Inspection on 01/07/08 for Beechlands

This inspection was carried out on 1st July 2008.

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

Beechlands 15/09/09

Beechlands 05/02/08

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

CARE HOMES FOR OLDER PEOPLE Beechlands 54 Church Road Huyton With Roby Liverpool Merseyside L36 9TP Lead Inspector Mrs Lynn Paterson Unannounced Inspection 1st July 2008 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 Beechlands DS0000070530.V367348.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. Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechlands Address 54 Church Road Huyton With Roby Liverpool Merseyside L36 9TP 0151 489 0598 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) sharon.skelhorn@blueyonder.co.uk Beechlands Care Home Ltd Manager post vacant Care Home 21 Category(ies) of Dementia (21) registration, with number of places Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - code PC, to people of either gender whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of people who can be accommodated is 21. Date of last inspection 5th February 2008 Brief Description of the Service: Beechlands care home is registered to accommodate 21 older people who experience dementia. The premises comprises of 18 single and 3 double bedrooms, 5 of which have en-suite facilities. Accommodation is provided over 2 floors the upper floor being accessible via a passenger lift. A variety of lounges and sitting areas are available together with a dining area and secure rear gardens. The home is located close to public transport facilities to include rail travel and is within easy reach of local shops and amenities. Fees are £399.91 to £473.37 per week Beechlands DS0000070530.V367348.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 one star. This means that people who use the service receive adequate outcomes. An unannounced visit was carried out over an eight -hour period, and the methods used to assess the service, included discussions with the people living in the home, their representatives, the manager and staff. To ensure that the home is managed in the residents best interests records on staffing and health and safety were looked at. Five care files were randomly selected and assessed in detail to ensure that they contained full information to enable staff to have sufficient guidance to support each individual. Four staff files were looked at to ensure that the recruitment and selection process ensures the protection of the people living in the home. A tour of the premises was carried to assess the environmental standards of the premises and activities of daily life for the people living in the home were observed. The manager completed the Annual Quality Assurance Assessment (AQAA). This is a self-assessment document, which gives information about how the home has improved in the last twelve months, plans for ongoing development of the service and barriers to improvement. What the service does well: Residents families say that the home provides good quality care for the people living in the home. Comments include: “The staff, provide good care for my mother, she is very settled here” “Staff are kind and caring and most of them have been here for while so they are able to provide consistency of care”. Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 6 “Staff care for us as well as our relatives, they are always cheerful and keep us up to date with what is going on”. What has improved since the last inspection? What they could do better: The manager has been in place for a three -month period and it was noted that she has addressed some shortfalls in respect of policies, procedures, staff training and daily recording since her arrival. However improvements are still necessary in the following areas to ensure the home provides a safe environment for the people living there. Care planning information is inconsistent and does not fully detail all aspects of care planning especially in managing challenging behaviours. Whilst the manager is aware of the need to add more information to care plans it must be addressed as a matter of urgency to make sure that all health and personal care needs are clearly set out and agreed by all people involved in their compilation. Records show that medication records have been mismanaged. Ongoing Staff training should be provided to ensure that staff, are fully aware of their responsibilities with the medication process as laid down in the policies and procedures within the home. Staff carry out some activities with the residents however staff spoken with said they did not have much time to arrange activities as they were generally busy carrying out the caring role. An activities co-ordinator must be recruited Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 7 and an activities programme put in place to ensure the residents are provided with stimulation and interest in their daily life. Health and hygiene records for the kitchen area are not maintained and discussions with environmental health officers revealed that they supply a booklet to each care home to enable staff to record daily menus, food and fridge temperatures etc. The manager confirmed that these records have to been maintained and as a consequence staff have been spoken with. The manager understands the need to keep clear records and has given assurances that records will be in place with immediate effect. A tour of the home revealed that the premise’s is in need of a total refurbishment to include fabrics, furnishings and decoration of the communal areas and bedrooms. Bathrooms, kitchen and laundry areas would also benefit from an update. Electrical services are also in need of review. It was noted that the newly appointed manager had not yet been part of the recruitment and selection process in the home. However 2 recently appointed staff files were examined and they did not meet the requirements laid down in the homes recruitment policy. The 2 files were without full references and police checks. This was contrary to the system of recruitment as stated in the home policy.. Staff should not be appointed to commence work within the home until all necessary checks have been completed to ensure the safety and wellbeing of the people living in the home. Staffing levels appeared to be adequate during the day- time hours but records show that on occasion’s staff numbers have been reduced between the hours of 6pm and 8am. Staffing levels must at all times be sufficient to meet the assessed needs of the people living in the home. It was noted that the home were accommodating six extra people as a day care service that were also using the residential care facilities. The home must arrange for any day care to be provided outside of the residential home setting and separate staff must be provided to carry out daily care and support. The manager must ensure that the numbers of people using the services of Beechlands do not exceed the registered number of twenty-one. The manager advised that she had been invited for interview by CSCI to be registered as manager of Beechlands. It is important that the home- owner employ a manager who is registered with CSCI and who is able to fully manage the home and have appropriate funding to ensure the home is fully fit for purpose. Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 8 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. Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 9 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 Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3.6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are confident the home can meet their identified care needs and personal aspirations in a safe environment. EVIDENCE: Examination of four residents care files indicate on the whole the manager carries out formal assessments of prospective residents needs. Discussion with members of the staff team confirms that assessments are carried out and that they receive the information prior to the person being admitted. Discussion with the manager and her deputy confirmed they feel the need to ensure pre admission assessments seek information about the holistic needs of prospective residents’ including life experiences and significant people in their Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 11 lives. This is to ensure the home can meet prospective residents needs and can provide the lifestyle choices a detailed assessments would identify. Examination of a care file of a newly admitted resident identified that needs had been assessed prior to admission. Staff members confirmed that pre admission assessment enabled them to assist the person to settle into the home. The home does not provide intermediate care. Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 12 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. Care planning and risk management strategies currently used by the home do not accurately reflect the care and support needs of residents EVIDENCE: A random sample of four care - plans were viewed. Inconsistencies were noted in the provision of information about residents’ care needs, preferred routines, likes/dislikes or life experiences. However the manager advised that she had noted the inconsistency and had already implemented staff training to ensure residents are not at risk at risk of receiving generalised care rather than a person centred and individualised care service. Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 13 Care plans did not always show the type and amount of support residents’ need with their personal, psychological and emotional needs particularly where specialised needs had been identified such as challenging behaviour. Little information about residents’ life experiences or activities of daily living was recorded. The manager acknowledged these issues and had already identified the need to review care plans and was in the process of gathering information about more suitable care planning formats. The staff team completes daily records however the information recorded is basic with generalised comments being used. Detailed daily records are an important tool in the reviewing of residents holistic needs. Discussions with the manager revealed that she had already identified this and would be providing training for the staff team as part of the review of the care planning system. A sample of risk assessments were looked at they did not provide detailed information about the risks identified. Clear guidance was not provided for the staff team to enable them to offer safe support and supervision to residents who are presenting with risky or aggressive behaviour. However health care needs were recorded on file and all health care appointments, district nursing and General Practitioner notes were held on file. All residents’ medication and the accompanying Medication Administration Records (MAR) were examined and the manager advised that a full pharmacy inspection of medication had been undertaken the previous day. Shortfalls noted included MAR sheets signed to indicate medication had been given however tablets counts revealed inconsistency with the number of tablets remaining. The manager advised that a staff meeting would be held to discuss these concerns, staff refresher training would be put in place to ensure residents health and welfare are promoted. Staff spoken with and observed carrying out care practices with residents revealed they carried out this out with sensitivity and respect and appeared to understand the needs, capabilities and preferences of all the people living in the home. Beechlands DS0000070530.V367348.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, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are no structured social or leisure activities available for residents to engage in resulting in little stimulation for the people living in the home. EVIDENCE: In general the information held in care plans and risk assessments about the social and leisure activities residents enjoy is limited. The manager advised that she is currently in the process of recruiting an activities co-ordinator as she realised that the activities of daily life for the resident is currently very restricted. She advised that wherever possible she would ensure staff obtained information about residents choices and capabilities in respect of hobbies, interests and activities and would endeavour to introduce an activities programme to suit everyone. Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 15 Visitors were observed coming and going from the home and joining the residents in the communal areas of the home. Visitors spoken with and comments gained from questionnaires and telephone conversations indicated that more activities had been arranged for residents in the past but due to home ownership changes and the lack of a designated person to arrange activities, they were currently quite limited. However it was said that because staff of the home fully engage with residents using humour and cheerful banter, residents feel “entertained”. Meal times at Beechlands comprise of the majority residents eating their meals from their armchairs in the communal areas of the home. Observations of lunch- time identified that several residents were in need of full assistance from staff whilst eating and others were given a little assistance but were able to manage their food intake whilst sitting in their lounge chairs. The conservatory at the rear of the premises was set up as a dining area with small tables and chairs in place. Day care users, and three residents of the home used this area. Residents said they did not know what the menu was or if they could have choices. However all residents appeared to fully enjoy their meals with most plates being left empty. The manager said that the cook on duty had been employed for a few months and discussion with him identified that kitchen health and hygiene records were not in place to include food menus, fridge/freezer temperatures. Discussion with the manager revealed that she was aware of some shortfalls in this area and had made requests for them to be addressed as a matter of urgency. Beechlands DS0000070530.V367348.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, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are complaints and safeguarding vulnerable adults procedures in place. However at times risky or aggressively challenging behaviour is not being risk assessed resulting in a negative impact on the resident and staff group. EVIDENCE: Beechlands has a complaints policy and procedure which gives timescales for responses to complaints and concerns raised with the manager. The complaints policy is available in the main entrance of the home for all visitors to see and is provided to each resident on admission. Visitors spoken with said they knew of the complaints procedure but had not need to use it. Record show the home has received one complaint since the last inspection, which was dealt with within the time scales as determined by the home policy. Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 17 Discussions with the manager and examination of training plans show the staff team have either received or are currently awaiting protection of vulnerable adults training. Staff spoken with said they had received updated training in adult protection and felt confident that they would now recognise any signs of abuse. However the lack of detailed risk management strategies leaves residents at risk of not being appropriately supported or safeguarded from risky or aggressive behaviours. It is advised that the manager provides risk assessment and challenging behaviour management training for the staff team as part of the review of the risk management strategies used. Beechlands DS0000070530.V367348.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, 20, 25, 16 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Not all areas of Beechlands provide a comfortable, attractive and safe environment for residents to live in. Resulting in residents not benefiting from an environment that meets their needs. EVIDENCE: A tour of the building indicates significant work needs to be carried out to the fabric of the building to ensure residents live in a pleasant, homely and safe environment. The following issues were raised with the manager: Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 19 Lounge areas The floor is uneven and the carpets are stained. The decoration is worn and damaged. The sofas and chairs are worn and damaged. Throws are used to cover damaged chairs. The entrance hall The skirting is dirty and the carpets are stained. Flooring is uneven. The decoration is worn and damaged. Water damage to many areas of the home. Ceilings that have water stains visible need to be repaired and the source of the damage investigated. Evidence of damp patches in bedrooms are in need of attention. Bathrooms Baths that are stained and damaged need to be cleaned, repaired and if necessary replaced. Tiles that are damaged need to be repaired or replaced. Bath panels that are damaged are to be replaced. Damaged paintwork and plaster is to be repaired. Damaged toilet seats are to be repaired or replaced. Ground floor bathroom drainage cover to be replaced. Carpets Damaged and badly worn carpets are to be replaced. Bedrooms During the site visit bedroom 4 held 3 wheelchairs a weighing machine. The bed was without a secure base the mattress stained and damaged and without a headboard. No ventilation was afforded to the room. Bedroom 3 window overlooks staff corridor and does not afford privacy. Most bedrooms would benefit from redecoration. Bedrooms in the annex area that are equipped with en-suite facilities show signs of damp. The en-suite toilets do not provide adequate ventilation and no regulators are provided on the sink taps. Alarm call system The call system was not functioning and it was necessary for the manager to provide additional staff to ensure the safety of the residents. Whilst the system was seen to be functioning on the second visit to the home it is essential that Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 20 the system is regularly checked and tested to ensure the safety and wellbeing. of the people who live in the home. Kitchen/food storage areas The kitchen is in need of a deep clean to ensure full kitchen hygiene. The larder room food storage area has faulty flooring and shows signs of damp. Conservatory/dining area The floor surface in this area is seen as a potential hazard due to the slippery surface of the tiles. This flooring needs replacing as a matter of urgency. Electrics The cellar of the home is used as a storage area for cleaning materials. On inspection this area was seen to have faulty electrics with wiring hanging loosely from above. The electrics in the home need to have an immediate inspection by a person qualified to do this to ensure that the electrical system is safe for use. Discussions with the manager and deputy highlighted the need to continue with a structured refurbishment and maintenance programme. This is to ensure the living environment is appropriate for the particular lifestyle and needs of the people who live there and is homely, clean, safe, well maintained and reflects their individuality. Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 21 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 home’s recruitment and training processes do not always promote residents’ safety or a person centred approach to their holistic needs. Staffing levels fluctuate and staff are not always able to provide needs led care. EVIDENCE: Examination of training records and discussion with the manager indicates little specialised training has been provided to the staff team regarding residents identified needs. This lack of training may lead to residents receiving inappropriate care and support particularly when they are presenting with risky or aggressive behaviours. The manager said she had begun to identify training needs and had booked some training such as basic food hygiene, first aid and recording of information. She had identified staff who were in need of training updates and had produced a wall chart to show when this training would take place. The manager said that it was her intention to also provide more specialised training Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 22 to ensure residents receive a person centred and individualised care service rather than a generalised approach to their care and support. Discussions with the manager and examination of records show regular team meetings have been introduced to ensure that staff are aware what is happening in the home and to enable them to contribute their views about how the home is managed. The manager said formal supervision has been introduced and now takes place every two months with information handovers taking place at the beginning of each work shift. Staff members spoken with confirmed this information. Staff rotas show that staffing levels are inconsistent and the evening and night staffing levels have been reduced. Resident’s families have commented about the drop in staffing levels and have said that they do not feel that the home utilise an adequate staffing ratio all the time. Discussions with staff identified that some staff shift numbers have been reduced but staff said that as they currently had four empty beds they felt that were able to just about manage to provide adequate care for each resident. They did say however that they were unable to provide activities for the people living in the home due to having to carry out the caring role. Examination of staff files reveal that people have been employed without valid references or full police checks being carried out before being offered employment in the home. The newly appointed manager noted this shortfall and advised that she would ensure that the full recruitment and selection policies were followed at all times. Staff spoken with said they fully enjoyed their work within the home and felt that the change of manager had already effected good improvements to staff moral. Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 23 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, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff, feel the management of the home has improved. However they agree that the health safety and welfare of the people living and working in the home are not fully protected. EVIDENCE: Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 24 The manager has over twenty years experience in care services and has completed the Registered Managers Award. She has recently been appointed as manager of Beechlands, which has been without a registered manager for an eight-month period. The manager had already noted several shortfalls with the running of the home and in the short time since her appointment has worked hard to find solutions to the identified problems. A number of issues have been raised with the manager and her deputy during the site visit to include many environmental and health and safety issue. These are listed in the environment section of this report. The training programme has been reviewed to ensure specialised training is provided to ensure residents are cared for and supported safely and appropriately. This type of training will enable the staff team to gain insight into the impact specific conditions and behaviours have on the quality of life of those individuals. It will provide the staff team with skills and knowledge to enable them to adapt their support and build strategies with individuals to reduce the negative impact of risky and aggressive behaviour on them and the wider resident group. This will enable the manager and the staff team to evidence that Beechlands is run in the best interests of the people who live there. It is a requirement of the owner that they carry out monthly visits to check how the service is operating, however this monthly report was not accessible. It was therefore not possible to check the content of this document. The monthly report is to ensure a broad sample of the operations of the service is undertaken such as talking to residents, looking at samples of records, talking to staff members and touring of the building. This process should be used as part of Beechlands quality assurance process. However neither staff nor residents and their representatives could recall this taking place. It is important that this process is undertaken to ensure the home is run in the best interests of those who live there. The home’s manager has arranged for an annual quality assurance survey to be carried out amongst residents and their families requesting their opinion about the services provided. Discussions with three residents representatives revealed that they have seen positive changes in the running of the home since the commencement of the new managers. Comments included: “The new manager is always around to speak with, she appears to know her stuff and is pleasant and professional”. “The manager has sorted this home out already in the short time she has been here. She has made sure all the relevant documentation is available to us and she keeps us updated with information” Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 25 “The manager has arranged for family meetings to take place and has invited us to social events such as quizzes in the home. I thin k she has turned this place around as before she came it was organised chaos”. Staff spoken with said they were initially wary of change but say that the manager “is clever”, ”knows what she is about”, ”is fair but firm”, “is approachable and a good listener” ”is not afraid to challenge bad practice”, ”is not afraid to do the right thing in respect of dealing with staff”. The general consensus of opinion from the staff is that the manager is open and transparent and had a very hard job to “get to grips with his home”. They feel she has done it well and she has their respect. Health and safety in the home are currently under review and staff, are being provided with refresher training to ensure residents are safe and content within the home. It is essential however that the registered manager of the home, ensures that the numbers of people receiving services in the home does not exceed the numbers stated on the homes registration certificate. Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 X X X 2 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 Requirement Residents care plans must be consistent in their recording and contain all aspects of information about individual need, choice and capability and how these needs will be met. Regular reviews of care should be held and records kept on file. Medication must be managed as per the homes policies and procedures and audits must be in place to ensure that all medication is provided as recorded on the medication record sheet. Quality audits must be used to ensure medication records are accurate at all times. Routines of daily living must be made flexible to meet the needs of the residents. Risk assessment s must be carried out to ensure that any challenging or aggressive behaviours are identified and plans put in place on how to minimise risk to the individual and other residents in the home. The home must be maintained to ensure residents live in safe DS0000070530.V367348.R01.S.doc Timescale for action 01/11/08 2. OP9 13 01/10/08 3. 4. OP12 OP18 15 18 01/11/08 01/11/08 5. OP19 23 (a)(b) 01/11/08 Beechlands Version 5.2 Page 28 6. 7. OP21 OP25 23(a)(b) 23(a)(b) 8. OP26 23(a)(b) 9. OP29 18 10. OP30 18 11. OP31 18 12. OP38 18 environment. Toilet, washing and bathing facilities must be provided that are safe and fit for purpose. The heating lighting and environmental factors of resident’s accommodation must meet the relevant health and safety regulations. The premises must be clean hygienic and systems must be in place to control the spread of infection. The homes recruitment and selection procedures must be followed at all times to ensure the safety and well being of the people living in the home. All the necessary information must be gathered about staff before they are employed to ensure they are suitable to work with vulnerable adults. In this instance staff have been employed without all information being provided. A staff training and development programme must be in place to meet the training needs of the staff and enable them to meet the specialised needs of the residents. The home must employ a registered manager who is qualified and experienced to run the home. The registered manager must ensure the health and safety of all who live and work in the home. This must include not providing accommodation for more than the number of residents as stated on the registration certificate. 01/11/08 01/11/08 01/11/08 01/10/08 01/11/08 01/11/08 01/11/08 Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP33 Good Practice Recommendations The registered owner should ensure that monthly visits are carried out to ensure the views of the people living in the home are recorded and acted upon. Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 30 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 Beechlands DS0000070530.V367348.R01.S.doc Version 5.2 Page 31 - 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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