Inspection on 27/04/06 for Beechwood

This inspection was carried out on 27th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beechwood 25/06/07

Beechwood 31/10/05

Beechwood 23/06/05

Beechwood 10/05/05

Beechwood 29/11/04

Beechwood 08/09/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Beechwood The Lodge High Pitfold Hindhead Surrey GU26 6BN Lead Inspector Christine Bowman Unannounced Inspection 27th April 2006 12:00 Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 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 Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 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. Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beechwood Address The Lodge High Pitfold Hindhead Surrey GU26 6BN 01428 604278 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) Robinia Care South Limited To Be Confirmed Care Home 6 Category(ies) of Learning disability (6), Sensory impairment (1) registration, with number of places Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be 18-50 YEARS To accommodate one person with a sensory impairment. Date of last inspection 31st October 2005 Brief Description of the Service: Beechwood and The Lodge are both part of Robinia Care Group. The Southern Region Organisation specialises in services for people with learning disabilities and challenging behaviours. The homes are located on the Robinia South Old Grove site, just off the A3 South of Hindhead and situated on a small complex of largely purpose built single storey buildings, one providing day care (The Grove) and the remainder are residential. Beechwood is a five-bedroom bungalow and The Lodge is a two-bedroom bungalow with one service user, supported by two members of staff over a twenty-four hour period. The Lodge is registered for one service user only. Beechwood and The Lodge are staffed independently of each other with the Registered Manager overseeing the two homes. Each of the homes has its own communal facilities and enclosed secluded gardens with adjacent parking. The service users all present with challenging behaviours. The service is some distance from the local facilities transport may be available on occasion at Beechwood to access the community and the amenities at Hindhead, Grayshott and Haslemere. The Lodge has access to transport on a regular basis. The service users, on weekdays access the on-site day centre, with its cafeteria facilities. Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection for the inspection year 2006 –2007 under Inspecting for Better Lives. The inspection was a ‘key’ inspection and considered all the key standards which are noted within the report. In addition the inspection report contains a judgement noting whether the home is poor, adequate, good or excellent at meeting the outcome areas. This inspection was unannounced, commenced at 12.00 a.m. and took six and a half hours to complete. The acting manager was interviewed and staff were spoken with as they engaged in their daily tasks. The people who live in the home are known as ‘service users’. They have severe communication difficulties and challenging behaviours so their experiences of the service were gathered through case tracking and direct observation and efforts were made to ensure the calm atmosphere and routines were not affected by the intrusion of the field visit. Throughout the afternoon service users were involved in activities, which had been planned and were supported by the staff allocated on the timetable. The service users responded to the staff with pleasure, smiles of recognition on their faces and sometimes a hug. One service user was able to make his wishes known by taking the hand of a member of staff, leading them and pointing. A sample of service user, staff personnel files and other records were viewed and a partial tour of the premises was completed. The provider had responded to the requirements of the previous inspection with an action plan and the result of the quality assurance survey for 2005 for the South East Region and action plan with dates of completion had been received at the CSCI local office. What the service does well: What has improved since the last inspection? The Statement of Purpose had been reviewed to ensure that up-to date information was available to present and prospective service users. Risk assessments had been reviewed, signed and dated to protect service users from potential hazards. Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 6 Improvements had been made to the quality and variety of the food provided to the service users to improve their health. The kitchen and bathroom had been refurbished resulting in a pleasant and safe environment for service users to enjoy. A carpet had been removed from a service user’s bedroom making the space more hygienic. The new sharp box in use at the time of the inspection was dated at the time of opening for the purposes of disposal. Staff job descriptions were held on personnel files to ensure the staff were aware of their responsibilities with respect to the service users, and a number of staff had been enrolled on appropriate National Vocational Qualification courses, as planned, to support their learning and development and improve their performance. The organisation’s homes in Surrey have been subject to an investigation by the CSCI, a number of the matters have now been resolved or are nearing completion. These matters are now noted here more fully. 1. Service users finances from February 2002 to January 2005 had been of concern. The organisation has agreed with the CSCI and under Surrey County Council multi-agency procedures that recompense will be paid to all service users in residence during that time. Payments will be dealt with on an individual basis and may take into account pro-rata amounts. 2. Payments for holidays, meals out of the home and any other additional staff costs have ensured that; (a) Holidays are either part funded by Robinia Care South or that each prospective service user will have £500 toward the cost of an annual holiday included in his or her fee. See Standard 14.4 of the National Minimum Standards for Young Adults (18-65). (b) Additional staffing costs will not be taken from resident’s own monies. (c) Service users will not fund meals out for staff nor will they pay the full cost of the meal. This as the cost of meals is inclusive in the fee; the difference will be funded directly by the service user. 3. Residents through their mobility benefits were paying for transport provision. This method had not clearly been agreed with local authorities or families and or residents. This matter has been resolved and individual agreements made with appropriate persons completed to ensure that any payment made is agreed and recorded clearly. 4. The organisation has introduced a new policy and procedure for dealing with resident finances in order to ensure that members of staff follow consistent guidance. Members of staff have received training on this matter, as have the managers of the homes. 5. The organisation has provided each home with a clear chart informing staff of what to do and what not to do in the event of an allegation of adult abuse. The organisation has agreed to revise their policies and procedures in relation to the protection of vulnerable adults to ensure Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 7 they are clear, easy to follow and are in line with local guidelines. This matter has not been confirmed as being finalised as yet. 6. Further training for members of staff was also agreed as part of the investigation. The organisation has employed a specialist service to train Robinia Care South members of staff to communicate and engage with their residents more effectively. In particular engaging with individuals who have non-verbal communication needs. At the time of this visit the staff team of The Willows reported that only the manager had received this training and had provided the team with information from the course. 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. Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 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 Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 &5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The reviewed statement of purpose needed further work and the contract stating terms and conditions, which was available in an appropriate format had not been completed on behalf of individual service users. Appropriate assessments ensure the home is able to fulfil the service user’s needs. EVIDENCE: The Statement of Purpose and the Service User’s Guide had been reviewed and the misleading information, which indicated that the home could meet specialist needs of particular residents, had been removed. The recent admission of a new client means that further work is required and there was no reference in The Statement of Purpose of the training or experience of staff to meet the communication needs of service users despite this being a fundamental need. A copy of the terms and conditions of the home was contained in the service user’s guide and had been reviewed in order to clarify the financial terms generally with regard to transport costs, the reimbursement of meals out and the contribution to annual holidays. This contract contained symbols and was written in large print to enable service users to understand the content, but there was no signed copy of this contract on the individual service user’s files specifying which room the service user was to occupy or any other information individual to the service user. Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed care plans inform staff of how to support service users to meet their assessed needs, and improvements had been made in the reviewing of risk assessments to reduce the risk of harm to service users Personal information with regard to service users must be protected by secure storage. EVIDENCE: A sample of service user’s files was inspected, and care plans and risk assessments were viewed. Care plans were detailed and covered all areas of need including medication, personal hygiene, activities, method of communication, family/social contact etc. One-to-one support was specified with the identified need. Files sampled contained the service user’s circle of support with their photograph at the centre surrounded by key workers, care managers, physiotherapist, family, tutors etc. Information with regard to the availability of advocacy was available and posted on notice boards. Details of support required to enable service users to Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 11 manage their finances was in the care plan and staff were observed enabling service users to make decisions. Risk assessments were comprehensive, had been reviewed and were signed and dated. Standard 10 was not thoroughly inspected but the service user’s files were stored on an open shelf in the office and accessible. The acting manager stated that the reason this had occurred was that the cabinet in which they had been stored, which was lockable, had become unsafe and a new metal one had been ordered. Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 &17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Opportunities to develop, have their rights and responsibilities respected in daily life, to be part of the community, retain family links and develop interests and friendships are available to service users but limitations remained with regard to transport. The introduction of a more wholesome diet is an improvement in the provision of a healthy lifestyle for service users. EVIDENCE: Access to further education was available at The Grove Resource Centre, which was a short walk from the home, and the timetable showed that art, communication, swimming, rambling, horticulture, cooking, dance and music were available. These activities took place as scheduled on the day of inspection. The manager reported that the reliability of the provision had been improved due to a successful recruitment campaign and that it was rare for sessions to be missed. Transport had been a problem for service users of Beechwood because the home does not have its own dedicated transport. The acting manager stated that two vehicles each with the capacity to seat seven people had been allocated to the home and were in the process of being Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 13 insured. There was no documentary evidence to confirm this or when the transport would be in operation, but one of the vehicles was parked in the driveway and the acting manager stated they would be in use within the next two weeks. In addition to the use of some of the facilities of the Resource Centre, including the gymnasium with trampoline, climbing frames, ropes etc, basket ball, football, giant ‘connect four’, swimming and ten-pin bowling, during leisure time, community leisure facilities are also accessed, the acting manager stated. Service users’ records confirmed that theatre trips, ice-skating, bowling, boat-rides, shopping expeditions and nightclubs were accessed in Portsmouth, Havant and Guildford etc. Care plans confirmed family involvement and that daily routines promote independence and choice. Observations of service users revealed that they chose to be alone at times and to interact at other times. Only one service user was at home for lunch, which was shepherd’s pie and vegetables, other service users were at the Grove Resource Centre, where there was a choice of four main courses, the acting manager stated. Another service user, who was on a bowling trip with one-to one support, selected her venue for lunch every Thursday. (Healthy options were available and recommended by the staff, but this particular service user had very specific tastes, and does choose fast-food outlets, the acting manager stated.) Teatime was relaxed, with gentle music playing in the background, and all except for one service user, who wanted to eat later, gathered around the dining table. Tuna and salad sandwiches made with wholemeal bread were served with squash and fresh fruit to follow. The staff were attentive and supportive throughout the meal without being obtrusive. Facial expressions indicated the service users were enjoying the meal and staff and some service users used signing. Menus were planned weekly and colour picture cards enabled service users to make choices. A record was kept of food consumed and a random sample showed that meals were varied, well balanced and nutritious. Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive individual support and have their personal preference respected with regard to personal and health care, however the recording of the administration of medication must be improved to ensure their safety. EVIDENCE: Service user’s files contained information with regard to visits by other professionals and the physiotherapist was just leaving after visiting a client when the inspection commenced. There was flexibility in the routines of the home and the staff were aware of the personal preferences and individual needs and interests of service users. All had very individual routines at bedtime. One service user liked to go to bed very early and encouragement was needed to persuade him to not to go before 7.30 p.m., the manager stated. Another service user preferred to stay up late. Medication was prepared by the local pharmacist and in blister pack form. The MAR chart in use had a recording error, which had not been explained on the back of the sheet. A member of staff had signed in the wrong place and attempted to cross out the error. The acting manager must ensure that staff are supervised adequately and that he monitors the medication records to ensure they are completed correctly. Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A local procedure to inform staff of how to report allegations of abuse is not available to protect service users, and the complaints procedure could be made more accessible to them, however the extent to which service users contribute to extra charges had been clarified. EVIDENCE: Observations of interactions between service users and staff confirmed that service users needs and feelings were well understood by staff and that service users trusted them. The complaints procedure was in the Service User’s Guide in small print. Making this procedure available in a symbolic format could make the information more available to service users. No complaints had been recorded since the last inspection. A copy of The Surrey Adult Protection Procedures was available in the home and there was evidence in staff files of attendance on courses identifying abuse, but there was no local procedure in place reflecting this and clarifying actions and timescales in reporting allegations of abuse. Service user’s financial records showed that £1.50 was refunded when meals were purchased outside the home and the new system was in place for transport costs. Service users were charged individually at 25 pence per mile for journeys taken. Bank Statements were only available up to January 2006 and it was not possible to ascertain if refunds had been made to service users who had been over-charged for holidays, transport and meals out. Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements made to the environment created a homely, comfortable living space for service users to enjoy, which was clean and hygienic. EVIDENCE: The environment was homely and domestic and provided sufficient shared space for service users to be alone or together. The furnishings were domestic and comfortable but solid, and framed pictures on the walls, a television, DVD and music centre, cushions and rugs created a pleasant atmosphere. The acting manager commented that service users had chosen the colours for the new sofas and carpets. Standards 26, 27, 28 and 29 were not covered in detail but requirements had been made at the previous inspection for which evidence was required. The carpet in one service user’s bedroom, which emitted an unpleasant odour had been removed. The furniture in another bedroom, which had been repainted but looked unsightly, had been re-stripped and varnished and was more pleasing to the eye. Work had been completed on the bathrooms in that tiles had been replaced in one bathroom with reinforced plastic because one service user liked to hit the wall when relaxing in the bath so damaging the tiles. A new shower with a detachable head had been purchased. Handrails had been Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 17 replaced and the bathrooms had been redecorated and a safer and more hygienic environment had been created. The kitchen had been completely refurbished to a good standard and was domestic in scale. Some of the work planned for the external areas had been completed. The rear gate, which is the means of evacuation in case of fire had been difficult to open due to a stiff bolt, which the acting manager had treated with oil in order to loosen it. A footpath was in the process of being created for safe access. The trellis fencing intended to hide a large skip in the neighbouring area had not yet been provided, and work was still required on the guttering of The Lodge. The home was clean, hygienic and free from odours. Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 The training opportunities accessed by the staff to develop skills and raise awareness in fulfilling the needs of the service users were good but shortfalls in the recruitment process leaves service users at potential risk. EVIDENCE: Sufficient staff were available to meet the needs of service users. Throughout the afternoon staff were observed working well as a team to support them. A sample of staff personnel files contained an application form, proof of identity, job description, a statement with regard to health and a signed declaration of criminal offences. One carer had been transferred from another Robinia home and the original references were not in her file. Another carer had not completed the section giving reasons for leaving the previous post. The acting manager kept a record of Criminal Record Bureau numbers separately. He stated that the system had changed and he now applies for CRB and the Protection of Vulnerable Adult checks for the staff. Induction and supervision records were viewed and certificates in the training and development section. The extent of training opportunities accessed by carers was commendable. In addition to the mandatory training many specialist courses were offered including Makaton 1 & 2, Communication 1 & 2, Epilepsy, SCIP, Autism, Bereavement, Beat Bullying, Family Support, Visual Impairment and Learning Disability and many others. English lessons were provided for staff from overseas Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 &42 There is a high regard for health and safety matters and the results of the quality assurance questionnaire highlight future developments and improvements but suitable arrangements had not been made for the manager’s training needs to be fulfilled. EVIDENCE: The acting manager had made application to the CSCI local office for consideration as the registered manager. He stated that he had commenced the NVQ Level4 in care, but had not been informed by the company of an enrolment date to undertake the Registered Manager’s Award. Confirmation of this date had been required at the previous inspection. A quality assurance audit had been carried out and the results had been received at the CSCI local office. An action plan had been produced with dates for completion. Issues raised by social workers included client activity programmes and communication; families also raised communication and the quality of the food. Transport and more flexibility with respect to timing of mandatory training were also identified. Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 20 There was regard in the home for the safe storage of chemicals and mandatory training on moving and handling and fire safety. A poster was displayed reminding staff of their personal and the company’s corporate responsibilities with regard to Health and Safety. The washing machine had a sluice programme. The laundry room was in need of some refurbishment, but was not unsafe. Fire fighting equipment and freezer had been checked and the date recorded. The kitchen door was locked when the staff were not working there in order to protect service users. A record of fridge and probe temperatures was kept and an up to date legionella certificate was viewed. Certificates were viewed confirming that the boiler, electrical mains and portable appliances had been serviced or safety checked. The fire alarm system and the emergency lighting had been fully checked and staff had carried out weekly checks. Emergency evacuations were recorded. A full fire risk assessment was recorded for all service users and the accident book was in keeping with The Data Protection Act 1998 and safeguarded the personal information of service user’s and staff appropriately. Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 21 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 3 X Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 22 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 YA1 Regulation 4(1)(c) Requirement The registered person must ensure the statement of purpose is updated to reflect the changes to the client group. The registered person must inform and keep informed the CSCI regarding the progress of providing a contract of terms and conditions for service users. The registered person must ensure that documents and other records relating to the service user are kept securely in the home. The registered person must ensure that staff are trained and supervised adequately in the completion of documents required by the home. In this instance in the recording of the administration of medication. Timescale for action 27/05/06 2. YA5 5 27/05/06 3. YA10 17(b) 27/05/06 4. YA20 17(1)(a) Schedule 3 27/05/06 Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 23 5. YA23 6. YA23 7. YA34 8. YA37 The registered person must ensure a local procedure for the protection of adults, reflecting The Surrey MultiAgency Vulnerable Adults Procedures, is available to inform staff. 13(6) The registered person must inform the CSCI of the progress of recompense payments to those service users resident during the period noted in this report and as previously agreed. 19(1)(a)(b) The registered person must (c)(5)(d)(9) ensure that all the required (10)(a)(b)(11) documentation with respect (a-c) Schedule to recruitment is available on 2 all staff personnel files. 18(1)(a)(c)(ii) The registered person must review the start date for the registered managers award for the acting manager and inform the CSCI of the revised start date. This is the second time this requirement has been made and a new timescale agreed. 13(6) 27/05/06 27/05/06 27/05/06 27/05/06 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 YA22 Good Practice Recommendations A symbolic format would make the complaints procedure more accessible to service users. Beechwood DS0000013702.V291004.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 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. 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