled by service users. Many rooms, including the communal bathroom felt cold. This was discussed with the owners, who suggested that some service users were confused by the thermostat, and possibly were not using it correctly. The inspector requires the home assesses whether individuals are able to use the thermostat, and in cases where it is found to be inappropriate for service users to be responsible for the temperature in their rooms, the owners override the system to ensure rooms are heated to appropriate temperatures. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? At the time of the inspection the premises were clean throughout and free from offensive odours. The homes laundry facilities are situated separately from the kitchen and food supplies. Paper towels and gloves are supplied as appropriate.BeechfieldsPage 25 BeechfieldsPage 26 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 4 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff 5 0 427.44 No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 308 X X XX 3 X3 Key findings/Evidence Standard met? The total number of hours of 427.44 is based upon guidance from the Residential Forum and includes allowances for personal care, social, recreational and cultural activities. The total hours of 308 are those hours declared by the manager to be hours where staff are working directly with residents and does not include time spent by staff on administration, paperwork or time spent with relatives of residents, meetings etc. From the information given and the observations made by the inspector during the inspection the staffing is adequate to meet the present needs of the current service users in the home. Beechfields Page 27 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence Not inspected. X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Evidence for this Standard was gained by discussion with the homeowner and inspection of a staff file. Examination of the staff file evidenced appropriate recruitment as directed by Standards 29.1 ­ 29.6. All matters listed in Schedule 2 are included. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not inspected.BeechfieldsPage 28 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? Not inspected.Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The inspector observed a good working relationship between the staff and owner. The home has a relaxed and informal atmosphere and many of the staff have worked there for a number of years. The owner is available in the home and works alongside staff on a daily basis. Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? Not inspected.BeechfieldsPage 29 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? Not inspected.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Not inspected. Standard met? 0 X X XStandard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? Not inspected.BeechfieldsPage 30 Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? Not inspected.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Risk assessments viewed contained detailed assessments pertaining to ensure the health and safety of all service users. Staff and management informed the inspector they had received training in health and safety. Environmental adaptations around the home, and aids for individual service users, further ensured the health and safety of service users.BeechfieldsPage 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead InspectorSarah Montgomery Signature Signature Signature 25th January 2005 Page 32Second Inspector Regulation Manager Date Beechfields Public reports It should be noted that all CSCI inspection reports are public documents.BeechfieldsPage 33 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 21st July 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleBeechfieldsPage 34 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 31st March 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here BeechfieldsPage 35 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mrs Saffrey of Beechfields confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Mrs Saffrey of Beechfields am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.BeechfieldsPage 36 Beechfields / 21st January 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000023905.V200228.R01© This report may only be used in its entirety. 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