Inspection on 31/10/07 for Beecholme House

This inspection was carried out on 31st October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beecholme House 23/11/09

Beecholme House 09/09/09

Beecholme House 14/10/08

Beecholme House 24/04/08

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Beecholme House 2-4 Beecholme Avenue Mitcham Surrey CR4 2HT Lead Inspector Liz O`Reilly Key Unannounced Inspection 31st October & 6th November 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beecholme House DS0000070341.V355805.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. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beecholme House Address 2-4 Beecholme Avenue Mitcham Surrey CR4 2HT 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) 020 8648 6681 020 8288 9797 Sharon Egbo Lartey Joseph Benedict Awolowo Kpebi Care Home 15 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (12) of places Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service onlyCare home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category - Code OP (maximum number of places:12) Dementia over 65 years of age - Code DE(E) (maximum number of places:3) The maximum number of service users who can be accommodated is: 15 N/A 2. Date of last inspection Brief Description of the Service: Beecholme House is a registered care home for up to fifteen older people. The building is made up of two houses which have been joined together and extended. The home is situated in a residential area of Mitcham with a small number of shops within a short walking distance. Parking is to the front of the building. Public transport bus services are within a short distance of the home. Two double bedrooms and eleven single bedrooms are available. One bedroom has an en suite bathroom. Weekly fees for this service are £550 to £700 per week. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two regulation inspectors and consisted of two visits to the service, discussions with people who use the service, care staff, the manager and one of the home owners. Surveys were left for people who use the service and staff. Judgements in this report are based on evidence from all of the above sources as well as inspectors observations at the time of visits. This is the first inspection of the home since the new owners purchased the service in July 2007. What the service does well: What has improved since the last inspection? What they could do better: The manager needs to make sure that medication is managed properly and that the correct checks are carried out on staff before they start work. The care planning system needs to be more person centred and care plans need to be reviewed at least once a month. Checks need to be made on daily recording to make sure that entries are relevant and reflect respect for individuals. The manager must make sure that people who use the service have access to GP services. Further work needs to be done to make sure that people who use the service have access to activities of their own choice and mealtimes need to be reviewed to allow a greater choice and more involvement. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 6 The improvements in the environment need to be continued, the manager needs to make sure that repairs are attended to quickly. Where it is clear that the home cannot meet the needs of any individual the manager must take action quickly. A review of the training needs of each member of staff needs to be carried out. Health and safety checks need to be undertaken regularly and recorded. 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. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 7 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 Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 8 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 People who use this service receive adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Systems are in place to make sure that individual assessments are carried out before anyone is admitted to the home. This ensures that staff have information on the needs of individuals before they arrive. Care must be taken in future to make sure that the service can meet the needs of each person who is admitted. EVIDENCE: Before anyone moves into the home an assessment of their individual needs is carried out. For those people supported by a local authority to move in an assessment is carried out by the Care Manager and a copy of this document is provided to the service. In addition staff from the home will be visiting people before they move in to make their own assessment. It was noted that the needs of one person who was living at the service were not being met and this was also having a detrimental effect on the rest of the group. We are aware that this person was admitted to the service before the Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 9 new owners took over but care must be taken to make sure that only those people whose needs can be met are admitted. This service does not offer intermediate care. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 10 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 People who use this service receive poor quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The care planning in place is not consistent or person centred and does not provide clear information on the care provided. The health care needs of individuals are partly met. The management of medication is poor. EVIDENCE: We examined a sample of care plans. These plans did not give up to date information on the strengths and needs of individuals or information for staff on how they were to support people. Staff had produced in one instance a comprehensive review report but the needs of this individual had changed and this was not reflected in the plans or reviews. We found inaccuracies and contradictions in the records with documents not completed or recoding not continued. There was little information on the life history of individuals which could assist staff in communicating and understanding people they support. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 11 There is little evidence of care plans being compiled in consultation with people who use the service or their representatives. The lack of clear information on the physical, social, emotional and cultural needs and strengths of each person leaves staff with little guidance on how they are to meet the needs of people. A review of the care planning system needs to be carried out and action taken to ensure that care plans are person centred, up to date, accurate and reviewed on a monthly basis or more frequently if there should be any changes. Clear information on how the needs of individuals will be met with timescales for any goals set must be in place. We were informed that staff had been working to update the care planning system since the new owners took over. However at the time of this inspection only nine people were living at the home and little progress had been made. Daily recording did not include full information on the care provided. The style and language used in the daily records indicated a lack of respect for the person and a lack of knowledge on dementia care. Staff appeared to be focused on recording negative interactions with people who use the service. We heard staff using infantile language when talking to people who use the service on more than one occasion Risk assessments are in place however these need to be related to the risks for individuals and if needed, risk to others. We found, where one individual had shown violence towards staff, no risk assessment and no information for staff on how to deal with these situations. There was no information for staff on what may trigger this behaviour. People who use the service told us that “you can see the doctor if you’re not feeling well” and “I have seen the dentist and the optician”. Arrangements are in place for regular optical, dental and chiropody services to be provided in the home. People can go out to use the community services if they wish. The manager must ensure that every person who uses the service is provided with the opportunity of at least an annual health check through their GP service. The manager and the home owner both informed us that they were experiencing some difficulty in getting visits from the GP. This problem must be solved without delay. We found the management of medication to be of a poor standard. Staff had not opened the medication sent from the hospital for one person from the day before. An up to date and accurate record of medication for each person was not kept. Medication prescribed to be given “as required” did not include enough information for staff to administer them safely. An up to date and Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 12 accurate record of medication given was not available. Where medication was not given a clear reason why was not kept. Immediate requirements about medication were made following our first visit to the home. The service was required to have the medication in order by 5th November 2007. We received written confirmation from the manager on 5th November 2007 that all the requirements had been met. However when we visited the service on 6th November 2007 we found that the majority of the requirements had not been met. We have subsequently met with the home owner and received verbal assurances that action has now been taken. A written warning letter will be delivered to the registered persons and further unannounced visits will be carried out to the service by inspectors to make sure that medication is managed properly. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service receive poor quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The service has an open visiting policy which assists in supporting people to maintain contact with relatives and friends. Activities are being provided on an ad hoc basis with no clear plan for either group or individual activities. Mealtimes are not viewed as an important social event. EVIDENCE: People who use the service told us there was “not a lot going on”, “we don’t get out much”, “its quiet”,“ we never go out in the evenings or at all” and “I’d like to go out for a cup of tea”. We could find no plan for the provision of activities. Staff must work on supporting people to meet their social, emotional, cultural and religious needs and wishes. On the first visit to the home we found no activities going on. The needs of one person were taking up the majority of staff time which left little opportunity for other people to be engaged in any meaningful activity. On the second visit some activity was going on but there was no evidence that the activity was chosen by people who live at the home. It is recommended that Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 14 at least one member of staff is provided with training on activities and that people are provided with the chance to get more involved in purposeful activity. A more person centred care planning system will provide more information for staff on individual wishes. We did note that one person was provided with a quiet area to relax and listen to music of their choosing. This type of attention needs to be expanded. In discussion about the meals, people who use the service told us; “the food is alright”, “food is quite nice I get good meals”, “it’s good but not much choice”, “we get the same thing every day, yoghurt five days a week” and “sometimes I like it sometimes I don’t”. With regard to choices people told us; “I was asked what I liked but they are going back to what they always do” and “I’ve not a clue what is for lunch they put it in front of me” Of the four staff in the home at the mealtime two were not assisting. As the meal progressed only one member of staff was left in the dining room. People were allowed little opportunity to participate in the mealtime as meals were provided ready plated. Only one person was told what they were being given. People were given a choice of juices and we observed some good practice from one member of staff who was assisting someone with their meal. Unfortunately as this member of staff was eventually left alone they had to leave off supporting this person between courses. We also noted poor practice with one person told by staff that if they wanted their pudding they must sit down. The use of plastic over tablecloths gives an institutional appearance to the dining room. A full review of mealtimes must be carried out to ensure that there are sufficient staff available and that they are supervised. The menu must be reviewed and must show the alternatives on offer. How people are offered choices at mealtimes needs to be evidenced. Staff must look at how meal times can be made more of a social occasion, which people who use the service can contribute to. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service receive adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. A complaints procedure is on display. Systems are in place for recording complaints. Copies of the local authority procedures regarding safeguarding adults are available. Plans are in place for new staff to be provided with training on safeguarding adults. EVIDENCE: The complaints procedure is accessible and on display. No complaints were recorded as received in the home. We are aware that one complaint was received by the local authority regarding the care provided for one person before they were admitted to hospital. This complaint was judged to be unfounded. However the quality of recording in the home did not assist in this investigation. One person who uses the service told us; “I tell the staff if I have a problem. I don’t know if they take it further” Staff should make sure that they let people know the outcome if any concern is raised with them. The manager should make sure that he talks to each person using the service on a regular basis which will enable them to bring up any concerns and find out what action has been taken. The service has a number of new staff and arrangements are in place for these staff to receive training on safeguarding adults. This will ensure that staff are Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 16 aware of their responsibilities to report any concerns they may have to the appropriate person. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22 & 26 People who use this service receive adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The new management are making progress in improving the environment. However repairs must be attended to promptly. A review of the equipment and aids available needs to be carried out. The home is clean and tidy. EVIDENCE: We are aware that there was a significant amount of furnishings in need of replacement when the new owners took over the service. The new owners have started the process of replacement and redecoration. At the time of the first visit new sofas were being installed in the conservatory. Five beds have been replaced, new bedspreads and new mattresses have been bought. Consideration is being given to the installation of a stair lift. However we found the condition of bathrooms had deteriorated. Toilet seats were missing and there were no soap or paper towels for hand washing. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 18 Three bedrooms which the manager confirmed were in use had no curtains up at the windows one room had no curtain rail. In another room the curtains did not fit properly. The manager was advised to move curtains from rooms which were not in use to the rooms in use without curtains. The manager must ensure that the privacy of people who use the service is protected and rooms are not left without curtains. One bed was fitted with a Mickey Mouse bedspread. The manager confirmed that this did not belong to the person. People who use the service must be provided with furnishings appropriate to their age and wishes. Items such as this need to be removed from the home. We were informed by the manager that none of the people using the service required a hoist to assist with mobility. However we observed a member of staff assisting one person up from a chair in an inappropriate manner. An assessment by a suitably qualified person must be carried out to ensure that appropriate aids are available to assist in promoting independence and mobility. The home was found to be clean and fresh. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use this service receive poor quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. People who use the service are generally satisfied with the care they receive. However there have been significant staff changes and they are not always kept informed of these changes. A comprehensive training plan is not as yet in place. The recruitment procedure had not been followed in one instance. Staff are not skilled in meeting the needs of people living with dementia. EVIDENCE: People who use the service told us that; “staff are nice”, “staff are ok”, “they are pretty good”, “they work hard” and “they do listen but then just carry on”. On the first visit, staff were clearly struggling to meet the needs of one particular person. This was impacting on the care provided for other people using the service. At the time of the second visit this person had moved to a more appropriate place for their needs and staff had more time to meet the needs the resident group. Two care staff are available at all times. The manager is also on duty five days a week. At the time of this inspection the home owner was also working. A cook and domestic staff are also employed. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 20 Since the ownership of the home changed there have been significant changes in the staff group. One person who uses the service told us that there had been “quite a lot of new staff I don’t know what is going on”. The senior management should keep people who use the service well informed of changes in the staff group. The manager must carry out an audit of the training needs of individual staff members and develop a training plan. Observations indicated that staff need training on dementia care, communication and moving and handling. It is recommended that the manager use the Skills for Care induction programme for new staff. The manager informed us that two staff have completed NVQ level 2 and two staff have registered on this course. We looked at a sample of staff records. In one instance references had been sent for but had not been returned. In two instances Criminal Records Bureau checks had been applied for but had not been returned. Checks had been made on List 99 which is a list of people not suitable to work with children. Staff can commence work while waiting for Criminal Records Bureau checks are carried out but a POVA first check must have been carried out and these staff must not work unsupervised. The lack of appropriate checks on new staff put at risk the welfare of people who use the service. An immediate requirement was made regarding this issue. The home owner has contacted the organisation who carries out the checks to rectify this issue. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use this service receive adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The manager has the necessary experience to run the home but further training would benefit the service. Systems are in place for staff to make regular checks to protect the health and safety of people who use the service. The manager must make sure that these checks take place. The records of money held are well maintained. EVIDENCE: The manager has previously run care services. In order to meet the needs of people who use this service and provide staff with guidance on good practice the manager should take part in further training on supporting older people, particularly those living with dementia. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 22 It is of some concern that advice given by the inspectors regarding the suitability of the service for one person living at the home at the time of the first visit was not acted upon until the situation reached a crisis. The manager must ensure that action is taken without delay when it is clear that the needs of individuals are not being met by the service. It is also of concern that information provided to the CSCI, stating that immediate requirements had been met, was not accurate. The manager should make sure that any information provided to the regulator is up to date and accurate. People who use the service can deposit small amounts of money for safekeeping in the home. Individual records are kept and the sample examined were well maintained up to date and accurate. A quality monitoring and assessment system is in place. The manager has set up meetings with people who use the service. The records of these meetings need to include what actions have been taken following the meetings. Staff are being provided with supervision which will assist in making sure that they are working in line with the aims and objectives of the home as well as offering support to individuals. Checks are carried out to ensure the health and safety of everyone who lives, works or visits the service. It was noted that the weekly testing of the fire alarm system had not been carried out for the previous two weeks. To make sure that people who use the service are safeguarded staff must check and record the temperature of the water before anyone is helped into a bath or shower. This record must be kept in the home. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 2 X X X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 To make sure that people who use the service receive the support they need a review of the care planning must be carried out. Care plans must:• Be up to date and accurate. • Be compiled in consultation with people who use the service and or their representatives wherever possible. • Provide clear information on how the needs of people will be met. • Be reviewed on a regular basis. • Checks need to be made on daily recording to ensure that entries are relevant and reflect respect for the individual. To make sure the health and safety of people who use the service and staff individual risk assessments setting out the actions to be taken to reduce risks must be in place. DS0000070341.V355805.R01.S.doc Timescale for action 15/01/08 2. OP7 13(4) 15/01/08 Beecholme House Version 5.2 Page 25 3. OP8 12(1) In order to ensure the health and 20/12/07 welfare of people who use the service the registered persons must ensure that people have access to full GP services. To ensure the health and welfare 10/12/07 of people who use the service a review of all medication must be carried out to make sure that: An up to date and accurate record of all medication prescribed for each person is maintained. An up to date and accurate record of all medication administered is maintained. That people who use the service receive their prescribed medication at the prescribed time. A record of all medication received into the home and returned to the pharmacy is maintained. That clear instructions are available to staff for any medication to be given “as required”. Where medication is not given a clear reason why the medication has not been given must be available. This was the subject of an immediate requirement to be met by 5/11/07. This timescale was not met. 4. OP9 13(2) 5. OP10 12(4)(a) All staff must be provided with clear written guidance and training on treating people who use the service with respect. To ensure the needs and wishes of people who use the service are met a review of the activities DS0000070341.V355805.R01.S.doc 15/01/08 6. OP12 16(2)(m) (n) 15/01/08 Beecholme House Version 5.2 Page 26 on offer must be carried out. This review must include :• Individual consultation on social, cultural and religious needs and wishes. • Inclusion of social activities and how these will be met in care plans. • Up to date information on activities being made available to people who use the service. 7. OP15 16(2)(i) To ensure that people who use 15/01/08 the service are provided with food which meets their needs and preferences a review of meal times must be carried out. This review must include:• How people are offered choices at mealtimes. • Inclusion on the menu the alternatives at each meal time. • Ensuring that sufficient staff are available to support people at meal times. • Providing opportunities for people to maintain their independence at meal times. In order to provide people who use the service with a well maintained environment the following repairs and actions must be taken:• All toilets must be kept in good working order with toilet seats in place. • All occupied bedrooms must be supplied with curtains of an appropriate size. • Bedding and other furnishings supplied by the service must be age DS0000070341.V355805.R01.S.doc 8. OP19 23 (2)(c) 16(2)(c ) 20/12/07 Beecholme House Version 5.2 Page 27 appropriate. 9. OP26 13(3) In order to protect the health of people who use the service and prevent the spread of infection soap and paper towels must be available in all toilets. 20/12/07 10. OP22 13(5) To ensure that people who use 01/02/08 the service are provided with appropriate aids an assessment of the moving and handling equipment in the home must be carried out by a suitably qualified person. To ensure the safety of people 10/12/07 who use the service urgent action must be taken to ensure that POVA First checks are carried out for any staff for whom you do not have a full and satisfactory Criminal Records Bureau check. Staff who are working with POVA First checks only must not work with people who use the service unsupervised. An action plan on how this was to be achieved was the subject of an immediate requirement to be completed by 6th November 2007. 11. OP29 19 Schedule 2 12. OP30 18(1)(c ) To ensure that people who use the service are supported by well trained staff the manager must carry out an audit of the individual training needs of all staff. Arrangements must be made for staff to receive the training they need. All staff must be provided with training on moving and handling and dementia care. 15/01/08 Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 28 13. OP38 13(4) To ensure the health and safety of people who use the service staff must check the temperature of any bath or shower before they help anyone into a bath or shower. A record of these temperatures must be kept. To ensure the safety of people who use the service staff must make weekly checks on the fire alarm system. A record of these checks must be maintained. 15/12/07 14. OP38 13(4) 15/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP30 OP31 OP31 OP31 OP31 Good Practice Recommendations It is recommended that at least one member of staff is provided with training on organising activities. It is recommended that the manager takes part in further training on meeting the needs of older people living with dementia. The manager should make sure that action is taken without delay should the service be unable to meet the needs of any individual. The manager should make sure that information provided to the CSCI is up to date and accurate. The manager should ensure that people who use the service are kept informed of any changes including staff changes. Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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 Beecholme House DS0000070341.V355805.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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