Inspection on 09/05/07 for Beechill Nursing Home

This inspection was carried out on 9th May 2007.

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

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

Other inspections for this house

Beechill Nursing Home 09/02/09

Beechill Nursing Home 21/05/08

Beechill Nursing Home 24/11/06

Similar services:

Chirnside House

Keer Sands Residential Home

Sunny Bank (P.R.S.) Ltd

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Clover House

Langrigg House

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

CARE HOMES FOR OLDER PEOPLE Beechill Nursing Home 25 Smedley Lane Cheetham Hill Manchester M8 8XG Lead Inspector Geraldine Blow Unannounced Inspection 9th May 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beechill Nursing Home DS0000066845.V339094.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. Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechill Nursing Home Address 25 Smedley Lane Cheetham Hill Manchester M8 8XG 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) 0161 205 0069 0161 205 0069 beechillcare@yahoo.co.uk Skolak Homes Limited Mrs Jackie Crewe Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (19), Physical disability (12) of places Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing: Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category: Code OP (maximum number of places: 19). Physical disability: Code PD (maximum number of places: 12). The maximum number of service users who can be accommodated is: 31. Twelve residents aged 18 - 60 who fall within the category of physical disability are currently accommodated. Should these residents no longer require the accommodation offered by Beechill Nursing Home the category will revert to OP (old age). The responsible individual must undertake Protection of Vulnerable Adult Training by 15 September 2006. 30th January 2007 2. 3. Date of last inspection Brief Description of the Service: Beechill Nursing Home is owned by Skolak Homes Limited and provides accommodation for a maximum of 31 people. The home is located in the North of the City of Manchester and is situated within easy walking distance of local services and amenities. Limited parking facilities are available to the front and rear of the property. The home is a three storey purpose-built building. Bedroom accommodation for residents is provided on the first 2 floors and the third floor is used as office space. There are 23 single rooms and 4 double rooms. No en-suite facilities are provided but each room has a wash hand basin. There is one lounge, a smoking room, a small quiet room, a hairdressing room and a dining room. The home offers a small garden and patio area to the rear of the property. The charges for fees range from £409.00 to £564.00 per week. Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on information gathered by the Commission for Social Care Inspection (CSCI) since the last inspection on 30 January 2007 and supporting information received in the Pre Inspection Questionnaire submitted by the home prior to this visit as well as 6 returned resident comment cards. This unannounced visit forms part of the overall inspection process and was conducted by 2 inspectors. The visit took place on Wednesday 9 May 2007. The opportunity was taken to look at all the core standards of the National Minimum Standards (NMS). This inspection was also used to decide how often the home needs to be visited to make sure that it meets the required standards. As part of the visit time was spent talking with the home’s manager, the project manager, several people living at the home, and some members of staff. Time was also spent observing how staff work with the residents, assessing relevant documents and files and a tour of the premises was undertaken. In this report the term of address for people living at the home is residents. What the service does well: The residents spoken to said that they had choice over their day to day lives and one resident said, “The staff are brilliant. They always do what you ask them to do”. The majority of the received comment cards indicated that staff are usually available when you need them. On the day of this visit the lunch looked and smelt appetising. There was a choice of main meal and a variety of sweets on the menu and the chef said that if residents did not like what was on the menu then he would prepare any reasonable alternative. The residents spoken to confirmed that alternatives to the menu were available on request and one resident said, “The chef is excellent”. Residents also confirmed that drinks were available on request. The home provided a clean and tidy environment for the residents who live there. Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: All the residents must be given details about their terms and conditions in relation to any top-up fee required to live at the home. To prevent any possible risk to residents the use of bed rails on resident’s beds must be thoroughly risk assessed before they are used. To ensure that medication continues to be given safely and as prescribed by the doctor it is recommended that the home do regular audits of the medication administration systems. A recommendation has made regarding the recording of drinks given to residents that need to be thickened. Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 7 Training was being provided in the home, however there was no system in place to assess that after the training staff were competent to be able to provide the support that residents need to meet their needs and maintain their health and safety To ensure that the financial interests of the residents are fully protected policies and procedures must be put into place, which all staff should be made aware of. To make the garden area more attractive for residents a recommendation has been made that the lawn to the rear of the property is mowed and the rubbish bins are stored in an enclosed area. 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. Beechill Nursing Home DS0000066845.V339094.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 Beechill Nursing Home DS0000066845.V339094.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): 2 & 3 (Standard 6 intermediate care is not provided at Beechill Nursing Home). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents needs are assessed prior to them being admitted to the home and they are provided with information to help them make that decision. However residents are not given sufficient information in relation to their terms and conditions and fees. EVIDENCE: There is a documented pre admission assessment form that is used to ensure that prospective residents are admitted on the basis of a full assessment of needs and for residents who are referred through Care Management arrangements the home obtains a summary of the Care Management Assessment. In addition following the pre admission assessment the manager responds in writing to that person detailing that the home was able /not able to meet their assessed needs. These documents were seen on files at the Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 10 previous inspection visit. However, the only person to be admitted to the home since then had died and the file had been archived, so were not viewed. The manager stated that no one living at the home was privately funded for the full amount of fees. Asked if all residents had a contract she stated that the home did not have written contracts between themselves and the purchasing authority for all residents and that she was in discussion with the local authority contracts department to rectify this. The manager stated that a number of residents paid a ‘top-up’ fee in addition to what the purchasing authority paid. There was no evidence of a contractual agreement between residents and the home in relation to this fee. The registered provider must ensure that residents are fully aware of the terms and conditions in relation to the top-up fee. The home’s terms of conditions and information regarding fees was available in the Statement of Purpose and Service User’s Guide. In light of the recent changes to the Care Homes Regulations 2001 in relation to fees, it is recommended that the home review and update, if required, the information they provide to residents in relation to fees charged. The home does not provide an intermediate care service. Beechill Nursing Home DS0000066845.V339094.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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall residents’ health care needs had been identified and systems were in place to meet their needs. EVIDENCE: Since the last visit care planning training had been provided to all the nurses and the senior carers and this was confirmed during discussion with one of the nurses. The registered nurse had been given the responsibility for updating all the care plans. She described the care planning process and how they involved residents and other relevant people. They gathered information about each resident from talking to the resident, where possible, their families and from staff who knew the resident. Once the plan was developed residents were offered the opportunity to read, or be read the plan and to sign if they were in agreement. A random selection of plans was examined. They were seen to be much improved and the files were well organised, well maintained and divided into relevant sections, which made them easy for staff to use daily as a working tool. The plans of care were found to be detailed, informative and clearly set Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 12 out the action that needed to be taken by staff to ensure that the health and personal care needs and the specific religious and cultural needs of the residents are met. It was noted that the home did not carry out an assessment of continence needs. To ensure that all the needs of residents are identified and met it is recommended that the home introduce an assessment of continence needs. All the care plans examined had been rewritten in April 2007. It was the intention that these will be reviewed on a monthly basis, by a registered nurse, to record whether there had been any changes and then update the care plan as required. It is recommended that the review system is revised to show that the implementation of the care plan continues to meet residents’ needs. Risk assessments had been included, however it was noted that the risk assessments relating to the use of bed rails did not address the risk of using the bed rail but only the risk of the resident falling from the bed. To ensure the safety of residents a thorough risk assessment must be completed. Medication Administration Record Sheets (MAR) were examined and were found to be accurate, with the exception of the recording of thickened fluids. The nurse said that thickened fluids given to residents were signed for on an input and output chart. However when the chart was examined it was noted that on average only three drinks had been recorded on a daily basis and it was not recorded that all of the drinks given had been thickened. The nurse in charge confirmed that the resident had in excess of 3 drinks daily. In order to ensure that residents’ care needs are being met an accurate record of thickened fluids given should be kept. There was no excess stock of medication and medication had been signed into the home and returned medication had been appropriate recorded and signed for. To ensure that residents receive the required assistance with taking their medication there was a brief description, in the MAR file, of any assistance required. This is seen as good practice. Although there was a monthly evaluation of the medication systems there was no formal record that a medication audit had been undertaken to show that residents had received all the required medication as prescribed by the GP. To ensure the continued safe administration of medication it is recommended that the home undertake a regular formal audit of medication. Staff were seen spending time talking to residents with respect and in a kind, patient manner. Beechill Nursing Home DS0000066845.V339094.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 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents were able to exercise some control over their day-to-day lives and some activities were provided. EVIDENCE: The comments received via the comment cards gave conflicting information regarding the activities provided. Two of the comments were that activities are never arranged by the home and a further comment was “activities are a problem as there is lack of them.” Day trips would be appreciated.” In contrast other comments were that activities are usually provided and a further comment was “I enjoy the entertainers that come into the home on a regular basis where they sing and do games. I also enjoy the trips out to Blackpool”. The manager said that the home has very recently employed an activities coordinator. She had not yet started in post but will spend time with residents finding out about their interests and what social and leisure activities they enjoy. Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 14 The home maintained a written activities log of the leisure and social activities and contacts with residents. This includes supporting residents to a local pub to celebrate their birthday, visits to local shops and time spent with residents in social activities such as chatting, doing make-up and nails. The owner has made a dedicated budget available to spend on social and leisure activities and equipment. It is recommended that the home ensure that they evidence the work of the activities co-ordinator in developing and implementing the activities programme. The Commission has recently received an anonymous concern about the home and part of that concern was that residents were not being given choice around what time they go to bed, choice of meals and choice of where to eat those meals. As part of this visit the concern was investigated. A number of residents and the chef were spoken to. The residents confirmed that they were given choices around going to bed, getting up in a morning and choices around meals. The mealtime was observed and residents were seen to take their meals in the dining room and in the lounge and the manager said that a number of residents regularly took their meals in their own room. On the day of this visit there was a choice on the menu for the main meal and several choices of sweets. The chef confirmed that if residents did not want what was on the menu then he was happy to prepare the resident any reasonable request. During a residents meeting the issue was raised that they wanted to change when they had their main meal. Residents preferred to have a lighter lunch and then have the main meal in the evening. The home had taken this idea on board and made the changes the residents wanted. In addition the chef and the manager were in the process of developing a summer menu. The manager said that once the provisional menu had been developed it would be discussed with the residents. A tour of the kitchen was undertaken and it was seen to be clean and well organised. Good supplies of food stocks were seen, which included fresh fruit and vegetables. Residents were seen freely moving around the home and one resident, who was on respite care said that she had seen big improvements on this visit. She said that staff “were nicer and kinder than the last time.” She said that on this visit when she asked for a cup of tea the staff made her one and when she asked for a shower the staff helped, where on previous visits to the home staff said there were too busy. Beechill Nursing Home DS0000066845.V339094.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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had policies and procedures in place to protect the residents from abuse. EVIDENCE: There was a complaint policy, which had been updated since the last visit. The Service User Guide and the Statement of Purpose contained details of how to make a complaint and all new residents are given a copy. All received comment cards, with the exception of 1, indicated that residents knew how to make a complaint and the residents spoken to confirmed this. The manager kept a record of the complaints made, which included the action to be taken and the outcome of the complaint investigation. Since the last visit the Commission has received 2 anonymous concerns, which were investigated as part of this visit and are referenced to in this report under the relevant sections. The concerns were not upheld. Evidence was seen that the home had updated its POVA policy and had copies of the Local Authority’s “No Secrets Guidance”. POVA training was being provided on an ongoing basis and it was seen that the majority of staff have now received the training. Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 16 At the time of this visit there was a POVA investigation in progress relating to resident finances. Beechill Nursing Home DS0000066845.V339094.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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A programme of refurbishment and redecoration was ongoing which has improved the environment in some of the areas for the residents who live there. EVIDENCE: As already referenced in this report the programme of refurbishment and redecoration was ongoing and further improvements were seen from the last inspection visit. One resident said that she thought, “the dining room and the lounge are really lovely now.” The home was clean, tidy and free from offensive smells. Four of the returned comment cards indicated that the home was always fresh and clean, 1 stated that the home was usually fresh and clean and 1 returned comment card indicated that the home was sometimes fresh and clean. Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 18 The home has a small garden area to the rear of the property that overlooks the car park and a number of waste disposal bins. The lawn was overgrown and the patio furniture required cleaning before residents could use them. It did not look very attractive for residents to use. The manager said that she had requested that the maintenance man mows the lawn and cleans the patio furniture. It is recommended that the garden area is made attractive for residents to use and that the waste bins are stored in an enclosed area. The home had an Infection Control Policy and Infection Control training had been proved. The home had wall mounted hand gels for people to use in an attempt to reduce the risk of cross infection. Beechill Nursing Home DS0000066845.V339094.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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The number and deployment of staff available appeared sufficient to meet the residents assessed needs. EVIDENCE: At the time of this visit the home accommodated 18 people. The Commission had received an anonymous concern that staff were not being provided in sufficient numbers to meet the needs of the residents. This was discussed with the manager who said on a weekly basis she assesses the number and needs of the residents accommodated and then the numbers and skill mix of staff are set accordingly. It was recommended that this be formally recorded. The majority of the returned comment cards indicated that staff were usually available when they were needed and the residents spoken to confirmed that staff were available to help when needed. From observation during the inspection the numbers and skill mix of the staff appeared to be sufficient to meet the needs of the number of residents accommodated on the day of this visit. Another anonymous concern received by the Commission indicated that night staff were not carrying out their duties as required. Evidence was seen that Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 20 the owner was aware of the concern, had completed an investigation and had given warning letters to those staff involved. In addition, as a result of the investigation, the manager stated that they had developed a new job descriptions and a ‘waking night’ procedure that staff have signed to signify their agreement. Files of the four most recently employed staff. All had completed application forms, photograph, two references and documentation confirming the person’s identity and current address. It is recommended that the home ensure that they gain evidence that a reference is from a prospective staff member’s current/previous employer. The home had applied for Criminal Record Bureau disclosure certificate and POVA check. The manager stated that they had had to start the new staff without the CRB certificate because four care staff had all left at the same time. The new staff had undergone a week’s induction and were being supported by an experienced care worker. The home had introduced a new way of providing and evidencing an Induction programme for new staff. Evidence was seen of the documentation to be used to record that staff had undertaken the required training and had been assessed as competent. At the time of the inspection no documented evidence had been completed. It is recommended that the home ensure that the induction programme meets the requirements of the Skills for Care Induction Modules. Evidence was seen that staff had access to a training programme of core training events. However, there was no evidence to show that staff competence had been assessed as to their understanding and application of knowledge gained through training events. The home must ensure that staff are competent to be able to provide the support that residents require to meet their needs and maintain their health and safety. Despite efforts made by the manager she had been unable to find appropriate training in supporting the needs of people who have additional needs associated with alcohol use, for staff to attend. The pre inspection questionnaire stated that the home employed 13 care staff, 10 of which had achieved NVQ level 2 or above. Beechill Nursing Home DS0000066845.V339094.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, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been improvements in the management of the home. However they do not have all the procedures in place to fully protect people’s financial interests. EVIDENCE: Since the last inspection the manager had successfully been registered with the Commission. She is not a Registered General Nurse but is supported, clinically, by the senior nurse in the home. At the last inspection visit it was recommended that a senior nurse undertakes the clinical supervision or is included in the clinical supervision of the nurses employed. The manager and the projects manager both confirmed that the senior nurse is now responsible for this. Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 22 The previous key inspection report highlighted the need for the home to revise their financial systems for the management of residents’ money. Samples of financial records were seen and found that all monies were being accurately recorded and relevant invoices kept for residents spending. The system was being audited and monitored on an ongoing basis to ensure that money balances are correct. Risk assessments for the level of support residents needed to manage their finances had been completed and actions/support recorded. The manager acknowledged that they hold residents’ cash cards and PIN numbers. Also that they supported residents to make decisions on spending money on personal items and withdrawing monies. However, there was no policy and procedures covering the management of residents such as the financial procedures, handling residents cash cards securely or how to make decisions regarding spending. The home must ensure that to protect residents they must develop a relevant policy and procedure covering all aspects of managing residents’ finances and the support and systems in place to protect residents. The requirement was reiterated. Although the home does not have a formal quality assurance programme it does have several ways to seek residents views on the home. The registered provider undertakes monthly visits where they speak to residents and gain their views on the service. In addition they also speak to relatives and staff and look at the standard of the environment. The manager holds bi-monthly meetings where residence have the opportunity to raise their views and feeling about the service and have raised issues such as social and leisure activities and meals. Evidence was provided, in the pre inspection questionnaire, that the home had appropriate service contracts in place for equipment and installations used in the home and that servicing is undertaken at the required intervals to ensure the safely of residents. Beechill Nursing Home DS0000066845.V339094.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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 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 3 X 2 X 2 3 X 3 Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP2 Regulation 5A 5B 13 (4) (c) Requirement Timescale for action 01/07/07 2. OP7 3. OP30 18 (1) (a) (c) (i) (ii) Residents must be made fully aware of their terms and conditions in relation to the topup fee. To ensure the health and safety 31/05/07 of residents risk assessments relating to the use bed rails must be reviewed and further developed to adequately assess the risk of the actual use of the bed rail. 1. Staff must be assessed as 01/07/07 competent to be able to provide the support that residents require to meet their needs and maintain their health and safety. 2. Staff must receive appropriate training to ensure the needs of the people who have additional needs associated with alcohol use are met. (The previous timescale of 30/01/07 had not been met). To protect and safeguard 31/05/07 residents policies and procedures must be developed for managing and recording their personal DS0000066845.V339094.R01.S.doc Version 5.2 4. OP35 12(a) 13 (6) Beechill Nursing Home Page 25 monies and this must include a clear auditing and monitoring system. (The previous timescale of 27/2/07 had not been met). 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. Refer to Standard OP2 OP7 Good Practice Recommendations It is recommended that the information given to residents in relation to the fees charged be reviewed and updated. 1. It is recommended that an assessment of continence needs be completed on admission. 2. It is recommended that the review system be revised to show that the implementation of the care plan continues to meet residents’ needs. 1. To ensure the care needs of residents are being met an accurate record should be maintained of all thickened fluids given. 2. To ensure the continued safe administration of medication it is recommended that the home undertake and keep records of regular audits of the medication administration systems. It is recommended that the home ensure that they evidence the work of the activities co-ordinator in developing and implementing the activities programme. It is recommended that the garden area is made attractive for residents to use and that the waste bins are stored in an enclosed area. It is recommended that the home ensures that they gain evidence that a reference is from a prospective staff members current/previous employers. It is recommended that the home ensure that the induction programme meets the requirements of the Skills for Care Induction Modules. 3. OP9 4. 5. 6. OP12 OP19 OP29 7. OP30 Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 26 8. OP33 It is recommended that a system for reviewing the quality of the service being provided be implemented and that the results of such a quality review are analysed and a report is produced and published based on the results. All staff should be made aware and understand the policy and procedures for managing residents’ money. 9. OP35 Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Beechill Nursing Home DS0000066845.V339094.R01.S.doc Version 5.2 Page 28 - 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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