Inspection on 16/05/07 for Beechlawns

This inspection was carried out on 16th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beechlawns 27/01/09

Beechlawns 28/01/08

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Beechlawns 20 Wood Street Wollaston Stourbridge West Midlands DY8 4NW Lead Inspector Jayne Fisher Key Unannounced Inspection 16th May and 17 May 2007 09:00 Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 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 Beechlawns DS0000069593.V338840.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 Adults 18-65. 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. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechlawns Address 20 Wood Street Wollaston Stourbridge West Midlands DY8 4NW 01384 835050 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) Select Health Care (2006) Limited Mrs Anita Wendy Homer-Golden Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: Learning Disability (LD 7) The maximum number of service users to be accommodated is 7. 2. Date of last inspection 6 December 2007 Brief Description of the Service: Beechlawns is a large detached property located in the Wollaston area of Stourbridge. It is situated in a quiet residential area and is within walking distance of the local village, which has numerous shops, public houses and other local amenities. The town centre of Stourbridge can be accessed by public transport. There is a small car parking area at the front of the property. The gardens are situated to the rear and side of the property. There is a ramp leading to the front door and into the garden. The Home was initially registered in 1993 to provide care for eight adults with learning disabilities. Resident accommodation is on the first and ground floor. The Home does not have a shaft lift or stair lift. All users accommodated on the first floor are fully mobile. There are seven single bedrooms. Residents bedrooms are all decorated individually and reflect residents differing tastes and personality. Residents can bring some of their own furniture if they wish, and on discussion with the Manager. The Home has two bathrooms one with a hoist and overhead shower. There are toilets located on the ground and first floors. There are two lounge areas and a dining room. Beechlawns provides care for residents with a range of learning disabilities and with complex communication, mental and health care needs. A statement of purpose and service user guide are available to inform residents of their entitlements. The manager was unable to supply up to date fee information. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place between 09.00 a.m. and 6.30 p.m. and was undertaken by two inspectors with the home being given no prior notice. A pharmacist inspector also visited the home on another day. We spoke with the manager and three staff members. Although we sent out questionnaires for people to fill in prior to our visit, these were not completed as the manager unfortunately did not receive them. We met all 4 people living at the home, and although they did not want to talk to us directly, we were able to see them interact with each other and with the staff members. We looked around the home, examined records and observed care practice. We also looked at all of the information that we have received about this home since it was last inspected. What the service does well: What has improved since the last inspection? There have been a number of improvements which have taken place since the new owners took over the running of this home on 12 March 2007. These include: providing residents with a range of information about the services to which they are entitled, and carrying out assessments to ensure that their needs can be identified and met. The manager is trying to enlist the support of speech and language therapists in order to help build communication programmes for residents. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 6 Staff have drawn up a list of residents’ likes and dislikes with regard to activities and outings and new ‘activity menus’ have been established. There are improved systems for monitoring activities. Residents now have more opportunities to participate in interesting and stimulating activities in the home and local community, unfortunately most of these are refused. Staff told us that residents are going out more frequently than they did before, but in general thought they should still go out more regularly. Staff told us they are finding it difficult to motivate people, possibly as they are unused to having these types of choices. Staff need more guidance and training and specialist support should be considered. Meals and mealtimes are improved and there are now pictorial menus in place. There are systems in place to find out if residents enjoy their food. Residents are now given more choices about what they would like to eat but again are unused to having such opportunities and need staff to help them in this area. Improvements have been made towards management of residents’ medication thereby ensuring their safety with only a few items requiring some further attention. There are clearer systems in place to help residents make their concerns known and these are discussed at residents’ meetings. There are safer systems in place with regard to managing residents’ finances. Residents are no longer being charged for items which are normally included as part of their fees which are paid by the Local Authority. A major refurbishment programme is currently underway in order to provide residents with a more comfortable and safer place to live. A huge investment has been made by the new owners in this area. The former shared bedroom is being converted to a single bedroom with an ensuite facility, the bathrooms are being refurbished and repairs are being made to residents’ bedrooms. A new boiler has been installed and there are improved fire evacuation systems to help people exit the building safely. All staff and the majority of agency staff have been told about these new procedures. The home is cleaner and there are improved systems in place to promote infection control with only a couple of areas requiring further action. There are extra staff on duty to support residents. Staff are being supported to undertake vocational training. There are more staff meetings and more frequent supervision of staff to help and guide them in supporting residents. The new owners have a comprehensive quality assurance system that is now starting to be introduced so that people can be assured that their views are taken into account and they have some control over the development of the home in which they live. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 7 Food hygiene practice is improved and there are systems in place to promote peoples’ health and safety with only a couple of issues needing further attention. What they could do better: 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. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is now an informative statement of purpose and service user guide in place although both need slight expansion to provide residents with more information about the service. All existing residents have now all been assessed in order for staff to be able to ensure that they can met their needs. Terms and conditions of occupancy are being drawn up with the new owners but residents have yet to be issued with the fully completed documents. EVIDENCE: We looked at the statement of purpose and service user guide which have been produced by the new senior management team. These documents contained lots of information but there were a couple of areas which needed expansion as we discussed with the manager. For example, there are no details of the size of rooms or relevant qualifications and experience of the registered provider in the statement of purpose. The service user guide also provides useful information to prospective and existing residents. However details of funding arrangements and payment of fees need to be included as well as any additional costs which may be incurred Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 10 by the resident. It is also recommended that this is reproduced in a format suitable for residents. The new owners have introduced comprehensive assessment tools so that new and existing residents’ needs can be measured and met. We looked at these and saw that they had been fully completed by staff in March and April 2007. We saw that residents have been issued with new contracts; there are some details which still need to be inserted into the contracts such as fee levels which the manager told us she is still awaiting details of. The manager told us that residents do not have to pay for their own toiletries as this is included as part of their fee, but that they do have to pay for toiletries if they do not like the ones provided by the home. This needs to be included in the additional charges section of the contract. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst some improvements have taken place with regard to care planning and risk management systems, further work is needed in order to provide staff with clearer guidelines in supporting residents and to ensure that documents accurately reflect the needs of the residents. EVIDENCE: We looked at two residents care plan folders and saw that there has been some progress made since the last inspection. The manager has actively tried to arrange for relatives of residents to attend meetings in order to review their care plans. Staff have started to complete person centred plans with residents, relatives and other significant professionals, although the ones we saw are not yet fully completed. The manager was able to demonstrate to us that she is actively trying to arrange for social workers to visit to participate in review meetings. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 12 Whilst we saw that there were a range of care plans in place with identified short term and long term goals, some care plans were out of date and contained conflicting information. For example, one person had a care plan in place entitled ‘encourage toileting regime’ this was dated 18 April 2006 but had not been reviewed since the date of implementation; it had not been updated to reflect the changing needs of the resident, who now has a catheter in place. There was a separate written ‘procedure for catheter care’ which needed to be included as part of any care plan regarding continence management. In addition there was also a care plan regarding ‘the patency of the catheter’. There was a care plan in place regarding the resident’s night time support which stated that he should be checked every two hours but made no mention that he required his catheter bag to be checked and emptied. The manager told us that she had been advised by the district nurses to carry out checks during the night at one and a half hourly intervals which in turn contradicted with advice in the ‘procedure for catheter care’ which stated that the leg bag needed emptying every 3-4 hours. The two residents we case tracked both have problems with mobility and had risk assessments in place regarding this subject, but neither had a care plan regarding their mobility. (Although confusingly one resident’s care plan entitled ‘support at meal times’ did allude to problems with mobility). We noted from one person’s assessment that they had a maximum of four cigarettes per day. The manager told us that this had been agreed with the resident as part of a management of behaviour regime but admitted that she had not yet had time to establish a care plan regarding this subject. Reassuringly, when we spoke to staff they were aware of these strategies which had been agreed with the resident. Although both residents can exhibit challenging behaviour there were no care plans in their ‘daily files’. We did find behavioural management plans in their second folders which the manager told us was an ‘information file’. These were dated 2005 and had not been reviewed. (See further comment in standard 23). Care plans contained limited information about the communication needs of residents and there were no detailed communication packages. On the day of our visit the manager had arranged to meet with an advocate to discuss the possibility of enlisting support from speech and language therapists which is a good initiative and needs to be pursued. There were pictorial advocacy leaflets in residents’ care plan folders. We saw that residents are no longer paying for items that should be provided by the home in respect of activity equipment. We looked at risk assessments and found the current system slightly confusing. One person had a moving and handling risk assessment and an assessment for risks ‘posed to the handler’. Neither of these identified the risks to staff or the resident as we saw that on occasions he needs assistance in getting up from a chair. Staff told us: “yes he can pull a bit”. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 13 The new owners have introduced a risk assessment proforma. It is apparent from reading the risk assessments which staff have recently completed, that they do not understand this new system and require some training. For example, there was a risk assessment for one person entitled ‘activities/outings’. The ‘personal requirements and risks involved’ section had been completed by staff stating “staff and X. X requires 1:1 support whilst doing activities and a minimum of 1:1 for outings”. It is not clear what the actual risk is, or to whom. There was a risk assessment in place entitled ‘community’. Staff had completed the risk section as ‘wheelchair assessment for any distance’. Again, this does not in itself constitute a risk. Residents had risk assessments in place entitled ‘medication’, but the risk section of the proforma had been left blank, so it was not possible to determine what the risk actually is. Another risk assessment entitled ‘behavioural risk’ cited preventative measures as ‘staff to follow care plans for behavioural management’. This needs to be expanded and should include some reference to staff training. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. More efforts are being made to offer residents a range of stimulating and meaningful activities, however staff are still finding difficulty in trying to motivate residents and encourage their participation. Staff support residents to maintain important links with their families. Residents are provided with a varied and balanced diet with staff trying to ascertain whether residents have enjoyed their food, although some further consideration needs to be given as to how to enable residents to make choices. EVIDENCE: One person attends a day centre. The manager told us that she is trying to explore opportunities for a second person to attend a day centre and has enlisted the support of the psychiatrists in finding a suitable resource. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 15 Since the last inspection visit the manager has introduced a new system for recording and monitoring activities. There is now an ‘activity menu’ for each resident which has been based upon their individual preferences from a list of their likes and dislikes, which has been established by staff. The ‘activity menus’ include a range of independent living skills, social and leisure activities plus outings into the community. We advised that the activity menu is expanded to include Saturdays and Sundays in order to make monitoring easier. There is no pictorial activity board and the manager acknowledged that this needs to be reinstated. During interviews staff reported that they are still finding it difficult to motivate residents to participate in activities. There would appear to have been a lack of meaningful activity for a number of years for these residents therefore making it difficult now for staff to attempt to gain their attention and interest. This is a skilled task, and staff have not had the training or guidance in the past regarding this aspect of support. We looked at the activity menu sheets which demonstrated that while activities were offered, the majority were refused as residents had displayed ‘no interest’. There are no individual activity programmes and staff complete the activity menu sheets retrospectively. We discussed with staff whether they thought it may be helpful to have some more structured, planning and co-ordination especially for those staff who are new to the service. It is suggested that consideration is given to identifying a member of staff to be responsible for coordinating and planning of activities and to provide them with suitable training. It is also recommended that specialist advice is sought for example from Occupational Therapists. Residents are offered a range of community based outings. Staff told us how they had recently taken residents out to a local disco but they appeared not to like it. Examination of records demonstrated that residents are able to go out as individuals or in groups. Generally residents go out once a week, usually food shopping. We saw that during three consecutive weekends one resident had not participated in any community outings. Staff told us that the resident does not like to go out at weekends because of crowds and being unsteady on her feet. It was not possible to determine if outings were offered and she had declined them, (another reason for expanding the activity menu to include weekends). We saw that another resident had been out at the weekend for a pub lunch. During interviews staff told us that residents had increased access to the community, but felt that they should still go out more. They said that residents often refuse to go out and lacked motivation (which was confirmed on examination of activity records). This would lead us to believe that they have low expectations in this area due to limited opportunities in the past, and that staff need to endeavour to continue to try and encourage them to participate in the local community. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 16 We saw lots of evidence of family contact. There is a special record sheet for this purpose. There were also records in people’s daily reports whereby they had been visited by their family members. We saw that daily routines promote residents’ independence and that they have unrestricted access around the home. For example, residents could choose which communal area to sit in (there are two lounges and one dining room) and one resident frequently went outside to take walks in the garden. Staff were seen sitting spending time with residents on a one to one basis, chatting and watching television together. We saw that care plan folders contained a range of ‘consent’ forms. Residents have been given the choice of holding their own bedroom door keys and staff to open their mail on their behalf. There are pictorial questionnaires to determine their wishes in this respect. Some have not yet been completed and the manager explained that she was waiting for contact from relatives. We saw that on occasions relatives have signed on behalf of residents in order to give their consent and indicate their agreement. We discussed this with the manager and the implications of the Mental Capacity Act 2005 in that relatives cannot make decisions on behalf of residents but staff can do so if they can demonstrate it is in their best interest. It is recommended that staff receive training in this area. We did not observe a meal time as residents went out for their lunch but we did see staff preparing an evening meal of lasagne. We were pleased to see that staff were making this themselves rather using a convenience ready meal. Staff told us “we normally make all our own meals”. New pictorial menus have been devised and staff have drawn up a list of residents’ likes and dislikes to demonstrate that the menu plan is based upon residents’ preferences. There are records of residents’ daily choices including supper and in addition there is a daily audit completed with the resident to determine whether they enjoyed the meals provided, which is an excellent initiative. There was plenty of food in the home and examination of records demonstrated that staff were following the daily menu plan. We did note that all residents appear to eat the same things each day despite there being a choice available, we discussed this with the manager. We also recommended that perhaps ‘taster’ sessions could be organised from time to time in order that staff could assess whether residents’ tastes have changed and give them the opportunity to try different foods. The manager said that she thought this was a good idea to try. We saw that nutritional screening tools have been completed. We discussed with the manager that it would be beneficial to identify residents’ ideal body weight using a tool such as the body mass index calculation. The manager agreed that this would be a useful aid to staff. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. More efforts are needed to ensure that residents receive personal support according to their needs and wishes. There are good systems in place to monitor most of the health care needs of residents, only slight improvements are needed. Medication management is also improved offering residents greater safeguards although there are a couple of areas which require more attention. EVIDENCE: Residents are able to choose when they wish to get up. When we arrived in the morning at 9.00 a.m. two residents were still in bed. There are records of residents’ preferred getting up and going to bed times. We saw detailed care plans regarding how residents are supported with personal care. The home employs both male and female staff so that residents are able to choose which gender to support them. There are ‘consent’ forms regarding same or cross gender care. These had been established in 2005 and had been signed by a former manager. It is recommended that these are reviewed, and where residents cannot verbally communicate their wishes, their observed preferences should be recorded. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 18 We saw that three residents’ assessments stated that they did not require any checks during the night time. A fourth resident’s assessment said that he did require night time checks but did not stipulate the frequency. We looked at ‘residents’ night monitoring’ forms which are completed by night staff and indicate that all residents receive hourly checks. The manager told us that staff did not enter bedrooms but simply listened outside their bedroom doors to determine if they were asleep or awake. She agreed with us that this was an unnecessary task. However, upon checking the records we saw that night staff were recording whether or not the resident had changed their position during the night which demonstrates that staff are entering their bedrooms. The manager agreed to review this practice. The manager told us that one resident has been assessed by an Occupational Therapist (O.T.) as to whether she needed a wheelchair. We were told that the O.T. had thought this unnecessary but would not supply a wheelchair for use outside. The manager said that relatives had agreed to purchase one for this purpose on behalf of the resident. We suggested that before this takes place the manager speaks with the O.T. to confirm that a wheelchair for outside is needed by the resident. A second person is also awaiting an assessment from an O.T. because of deteriorating mobility. The manager told us that there are plans to provide a stair lift for this person as his room is on the first floor. We saw that the resident needed assistance from staff upon rising from his chair. We asked that the technique used by staff be discussed with the O.T. as a more suitable rocking type motion may be more appropriate. On the whole there are good systems in place regarding monitoring of health care needs. We saw that there is a very useful ‘health check over view’ sheet. This lists a number of appointments and the outcomes. On occasions staff have made reference to a more detailed note in the daily reports and upon checking we saw that these did contain detailed reports. We saw that residents have received regular eye tests, chiropody, dental checks and have had a hearing check. There were also regular appointments with doctors and district nurses. Residents are receiving monthly weight checks. We saw that the ‘Priority for Health Screening’ tool remains only partially completed for one person. A second resident had no part of the booklet completed including the section that should have been filled in by support staff. The new area manager has made contact with the relevant agencies to request their assistance with completion of this booklet. The manager has written to the doctor requesting access to well person clinics. The doctor has replied that this resource is not available but has offered appointments for a ‘new patient check’, mammograms and cervical screening. It is recommended that these screening opportunities are pursued on behalf of residents and if necessary to enlist the support of the community learning disability nurse. The manager has agreed to do so. The manager told us she Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 19 was not happy to put in place systems whereby staff monitor through observations any abnormalities due to potential breast and testicular cancer. We discussed how this could be achieved unobtrusively or by amending care plans to raise staff awareness. We saw that continence assessments have been completed for residents. The manager told us that one resident is having one and half hourly checks during the night time to check if his catheter bag requires emptying. This conflicts with the frequency identified in the catheter care procedures. We suggested that this may excessive and unnecessary and we advised that this be discussed with the district nurse. We looked at fluid balance charts which showed some anomalies with large inputs but small outputs. We suggested that a better system of recording would be more beneficial and the manager agreed to put this in place. We looked at medication as part of case tracking and found that on one occasion a resident had been prescribed a treatment and although this ointment had been entered onto the medication administration record (MAR) sheet, there was no staff signature to confirm that it had been given. We saw that there are guidelines in place regarding ‘as and when required’ (PRN) medication. These lacked sufficient detail as they did not include the maximum dosage to be given in a twenty four hour period and did not include guidance as to how many consecutives days the medication can be given before further medical advice is needed. The manager told us that she had already written to the psychiatrist requesting further guidance in this matter. We saw that two prescriptions were pinned to a notice board in the kitchen area and asked the manager to ensure that these are held more securely. Pharmacist Inspector: During the inspection the manager was spoken with who was very helpful. Four service users medicine charts were looked at and one service users care plan was looked at. A medicine policy was available which was accessible to staff. It included information on how to administer medication, however it did not reflect how medication was actually administered to service users in the service. There were also procedures for the receipt and disposal of medication, selfadministration and ordering of medication. There was no procedure to follow in the event of an error involving medication. Medication storage was seen within a locked cupboard, however the padlock did not ensure that the doors were completely secure for safety. Creams and ointments were stored safely and separately from tablets and liquids to prevent contamination. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 20 The manager confirmed that staff who administer medication to service users had completed a ‘Safe Handling of Medication’ course. A document was seen which had been signed by members of staff agreeing to administer medication to service users. The manager said that none of the service users managed their own medicines. The current months medicine charts were seen, which were pre-printed by the pharmacy. The medicine charts did not state the allergy status of the service users. The medicine charts were all recorded accurately with two staff signatures to document administration of medication. Sometimes staff had hand-written new instructions or new medications onto the medicine charts, which had been double- checked and signed for accuracy by two members of the staff team. The receipt of medicine was recorded onto the medicine charts. The date of opening on the original container (box or bottle) or creams and ointments was not always recorded which meant that it was not always possible to accurately check that medication had been given to service users as prescribed by the GP. It was observed that there was an open and used tube of a cream available in the cupboard but there was no date of opening recorded. A disposal record was available at the inspection, which showed that unwanted medication was safely returned to the pharmacy. The care plan for one service user was seen together with their medicine chart. There was a printed document that showed the current prescribed medication. The use of an abbreviated Latin term ‘PRN’ (when required) did not state which medicine was to be administered for the service users behaviour management. The service users healthcare visits were recorded and up to date. It was relatively easy to track any advice or changes made to the service users’ medication. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 21 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There is a complaints procedure and information now available for people to understand how to access this process, although recording systems need slight improvement. There are now written policies and procedures in place to safeguard adults from abuse. However, there are still some practices which have the potential to place residents at risk of harm. EVIDENCE: The new owners have introduced a comprehensive complaints procedure and this has been reproduced in a pictorial format for residents. The manager told us that she has not given a copy of the pictorial format to residents but has explained and shown them the new formats. There has been one complaint since the last inspection which has been recorded on the new complaints format. There is in addition a monthly monitoring sheet as is good practice. Whilst the complaint log demonstrated the action taken and the outcome of the complaint made which was not upheld, it did not explain the nature of the complaint so we had to ask the manager for this information. The manager agreed that she would include this in the complaint record. We saw that the owners have also introduced new policies and procedures regarding vulnerable adult abuse. There was also a copy of the Local Authority multi-agency procedures ‘safeguard and protect’ plus a copy of the ‘no secrets’ guidance available at the home. There has been one alleged and potential allegation of vulnerable adult abuse at the home since the last inspection. The allegation was referred to the Local Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 22 Authority safeguarding manager who made the decision that appropriate action had been taken and not to instigate a formal investigation. Although there were a number of statements taken from staff by the manager and some handwritten notes, we discussed the importance of keeping a clearer audit trail. We were concerned to find that a senior member of staff failed to follow the correct procedures for reporting alleged incidents of abuse, and as a result the agency worker against whom the allegations were made, was allowed to work a further shift at the home before appropriate action was taken by the manager. The manager told us that she had taken action regarding the failure to follow the vulnerable adult protection procedures, however she had failed to maintain a record. We saw that staff have undertaken training in vulnerable adult abuse but according to their certificates this training is now out of date. Not all staff had signed the adult protection policy. We were also concerned to find that agency staff have been working at the home without the required police clearance checks and forms of identification. (See further comment in standard 34). We saw a daily report completed by staff on 5 May 2007 which gave details about a resident displaying verbal and physical aggression when staff were trying to assist him to bed. There is a separate behavioural monitoring sheet but this had not been accurately completed by staff who failed to record the incident. We discussed our concerns with the manager over the daily entry written by staff as it did not give any details about what action was taken by staff to support the resident and diffuse the situation. Staff had recorded that the resident had calmed down by 1.30 a.m. but there is no record of the time when the resident first became distressed. As he normally goes to bed by 9.00 p.m. it would seem that this episode had continued for a considerable period of time. There was no record to demonstrate why staff had failed to follow the protocol for the administration of ‘as and when’ required medication. The manager agreed to investigate the incident further. We looked at behavioural support plans which were dated 2005 and had not been reviewed since the date of implementation. These were filed in the ‘information’ folder. There were no other up to date plans found in the ‘daily’ folder. We saw that some of the strategies identified in the behavioural support plans were wholly inappropriate and punitive. They had not been agreed with a multi-disciplinary team. The manager reassured us that they were not in active use and agreed that they were inappropriate. She told us that she would remove them and establish new behavioural support plans immediately and that she would then get these ratified by a multi-disciplinary group. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 23 We looked at residents’ finances and carried out an audit of money which tallied with the records maintained. The recording and accounting systems are much improved and there is now an internal auditing system. We made a number of requirements at the last inspection regarding residents’ monies, policies and procedures, plus taking action regarding allegations made about former management. These have now been withdrawn as they are no longer appropriate given that new owners have taken over. For example, we could find no evidence that residents are being charged for their own activity equipment. However, previously residents have been charged for their own bedroom furniture and there was an outstanding requirement for the former owners to reimburse them for those items which are normally included as part of the basic contract fee. This does not appear to have taken place. It is recommended that this is discussed with the Local Authority commissioners to see if they wish to pursue this further with the former owners. Written records must be maintained of outcomes of discussions and actions. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 24 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A major refurbishment programme is currently well under way in order to provide residents with a more comfortable and homely environment. Infection control practice is much improved with only a couple of areas requiring attention. EVIDENCE: We toured the building and saw that a major refurbishment is ongoing. A number of improvements have already taken place or are underway which include refurbishment of the ground floor bathroom, refurbishment of bedroom 1 to include fitting of ensuite, replacement of the boiler, redecoration of bedrooms, doorframes being repaired, signage for a fire exit and replacing of rotten handrail on stairs. Advice has now been sought from a fire safety officer regarding the evacuation route and a new procedure has been established. During interviews staff were all aware of the fire evacuation procedure. Some requirements which we made previously have now been withdrawn but will remain as recommendations until they are fully completed such as the Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 25 need to establish a written maintenance and refurbishment programme and to forward this to the Commission. We looked at all communal areas and found these to be warm, comfortable and clean. There were a few new items which we raised with the manager and which need attention. These included: providing a window restrictor to bedroom no. 7 which had been removed (this was rectified when we pointed it out to the manager). seeking advice from the fire safety officer with regard to the door opener in bedroom no. 7 (a hook and eye attachment had been fitted in order to keep the door open for the resident who had deteriorating mobility) treatment of rust on inside of microwave and radiator in the kitchen. We noted that the bedroom doors were quite stiff and hard to open easily with one hand using the Yale type locking system. Given that residents are becoming older and frailer we suggested that the manager might want to consider if different door furniture may be necessary in the future. We saw that there have been good improvements towards improving infection control practice since we last visited. For example, the manager has sought the advice of the Health Protection Agency and urban waste department with regard to the management of clinical waste. Appropriate procedures are now in place and guidance displayed. Cleaning schedules have been expanded for the laundry, toilets and bathrooms. We did suggest that a copy of the cleaning schedule for the laundry should be stored or displayed in the laundry area itself. We raised only a couple of areas that needed attention. There was a slight malodour in bedroom 4. Staff reported that they had recently detected this themselves. The manager agreed to try and determine the cause and then take appropriate action. Bedroom no. 2 and the upstairs bathroom did not have a ready supply of hot water. This may be due to the ongoing refurbishment work and the manager agreed to monitor this. There is mould appearing all over the laundry walls and ceilings and there is a damp odour. The manager told us that the extractor fan had become broken and that once repaired the area would be redecorated. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff would benefit from more specialist training in order to meet the complex needs of residents. Staffing levels have been increased in order to meet people’s needs. The standard of vetting and recruitment practices have not improved with appropriate checks not being carried out, and potentially leaving residents at risk. New staff would benefit from more structured induction before starting to work with residents. EVIDENCE: The home employs ten support staff; only three staff have completed an NVQ II or above qualification. There is evidence however that three staff are currently undertaking a vocational qualification. Staff still require specialist training. They are currently completing person centred planning booklets with residents but demonstrated little knowledge regarding the principles of person centred approaches and agreed that they needed training. For example, one person was asked to explain the basics of person centred planning and stated “I don’t know, I’d look in the book”. When asked whether or not they had been provided with training in vulnerable Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 27 adult abuse the person stated “no I don’t think so, although I might have done some training at Merry Hill”. Only two staff had training certificates to confirm that they had received training in managing challenging behaviour. There is an outstanding requirement to provide staff with training in nutritional awareness which has now been made a recommendation. There were serious concerns at the last random inspection regarding poor staffing levels and these have now been increased. There are three support staff on duty per day time shift and the manager is now supernumerary. There are regular staff meetings. We looked at a staff file of a new member of staff who had been recruited before the new owners had taken over the running of the service. We found some discrepancies. For example, there was a gap in employment history with no written explanation. There were two written references but one of these was supplied by a former colleague rather than the manager of the establishment where the person had worked previously. There was no photograph and no record of any training undertaken. The application form had not been fully completed with only one referee being given. We have been informed by the area manager that a review of all staff files have been undertaken by the new personnel officer and missing information will be collated. We looked at agency staff records. We found that in January 2007 a member of staff had allowed an agency worker onto the premises without identification and without confirming that they had undergone police clearance checks. The member of staff had written “not had I.D. and CRB number today, will get next time on shift”. Some agency staff had a ‘carer’s profile’ which contained details of experience and training, but unfortunately not all staff had these in place. There were some gaps in the agency staff records. For example, one person had a criminal record bureau (CRB) disclosure check reference number but no date of validity to verify that the check had been undertaken within the last twelve months. We saw that there had been some improvements in the last month with regard to obtaining the required information; the manager told us that a different agency was being used. Whilst some agency staff had appropriate clearance checks in place, they had no previous experience of supporting people who have a learning disability, and did not have relevant training. For example one agency worker who had recently been employed only had training in moving and handling. Staff have not received induction and foundation training by an accredited learning disability awards framework (LDAF) provider. We looked at a new Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 28 member of staff who received an in-house induction. This was carried out in one day and there were sections which had been left blank by the supervisor. A new training and development plan is being established by the new senior management team. Once completed they will forward this to us. We saw that some staff have training and development assessment and profile but not all were fully completed. Two staff have received training in equality and diversity but others have yet to undergo this training. We looked at supervision records and found that the frequency of staff supervision has been improved. There is also good progress at ensuring all staff receive an annual appraisal, although we saw that one staff member had not undergone an appraisal since 2005. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 29 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The overall management of the home is starting to improve with the manager and her staff team now trying to raise standards so that residents’ health, safety and welfare is better promoted. There are still some improvements to be made but hopefully with the support of the new owners these will be undertaken. EVIDENCE: The registered manager has been in post for twelve months. During interviews staff told us that she was very approachable and helpful. Comments included: “She’s very fair and willing to help”. “She’s really good and always finds time for you”. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 30 As we discussed during our visit the manager would benefit from up dating her knowledge and skills in some areas for example with regard to new legislation such as the Mental Capacity Act 2005, and person centred planning. The manager told us that she is starting to implement the new owners quality assurance systems. Questionnaires had been sent out to relatives and stakeholders plus there are pictorial questionnaires for residents to complete. Once results have been collated an annual development plan needs to be established. There have been a number of improvements made to food hygiene practice and all the requirements identified in the Environmental Health report have now been addressed. The kitchen cleaning schedule has been expanded and there are systems in place to monitor that foods are stored appropriately. We could only find one recorded fire evacuation drill for 2007. Three staff had participated in this drill and residents are now given the opportunity to also take part in the evacuation. The majority of agency staff (although not all), have signed an induction sheet to say that they have been instructed in fire evacuation. We sampled maintenance and service records and found these to be largely up to date with a couple of exceptions. We could find no monthly checks for the testing of the emergency lighting system. There was no up to date gas safety certificate however the manager told us that this was awaited as the new boiler had been installed. We suggested to the manager that as there have been repairs to the water system that she enquires as to whether the system needs to be chlorinated and a bacterial analysis undertaken. She agreed to do so. We saw some risk assessments for safe working practices. There was no risk assessment undertaken for the refurbishment and redecoration work which is currently being carried out and the manager agreed she would need to ensure that one is established. It was difficult for us to gain an overall picture with regard to staff training. We looked at training certificates and found these were either out of date, or were not in place to cover all of the required mandatory training needed by staff. We have already discussed this with the senior management team who have given us an undertaking that they are going to repeat all training for staff in the near future as they felt that previous training provided was not to the standard they usually expect. As already stated, they have promised to send us an updated training plan. Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 1 33 3 34 1 35 1 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 x LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x 2 X 2 X X 2 x Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 32 YES Are there any outstanding requirements from the last inspection? 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 YA23 Regulation 13(6) Requirement Timescale for action 01/08/07 2. YA23 13(6) Arrangements must be made to ensure that all staff have a clear understanding of adult protection and whistle blowing procedures. This is to ensure that residents are not at risk of harm or abuse. Arrangements must be made to 01/08/07 ensure that physical and verbal aggression by a resident is understood and dealt with appropriately by staff. This is to ensure that residents are not at risk of harm. 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 YA1 Good Practice Recommendations To expand the statement of purpose to include all details required by the Care Homes Regulations 2001, Regulation 4 and Schedule 1 for example details of room sizes and qualifications and experience of the registered provider. To expand the service user guide to ensure that it contains Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 33 all of the details required by the Care Homes Regulations 2001, Regulation 5 such as details regarding fees and who will be responsible for paying them and information regarding additional charges. To consider producing the service user guide in formats suitable for residents. To continue to fully complete and issue new statements of conditions of residency to all residents. These should contain details of fee levels and be more explicit as to what is considered an additional charge. To ensure that care plans cover all aspects of personal and social support and healthcare needs as set out in the National Minimum Standards 2. To ensure that care plans are reviewed at least six monthly, or as and when residents’ needs change with the involvement of the resident, relative, advocate and other significant professionals. The Home should continue to introduce and complete a person centred approach (such as essential life style planning) and reproduce care plans in formats suitable for service users. 4. 5. YA7 YA9 To continue to pursue referrals to speech and language therapists with regard to support in establishing communication passports for residents. To expand risk assessments in order to ensure that they more accurately describe who is at risk, the nature of the risk, existing controls measures and any additional measures which are required. To consider identifying a member of staff to take responsibility for planning and co-ordinating activities and to provide suitable training. To consider referrals to specialists for support with introducing activities such as O.T.s To re-establish a pictorial activity board or programme. To consider expanding the ‘activity menu’ sheet to include weekends. To continue with attempts being made (by the senior area manager) to try to ensure that the cost of residents’ annual holiday is provided as part of the basic contract price. To continue to ensure that any restrictions on choices are DS0000069593.V338840.R01.S.doc Version 5.2 Page 34 2. YA5 3. YA6 6. YA12 7. YA14 8. YA16 Beechlawns 9. YA17 negotiated with all individual service users and advocates. Outcomes to be recorded in service user plans and reviewed regularly: for example the decision to not to provide bedroom door keys, front door keys, and the opening of service users mail. If residents cannot give their consent, then staff should consider making decisions in their best interests as in compliance with the Mental Capacity Act 2005. To consider calculating residents’ ideal weight utilizing a Body Mass Index scoring system and including this on nutritional screening tools. To consider introducing ‘taster’ sessions to help in determining residents’ choices and preferences. To review consents from residents with regard to same or cross gender personal care. Outcomes to be recorded in individual care plans. If consent cannot be gained then people’s observed preferences should be recorded. To review the practice of hourly checks undertaken during the night for service users. (If this level of monitoring is deemed necessary it must be discussed and agreed as part of a multi-disciplinary team with outcomes and guidelines for staff to be documented in individual care plans). To actively pursue an O.T. assessment for one resident and confirm: that the technique used in mobilizing is appropriate, and whether or not a wheelchair is needed for long distances. To continue to pursue other professionals to assist in the completion of Priority for Health screening tool (and for support staff to complete relevant sections of the booklet where required). To continue to pursue screening for breast, cervical and testicular cancer (enlisting the assistance of the community learning disability nurse if possible). To consider introducing a system for monitoring (or make reference in a care plan), regarding staff being observant for any abnormalities which could potentially relate to breast or testicular cancer. To liaise with the district nurse to determine whether a resident requires one and half hourly checks during the night time for catheter care. To consider implementing separate 24 hourly fluid balance 10. YA18 11. YA19 Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 35 charts. 12. YA20 1. It is recommended that the current medicine policy is reviewed and updated to ensure that the health and welfare of service users taking medication are safeguarded. 2. It is recommended that any protocol for ‘when required’ medication for behaviour management includes details of the medication prescribed in order to ensure that the service users records are accurate. 3. It is recommended that all service users allergy status is documented on their medicine record charts in order to ensure the safety of service users. 4. It is recommended that the date of opening of all medicine containers are recorded and any balances of medicines carried over onto a new medicine chart in order to undertake a medicine audit. 5. It is recommended that medication storage is checked for security in order to ensure that service users medication is safe. 13. 14. YA22 YA23 It is recommended that the complaints log includes details of the nature of the complaint which has been made. It is suggested that the manager seeks the advice of the Local Authority commissioners with regard to bedroom furniture which as been paid for by individual residents when the home was run by the former owners. Written records must be maintained of the outcomes from these discussions and any action taken. To progress with audit of the premises from which a written programme of refurbishment and redecoration must be produced together with timescales for completion. A copy must be forwarded to the Commission for Social Care Inspection. To repair and resurface the driveway and make safe the steps at the rear of the premises. To seek advice from a relevant agency to ensure the building and surrounding grounds complies where possible with the Disability Discrimination Act 2005. To action any recommendations made and to forward evidence of outcomes to the Commission. 15. YA24 Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 36 To seek the advice of the fire safety officer with regard to the door opener fitted to bedroom no. 7 and to record the outcome (or to include in fire safety risk assessment). 16. YA30 To investigate and eradicate the malodour in bedroom no.4. To treat damp in laundry area and redecorate affected areas. To ensure that all care staff hold an NVQ 2 or 3, or are working to obtain one by an agreed date (or the manager can demonstrate that through past work experience that staff meet this standard). To provide staff with nutritional awareness training. To provide management and staff with person centred planning training. To consider providing staff with training in risk management, the Mental Capacity Act 2005 and understanding challenging behaviour. 18. YA34 To complete audit of existing staff personal files and replace missing information as required by the Care Homes Regulations 2001, Regulation 19 and Schedule 2. To ensure that agency staff are suitably qualified and have appropriate experience to work at the home with written records maintained. To ensure that appropriate clearance checks are in place for agency staff prior to them commencing duties. To ensure that staff receive full and structured induction training suitable for the work they are to perform, and in order to meet the specialist needs of the residents. A written record must be maintained at the care home. To ensure that all staff receive equal opportunities including disability equality training. To provide induction and foundation training for staff by an accredited learning disability awards framework (LDAF) provider. To complete an up to date training needs assessment for the staff team and establish a training and development Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 37 17. YA32 19. YA35 plan. A copy to be forwarded to the Commission. To ensure that all staff have an up to date training and development assessment and profile in place. 20. 21. YA36 YA39 To continue to ensure that all staff have had an annual appraisal. To continue to fully implement effective quality assurance and quality monitoring systems based on seeking the views of service users, stakeholders, families and advocates. There should be an annual development plan for the home based on a systematic cycle of planning-action-review. To ensure that all staff participate in a fire evacuation drill preferably every six months with written records maintained. All agency and bank staff must be instructed in fire safety evacuation procedures, with records maintained. To ensure that there are monthly checks with written records maintained of the emergency lighting system. To ensure that risk assessments with regard to safe working practices are carried out including the current refurbishment programme. To seek advice as to whether following the replacement of the boiler, the water system requires chlorination and bacterial analysis. 22. YA42 Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 38 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Beechlawns DS0000069593.V338840.R01.S.doc Version 5.2 Page 39 - 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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