Inspection on 09/05/08 for Beechfields Nursing Home

This inspection was carried out on 9th May 2008.

CSCI found this care home to be providing an Poor service.

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

Beechfields Nursing Home 07/11/08

Beechfields Nursing Home 11/12/06

Beechfields Nursing Home 08/02/06

Beechfields Nursing Home 06/07/05

Beechfields Nursing Home 31/01/05

Similar services:

Aston Court Nursing Home

Breme

Ravenhurst

Westmead

Ashcroft Hollow Nursing Home

Bricklehampton Hall Nursing Home

Briar Hill House

Radbrook Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Beechfields Nursing Home 1 Wissage Road Lichfield Staffordshire WS13 6EJ Lead Inspector Dawn Dillion Key Unannounced Inspection 9th May 2008 09:00 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 Beechfields Nursing Home DS0000060813.V360329.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. Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechfields Nursing Home Address 1 Wissage Road Lichfield Staffordshire WS13 6EJ 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) 01543 418354 01543 411015 anil_r_patel@hotmail.com Tudor Care Plc Care Home 35 Category(ies) of Physical disability (35), Physical disability over registration, with number 65 years of age (35) of places Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care with nursing and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories:Physical Disability (PD) 35 Physical Disability over 65 years of age (PD(E) 35 The maximum number of service users to be accommodated is 35. 2. Date of last inspection 11th December 2006 Brief Description of the Service: Beechfields Nursing Home is situated in a quiet residential area in Lichfield, Staffordshire. The home provides a service for older people and also has a registration category that enables them to offer a service to people who have a physical disability. The two-storey property is set within its own grounds and consists of 31 single and 2 shared occupancy bedrooms, 19 of which are equipped with en suite. Bathrooms and toilet areas are located on both floors and are in close proximity to bedrooms and communal areas. The home also provides 3 lounges and a dining area, all of which are equipped with essential furnishings and fitments to ensure the comfort of people living in the home. The home also consists of an industrial kitchen and a separate laundry room. People living in the home had access to a well-maintained garden. Staffing is provided on a 24 hours basis to ensure the total supervision of people accessing the service. Information relating to the fees charged for the service provided at the home was not made available to us, the reader may wish to contact the home directly for this information. Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 Star. This means the people who use this service experience poor quality outcomes. The unannounced key inspection of Beechfields Nursing Home was undertaken within seven hours. The inspection methodologies that were used to establish the quality of care provided and the effectiveness of the management of the home, to promote equality, diversity and best practices, entailed the examination of the records relating to the homes policies and procedures. During the process of the inspection, three people that accessed the service, three staff members and four visiting relatives were interviewed. The Annual Quality Assurance Assessment, AQAA) was not received within the identified timescale but was submitted prior to the writing of this report. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. It is a legal requirement that this document be completed and returned to us within the specified timescales. Although received late, extracts from this document have been included within the contents of this report. Information received from questionnaires from people who use the service are also incorporated within the report. A tour of the property was undertaken, to ensure that the environment and systems in operation were safe and conducive in meeting the needs of the people who use the service. The Care Manager was present for the duration of the inspection. What the service does well: People that use the service and discussions with their relatives, confirmed their satisfaction about the service and provisions provided, these were their comments: “The member of staff on admission was excellent.” “All the family are very happy with the care, X gets lots of love and care from staff.” “The food is perfectly alright, no problems.” “I have no problems what so ever, I have never had to complain.” Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 6 “I am very happy with my bedroom, I can see the birds.” “The home has done a fantastic job.” “The Owner is very approachable, he has always got time for you.” The home provided a warm and welcoming atmosphere with staff taking the time during their daily routine to sit and talk with people. What has improved since the last inspection? What they could do better: The homes medication practices were not robust to ensure that people received their medicines as directed by the General Practitioner. The registered person should ensure that practices are monitored and that Nurses are subject to a competency assessment, to ensure that they have the up to date skills with regards to the safe handling of medicines, to guarantee the safety of people receiving assistance with their medication. Albeit that people were confident that any concerns shared with the Manager or the Nurses would be addressed, people who use the service were not aware of the homes complaint procedure. The registered person should ensure that all the people living in the home are in receipt of a copy of the complaints procedure to guarantee peoples safety. The management of people’s finances was not robust to protect them from abuse. The registered person should review the homes practices in relation to safeguarding peoples money and where necessary enable the individual to have access to a self advocate to promote their independence and safety. The Care Manager had not been registered with the Commission for Social Care Inspection, failing to comply with the Care Standards Act 2000, to ensure the effective running of the home and to promote the welfare of people accessing the home. Poor quality assurance systems and the registered providers failure to submit the Annual Quality Assurance Assessment within the allocated timescale and also the failure to respond to an urgent action letter subsequent to this inspection visit, compromises the welfare and safety provided to people living in the home. Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 7 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. Beechfields Nursing Home DS0000060813.V360329.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 Beechfields Nursing Home DS0000060813.V360329.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): 1, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people using the service can be assured that the Home will be able to meet their needs before they choose to move in, although the information available to them is not accurate which does not help them in their decision making. EVIDENCE: The homes Statement of Purpose and Service User Guide did not reflect the current service provided within the home. For example the property had recently been extended to provide additional bedrooms, the Service User Guide referred to the previous structure of the building. There was very little Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 10 information relating to the management structure and there was no reference to the fees charged for the service and provisions provided by the home. The Care Manager acknowledged that these documents were inadequate and said that they had not been given to new people entering the home because the information was so out of date. The homes Annual Quality Assurance Assessment identified the need to up date the homes brochure and to produce an up to date Service User Guide. Information obtained from a service user survey stated that, “The member of staff on admission was excellent.” Three care plans were randomly selected for examination, all contained evidence of the undertaking of a pre admission assessment, to establish whether the home would be suitable to meet the assessed needs of the people prior to admission to the home. Beechfields Nursing Home does not provide intermediate care. Beechfields Nursing Home DS0000060813.V360329.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 adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. Poor medication practices may compromise people’s health and general welfare. EVIDENCE: Information obtained during the process of the pre admission assessment provided the foundation for the development of the care plan. We looked at three care plans, which were randomly selected with regards to a varied spectrum of care needs. Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 12 All care plans provided detailed information relating to the level of support and assistance the individual required to meet their healthcare needs and to promote their independence and general wellbeing. Care plans were reviewed on a regular basis to reflect people’s current needs. The Care Manager informed us that where possible people were encouraged to be actively involved in the development of their care plan and subsequent reviews. A relative informed us that, “All the family are very happy with the care, X gets lots of love and care from staff.” The Annual Quality Assurance Assessment identified that people who use the service and their relatives are encouraged to review the care plan. We asked one person if there was anything they felt would improve the service, their reply was, “We only have a bath once a week, I would like to have another one.” The Care Manager informed us that this could be arranged. Care plans incorporated information relating to the intervention of other healthcare professionals, to promote the physical and mental health of people living in the home. For example records evidenced that people had access to a Dietician, General Practitioner and a Tissue Viability Nurse. Risk assessments were in place relating to moving and handling and pressure care. With reference to the homes medication system and practices, the Nomad method was used. The examination of medication administration records identified a number of signatory gaps, which failed to demonstrate that people were receiving their medication to ensure their general health. There was no information recorded to clarify why prescribed medicines had not been administered. The Care Manager informed us that one person administered their own medicines and that daily supplies of their medications were given to this person. The medication administration record was ticked instead of being signed, to indicate that this person had been given their medication for the day. This practice failed to provide an audit trail. The medication administration record evidenced that there was an inconsistency of ticks to demonstrate that this person was actually receiving their medication, the record identified that for four days this person had not received their medication to ensure their general health. Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 13 There was no risk assessment in place or any monitoring system, to ensure that this person was taking their medication appropriately in accordance to the direction given by the General Practitioner, to ensure this person’s wellbeing. It was also of concern that one medication administration record identified that one person did not receive their prescribed medication because it was out of stock for two days, compromising the health of this person. Other medication administration records also demonstrated inconsistencies with regards to the administration of medication to ensure the promotion of people’s general health. Discussions with the Care Manager confirmed that only the Registered Nurses were responsible for the administration of medication and that they had not been subject to a competency assessment, to ensure that they had the up to date practical skills with regards to the safe handling of medicines, to guarantee the health and safety of people requiring assistance with their medication. The homes Annual Quality Assurance Assessment was received after the date of the inspection and identified that the medication policy had been improved within the last twelve months. Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 14 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. People who use the service are able to make choices about their life style and to maintain contact with their family and the local community to promote social inclusion, choice and independence. EVIDENCE: During the process of the inspection staff were observed engaging in conversation with people living in the home, talking about the vegetables, flowers growing in the garden and the weather, whilst assisting them with a cup of tea and biscuits. The atmosphere was warm and welcoming. Staff were seen to encourage people to participate in exercise to music, and found the time during their daily routine to sit and chat with people who used the service. Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 15 Discussions with one person who lived at the home confirmed, “There is always something to join in with.” The Service User Guide identified that the following social activities were available within the home: cards, scrabble, bingo, draughts, painting and drawing. One relative informed us that, “The secretary is delightful and the social activities she does in the home.” The Annual Quality Assurance Assessment stated, “We encourage all residents to maintain their individuality.” “Assistance given to participate in activities arranged by the Activities Organiser if they wish to.” There was no one in residence from the ethnic minority group or with specific religious needs. Discussions with the Care Manager confirmed that every effort would be made to meet any future needs, to accommodate people from these groups. One person said, “We have one or two outings, the vicar visits the home.” We spoke to a number of relatives and friends of people living in the home who confirmed that they were able to visit the home at anytime within reason. One person who accessed the service told us that, “My daughter visits nearly every day.” A relative informed us that, “The home maintains contact with the family and we are able to visit at anytime.” The inspection of a number of bedrooms evidenced that people were able to bring in their personal possessions to personalise their bedrooms to reflect their interests and individuality. With reference to meals and mealtimes, the Care Manager informed us that people living in the home were asked the day before regarding their choice of meals. A four-week menu was in place, which provided an alternative choice to reflect the individuals likes and dislikes. We observed drinks being made available throughout the day. One person told us that, “The food is alright.” Another person confirmed, “The food is perfectly alright, no problems.” A relative informed us that, “Mum says the meals are very good.” Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 16 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, 17 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s safety may be compromised by the lack of accessibility to the complaints policy and staffs insufficient knowledge about policies and procedures to promote the safety of people living in the home. Appropriate recruitment procedures provide people with some element of safety to ensure their welfare. EVIDENCE: The home had a complaint policy; information of how to make a complaint was also incorporated within the Service User Guide and the Statement of Purpose. The registered person should ensure that these policies are reviewed to provide up to date information relating to contact details. One person who lived at the home informed us that, “If I have a complaint I would get in touch with the Manager or tell one of the nurses.” When we asked whether she had a copy of the complaints procedure, she said, “No.” Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 17 We spoke to another person who lived in the home who informed us that, “I have no problems what so ever, I have never had to complain.” Further discussions with this person confirmed that they were not aware of the homes complaint procedure. The Annual Quality Assurance Assessment identified the need to, “Inform residents/relatives of the complaints procedure.” The registered person should ensure that the homes complaint policy is accessible to people living in the home, to guarantee that they know how to make a complaint and in turn promote their safety. We have received one complaint about the service, which was of a sensitive nature; this complaint had already been referred to Social Services by the home, under the safeguarding procedures. Social Services informed us that the allegation was not substantiated. The Care Manager informed us that they had a safeguarding policy; this was not evidenced during the process of the inspection. The Care Manager told us that she was in the process of arranging safeguarding training for the staff and had developed a folder containing information relating to “Recognising and preventing abuse in a care home.” Three staff members were interviewed during the process of the inspection, one staff member was not aware of the term safeguarding, also known as adult protection. All three staff confirmed that they had not received training relating to safeguarding, which was confirmed by the Care Manager. Two out of three staff that were interviewed were not aware of the homes Whistle Blowing policy. With reference to people rights, discussions with the Care Manager confirmed that the people living in the home did not have access to a self-advocacy service, to provide them with independent support, to promote the rights of people who lack capacity. Three staff files that were examined evidenced that the appropriate safety checks were undertaken prior to the commencement of employment, to provide some element of safety to people living in the home. However one file only contained one written reference, discussions with the Administrator confirmed that this had been misfiled. Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 18 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 physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment that promotes the individuals independence. EVIDENCE: Beechfields Nursing Home is situated in a quiet residential area in Lichfield, Staffordshire. The two-storey property is set within its own grounds and consisted of 31 single and 2 shared occupancy bedrooms, 19 of which were equipped with en suite. Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 19 One person told us that, “I am very happy with my bedroom, I can see the birds.” Bathrooms and toilet areas were located on both floors and were in close proximity to bedrooms and communal areas. The home also provided 3 lounges and a dining area, all of which were equipped with essential furnishings and fitments to ensure the comfort of people living in the home. Appropriate aids and adaptations were in place, for example, assisted baths, grab rails, nurse call alarms and a passenger lift. The home also consisted of an industrial kitchen and a separate laundry room. People living in the home had access to a well-maintained garden. Appropriate systems were in place to promote infection control, the hygiene and the cleanliness of the home was of a good standard. A comment from a service user survey about the cleanliness of the home stated, “A really consistent feature of the home.” Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 20 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. Staff in the home are skilled and in sufficient numbers to support the people who use the service to ensure that their assessed needs are catered for. EVIDENCE: The home was registered to provide a service for thirty-five people; the Care Manager informed us that twenty-nine people were in residence on the day of the inspection. Discussions with the Care Manager and the examination of staff working rotas evidenced that sufficient staffing levels were provided to meet the needs of people living in the home. One relative queried the staffing levels with regards to the recent extension. The Care Manager was aware of the need to review the staffing levels when more people are admitted to the home or when the home is at its full capacity. Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 21 Discussions with one person who lived in the home informed us that, “The staff are good, I like the staff.” Another person said, “The staff are perfect, no grumbles at all.” As previously identified within the contents of this report, the examination of three files pertaining to people working in the home, evidenced that they were subject to the appropriate safety checks prior to the commencement of employment, to ensure the protection of people living in the home. The Care Manager informed us that all the care staff had obtained the National Vocational Qualification. We also looked at the training records and spoke to three staff members during the process of the inspection who informed us that they had received the following training: moving and handling, personal care, fire awareness, infection control and first aid. There is further work required in this area to ensure that all staff have the training needed to meet the needs of the people using the service. Staff have not received training in safe guarding principles and procedures and the continuing competency of medication practices is not monitored. Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 22 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 poor. This judgement has been made using available evidence including a visit to this service. Although the staff like and respect the new manager, the present managements do not fully safe guard the people using the service. EVIDENCE: Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 23 Discussions with the Care Manager confirmed that she was experienced in social and healthcare. We spoke to three members of staff during the process of the inspection; these were their comments in relation to the Care Manager: “The management support is very good, excellent I would say.” “The management support is great, always there when you need them.” “The manager is ‘hands on,’ its team work and helping each other.” “The management is brilliant, we are a close team.” It is of concern that the Care Manager was appointed in December 2007 and had not submitted an application for registration. This is a breach of the Care Standards Act 2000 and is the responsibility of the owner. Albeit that people living in the home, relatives and staff members were complimentary about the service and provisions provided, it is of concern that apart from questionnaires that were distributed to people who use the service, the home did not have a quality assurance system in place, to guarantee the effectiveness of the service delivery. For example the Care Manager informed us that the registered provider visited the home on a regular basis, but there was no evidence of this, no reports of visits were maintained to demonstrate the effectiveness and the quality of the service was being monitored, to promote the welfare of people accessing the service. One relative informed us that, “The Owner is very approachable, he has always got time for you.” Another relative said, “The home have done a fantastic job” The homes medication systems and practices were not robust to ensure the safety and welfare of people receiving assistance with their medicines and there was no evidence of practices being monitored. The home had also failed to submit their Annual Quality Assurance Assessment within the specified timescale. When finally submitted, the Assessment did not provide detailed information relating to how the home would improve the service in the future, to promote the welfare of people accessing the service. With reference to the management of finances for people who access the service, the Care Manager informed us that the respective families managed the financial affairs. The home held some cash for individuals and account records were maintained but it was of concern that the Care Manager was not aware of where the funds were kept. Discussions with the Administrator confirmed that funds for all the people living in the home had been deposited Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 24 in a “Beechfields Residents” account. This raised further concerns to who was receiving the interest paid to this account. Due to the concerns identified with the management of finances, this was referred to Social Services under the safeguarding procedure and an urgent action letter was sent to the registered provider for a review of the system, to ensure the protection of people’s finances. The registered provider has failed to respond to this letter within the identified timescale. With reference to systems and practices that promote the health, safety and welfare of people accessing the service, records were maintained of safety checks of appliances, systems and fire fighting equipment. Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 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 2 17 2 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 1 X X 3 Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 26 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 OP9 Regulation 13(2) Requirement Medication administration records identify a number of signatory gaps, which fail to demonstrate that people are receiving their prescribed medicines. The registered person should take the appropriate action to ensure that people receive their medication, to ensure the individuals health. Medication administration records identify that a prescribed medicine had been out of stock for two days. The registered person should review the medication system and practices to ensure that people using the service receive their medication as directed by the General Practitioner. With reference to one person who self-administers their medication, there is no risk assessment in place. The registered person should take the necessary measures to Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 27 Timescale for action 01/07/08 2. OP9 13(2) 01/07/08 3. OP9 13(2) 01/07/08 4. OP9 13(2) guarantee the health, safety and welfare of people receiving medication. Nurses are ticking medication administration record instead of signing. The registered person should take the necessary action, to improve medication practices, to provide an audit trail and guarantee that people receive their prescribed medicines to promote their health and welfare. Nurses have not been subject to a competency assessment. The registered person should ensure that the appropriate measures are taken to ensure that Nurses have the necessary skills to administer medication safely. The Care Manager has not submitted an application for registration. In order for legislation to be complied with, the Care Manager must apply for registration with us. 01/07/08 5. OP9 18(1)(c)(i ) 01/07/08 6. OP31 CSA 2000 Section 11(1) 01/07/08 7. OP33 24(1)(a)( b) There is no structured quality assurance system in place. The registered person should take the necessary actions to implement a quality assurance system to monitor the effectiveness of the service to ensure the health and welfare of people accessing the service. The homes procedure for the management of people’s financial affairs is not robust to protect individuals from abuse. DS0000060813.V360329.R01.S.doc 30/07/08 8. OP35 20(1)(a)( b) 21/05/08 Beechfields Nursing Home Version 5.2 Page 28 The registered person should take the necessary actions to ensure that financial systems are thorough, to promote the protection of people using the service. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard OP1 OP16 OP18 OP18 OP18 OP33 Good Practice Recommendations To ensure that the Statement of Purpose and the Service User Guide provides up to date information, to reflect the service and provisions provided in the home. People living in the home should be provided with a copy of the complaints policy. To ensure that all staff are in receipt of the homes Whistle Blowing policy. To ensure that two written references for people working in the home are maintained on file. The registered person should ensure that all staff receive safeguarding training. The registered provider should undertake monthly visits to the home, to monitor the quality of the service delivery. A written report of the visit should be maintained in the home. Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 Beechfields Nursing Home DS0000060813.V360329.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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