Inspection on 07/06/05 for Beechwood Care Home

This inspection was carried out on 7th June 2005.

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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beechwood Care Home 04/07/06

Beechwood Care Home 25/11/05

Beechwood Care Home 07/03/05

Beechwood Care Home 11/08/04

Beechwood Care Home 31/03/04

Beechwood Care Home 17/12/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Beechwood Care Home 60 Burlington Road Sherwood Nottingham NG5 2GS Lead Inspector Jayne Hilton Unannounced 7th June 2005 at 10:00 am 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 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 Stationary 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 Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Beechwood Care Home Address 60 Burlington Road Sherwood Nottingham NG5 2GS 0115 924 5893 0115 960 9077 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Fred Parsons Mr Wesley Williams Care Home (CRH) 8 (Eight) Category(ies) of Learning disability (LD) - 8 (Eight) registration, with number of places Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7/03/05 Brief Description of the Service: Beechwood is situated in the Sherwood area of Nottingham and is a large older adapted property, with much of its original character maintained. Arranged on 2 floors, the accommodation consists of 8 single bedrooms with shared bathing facilities, and communal lounge and dining rooms. It is close to local amenities and bus routes into Nottingham. Focusing on assisting service users to attain maximum personal development. Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 7th June 2005 and lasted four hours. There were three service users at home initially, but two went out to their daily activities shortly after the inspector arrived. Because of this, and that the inspector had difficulty communicating with the remaining service user, the methodology used at this inspection was by speaking with the manager, the service user, two ancillary staff and by examination of records in the home. A tour of the premises was also carried out. What the service does well: What has improved since the last inspection? The medicines management systems in the home have improved in relation to storage. Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 6 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 Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 8 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 standard(s) 1, 2, Prospective service users have the information they need to make an informed choice about where they live; this information needs to be reviewed and updated as required by regulation. Prospective service users needs are assessed, however these need to be reviewed and kept up to date as required by regulation. EVIDENCE: A Service User Guide including the Statement of Purpose has been produced and contains all the required elements, however the information regarding bedrooms on the ground floor was not up to date. A copy of the complaints procedure is included. A registered person is required by regulation to provide an up to date Statement of Purpose [Regulation 4] and a Service User Guide, which is to be issued to service users [Regulation 5]. The registered person is also required by Regulation 6 to keep the two documents under review and notify the Commission of any revision within 28 days. Three care plan files were examined. There is an assessment and admission procedure that includes professionals from multi disciplines on a panel chaired by an independent clinical psychologist. Service user case files contain assessment material the views of relatives are taken into account. There is an emphasis on the placement being able to meet individual needs, and initial Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 9 care plans have been drawn up in accordance with assessed needs. The assessment documentation was in most cases at least 5 years old. Regulation 14[2] requires that an assessment of service users needs is kept under review and revised when it is necessary as service users needs change. Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 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 standard(s) 6,7,8,9, Service users are involved in their care plans, which reflect the individual’s personal goals. The care plans are not up to date and this is an outstanding requirement from the previous inspection. Risk taking is clearly promoted both in the home and out and about in the community. EVIDENCE: Care/ support plans are drawn up based on initial assessments, and cover aspects of both personal and healthcare. Communication needs are clearly addressed. There is evidence of some reviews conducted by the local authority, but no system in place to ensure each service user’s plan is thoroughly reviewed and updated at least six monthly. Some plans are over three years old showing no development or change in needs. From discussions with staff it is clear that changes are identified and plans discussed verbally, but the manager must keep original written plans under review. This was identified at the previous inspection. The manager reported that he is committed to undertaking a review of the plans once time permits. The format of the care plan structure should be reviewed to current National Minimum Standard expectations and include service users preferred term of address; whether the service user is to be issued with a key to their bedroom door, front door and lockable facilities etc. Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 11 There was some good overview progress reports for both daily life and activities seen, and these could be used alongside the 6 monthly review of care plans and risk assessments if formatted in such a way. One service user had a road safety programme dated 1999, the review process should address, whether this has been re-assessed, whether there are any concerns etc. Another had a disclaimer for lockable facilities dated 2002, again this needs to indicate whether this is still applicable. There was evidence of service user consultation and signatures of service users, with photographs and a personal profile. Any restrictions on freedom or choice are based on risk assessments. Several of these are recorded on files and show appropriate action to be taken. It was noted that a monitor alarm was in place on an upstairs hallway. The manager explained why this was there, but there was no evidence to support this in the service user’s care plan. Risk assessments had not been reviewed. The inspector observed a service user being offered option regarding their lunchtime meal Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 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 standard(s) 11, 12, 13, 14, 15, 16, 17 Service users clearly live a busy and fulfilled lifestyle, where their rights are respected. There is a need to review the arrangements for service users’ holidays, where one service user is accompanied by one staff member. EVIDENCE: Service users follow individual programmes of daytime activities, and day services staff work in partnership with the residential staff. A separate education centre is used and a local college. Cookery and Music are available. Communication systems are used effectively, and speech and language therapists are consulted. Some service users are currently involved in a gardening project. Independent living skills are developed and encouraged within the home environment with regular times for household tasks. Holidays are arranged, and some risk assessments for these were seen. Recent holidays included Center Parks, Skegness and a trip to Spain is planned. The inspector was concerned that only one member of staff is to be provided and that this appears to be company policy. It is strongly recommended that this practice be reviewed as the service user would be seriously at risk should the staff member have an accident or take ill. It is Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 13 good for service users to have opportunity to travel abroad, but their health and safety must not be compromised. Service users go out in the minibus and take part in leisure activities with staff. Most leisure activities are individual, or in small groups to meet specific needs of the service users, though this is not clear within care plans. Regular swimming and bowling take place. Encouragement and support is given to maintain relationships with families, and weekend visits and telephone contact are recorded in daily notes. There was a detailed family birthday date list on one service users file, which was probably provided by relatives of the service user, it would be good practice to adopt a special person section, which identifies birthdays and contact arrangements. The provider organisation is, led by parents. It was reported that all service users have a key to their own rooms and have access to all communal areas including the rear garden. When at home, service users choose whether to stay in their own rooms or the lounge. On the day of the inspection a service user was observed to move freely around the home and spend private time in her room as she wished. Service users were noted to have varying responsibilities within the home from laying the table to their own bedroom cleaning. There is an 8 weekly cyclical menu, which demonstrated cooked breakfasts are provided at weekends. The menu only offers one choice of main meal, however there was evidence that service users could take alternatives in the form of records kept. It is recommended that alternatives are offered as a menu item for instance a meat item and a vegetarian option. Fresh fruit was seen in a bowl in the kitchen, and fresh salad and vegetables were seen in the fridge. The meal options offered appeared nutritious and varied. The cook works in the daytime, and prepares the main meal for the afternoon care staff to reheat and serve. As service users are out most of the day and take their main meal on an evening the inspector recommends that the catering hours be reviewed. Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 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 standard(s) 18, 19, 20, 21 Service users receive personal support in the way they prefer and require, and generally service users’ healthcare needs are met. There are some good practice recommendations made to ensure all health care needs of service users are incorporated into their personal plans. There is some improvement in the organisation of medicine management within the home, however medication records continue not be completed on every occasion. This is an outstanding requirement. The registered person needs to obtain information regarding arrangements for service users at the end of life. EVIDENCE: Health care is generally well monitored, and notes are kept of advice given by medical professionals. There were notes of frequent consultations with a General Practitioner on the files sampled. There is a book to record accidents. However, one service user who was clearly at risk of falls had no care plan or running record of falls within her planning documents. Service users should be encouraged to have an annual well-person check, and other checks such as regular smear tests, breast screening and hearing checks and this should be evidenced within the care plan structure. Service users wishes for the end of life should be obtained and recorded. Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 15 It is recommended that when the care plan format is reviewed, that separate record sheets are used for chiropody, dental, optician, annual well-person checks, smear tests etc, so that there is a running record of health checks and identified problems which remain in the file, which are easily accessible and used for follow up and evaluation. Some information in the files need archiving as it is more than 3 years old. There are action plans, which also are more than three years old and need reviewing. Weight charts were completed wel,l but these did not identify issues regarding weight gain and weight loss. The record should be reviewed and incorporate an action/comment box which staff would use to identify significance of changes in the service user’s weight, including well being and mental health. Behaviour management plans were seen although it was not clear if this was still applicable/current. There was information regarding medication in the service users’ files, however these should be further developed into a medication profile section, and include details of medication reviews and changes of medication. Consent forms for medication should also be part of this section. The medicines’ cupboards were found to be accessible and tidy, which had been issues raised at the previous inspection. The Boots blister pack system is used. The drug errors policy needs to include a prompt to report medicine errors under regulation 37 to CSCI. Photographs are used for identification on Medicine administration sheets. There were some noted gaps on the records where medication had not been signed for or indicated why not given. This was a requirement from the previous inspection and therefore is outstanding. Failure to meet the new timescale may result in enforcement action being taken. Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 16 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 standard(s) 22, 23 Complaints procedures are accessible to service users. Service users are protected from abuse, neglect and self harm but the provision of training for staff in adult protection is strongly recommended. EVIDENCE: A complaints procedure was displayed in the hallway, there are additional copies in pictorial/symbol formats. The procedure states that complaints will be responded to within three weeks. The complaint poster displayed near the front door needs updating to read CSCI as it currently states NCSC. There were no reported complaints since the previous inspection. There is a comprehensive set of policies and procedures relating to protection of service users. Staff have been trained in handling challenging behaviour, and are currently all developing skills in using safe methods of intervention. Each event of using physical intervention is clearly recorded. The deputy manager is an accredited trainer in these methods. There was no evidence of staff undertaking adult protection training. It is recommended that all staff, including anyone left in charge at the home also receive training in the recently amended area protection procedures. See www.nottsadultprotection.org.uk Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 17 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 standard(s) 24, 25, 26,27, 28, 29,30 Beechwood provides a homely, comfortable, clean and well furnished environment for service users. There are some safety issues identified to address regarding surface temperatures of radiators and window restrictors, but overall the home is well maintained. Requirements and recommendations for these issues will be included in standard 42. EVIDENCE: All areas of the premises are accessible to current service users. The home is well maintained, furnished and decorated in a domestic style. The lounge and dining room have ceiling fans. There is a small garden, consisting of a lawn and paved area. No changes have been made to sizes of bedrooms. The seven current service users have single rooms. Three bedrooms were seen as part of this inspection. They are very clean and well personalised. There are individual nameplates on all bedroom doors. A Service user spoken with was satisfied with her bedroom and all had the furniture and equipment to meet their needs. Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 18 A lounge to the front of the building is well furnished and comfortable with CD player and television. There is a pleasant dining room with sufficient seating for service users and staff and there is a serving hatch from the kitchen. It was noted that some chairs were sited in front or close to unguarded radiators. There was no evidence of risk assessments being carried out for surface temperatures of radiators and this is needed. The same issue was noted around the home and in particular where one service user’s bed head was placed against a radiator. The inspector discussed ideas with the manager of how to protect service users from surface temperatures, where protective cabinets would not be practicable. There were no window restrictors on the dining room window, which presents a security risk to the home, this should be rectified promptly. The premises were found to be very clean upon inspection. However, training records do not show any staff trained in Infection Control. Appropriate laundry facilities are provided in the cellar. Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36 Service users are supported by a well supported and supervised, committed staff team, however training and recruitment issues were highlighted as needing attention. EVIDENCE: Staff have job descriptions and roles, and their limitations are discussed within regular staff meetings as well as individual meetings. A staff supervision session was being held on the inspectors arrival. The staff rota was examined and shows there are always two residential staff on duty at all times. This is supplemented with day staff to meet individual needs and activities throughout Monday to Friday. There is a waking staff member and another sleeping in. A further member of the management team for all NORSACA homes is available on call for support. Domestic staff for cleaning and cooking, are employed in addition. There has been a shortage of staff recently and staff have worked overtime to ensure that the staffing hours have been maintained. The manager has also been working shifts to cover, however because of this, inevitably some of the management responsibilities have not been achieved, particularly in relation to the requirements and recommendations set at the previous inspection and in auditing the service overall to ensure NMS and regulations are met. Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 20 The registered manager informed the inspector that there had been some recruitment undertaken and so this should release him back to his managerial responsibilities shortly. There seemed to be a long length of time between the termination of employment notices, advertisements being placed and actual recruitment. It is noted that Criminal record and POVA first checks add to this time duration. However the overtime being paid to staff is on average 15 hours a week each and therefore improved recruitment efficiency time would be more cost effective and less stressful for staff covering the shifts. The training programme date July 2004, demonstrates that training in general is not up to date. All staff should receive mandatory training in Infection Control, fire safety, first aid, food hygiene, manual handling and health and safety. [Medicines management training for those authorised to dispense medication and competency assessments] Other training required for good practice includes challenging behaviour, physical intervention, adult protection and learning disability training specifically for autism. There were examples of some staff undertaking training in these subjects, however there is a need to prioritise this, particularly regarding newly recruited staff. Evidence should also be provided of induction to skills for work standards and LDAF [Learning disability accreditation framework] and other accredited training such as NVQ’s [National Vocational Qualifications] Evidence was seen of a training request application, which covers all of the required training specification. Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 41,42 Service users benefit from a generally run home, staffing shortages have prevented some areas being fully addressed. The staff team are committed and have maintained minimum staffing levels, which is commended. Record keeping on the whole was good, however some areas require attention. The health and safety and welfare of service users is generally well promoted and protected, again there are some areas to address to meet the standards completely. EVIDENCE: The manager is experienced and qualified in social care. He is currently completing the Registered Managers’ Award. Once the staff team is up to full compliment, and the manager is working supernumery, the overall management should be improved. At present the systems in place naturally have some gaps. Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 22 There are records of refrigerator and freezer temperatures being monitored; all substances hazardous to health (COSHH) have been assessed for risks and are held securely. Requirements and recommendations set at the last visit from the Environmental Health Officer had been met. Staff training records show some gaps in training in safe working practices, particularly in Infection Control and some staff may also require some updating where training was five to ten years ago. However most staff have received training recent in First Aid and records show that four staff had been trained in evacuation practice The Gas safety certificate was up to date. Weekly fire tests were satisfactory. There was evidence of systems in place to prevent legionella and records regarding water outlet temperatures were seen, however one bathroom was recorded to be at 47 degrees and did not indicate any action taken to reduce this to 43 degrees. The records need to include what action has been taken where temperatures reach above 43 degrees and provide evidence of a re-test. There was a large risk assessment folder, however there were no fire risk assessments in place as required by fire authority regulations and these must be carried out, neither were there any risk assessments for safe working practices within the home. A security review of the premises should be carried out taking into account where window restrictors are not in place etc. Risk assessments must be carried out for surface temperature records. The health and safety poster needs completing. Portable appliance tests were examined and found to be satisfactory Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 2 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 2 3 3 3 2 3 Standard No 31 32 33 34 35 36 Score 3 2 3 x 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beechwood Care Home Score 3 2 2 2 Standard No 37 38 39 40 41 42 43 Score 2 x x x 2 2 x C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 24 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 Timescale for action The Statement of Purpose must 1st be updated to contain the correct September information regarding room 05 numbers. The registered person must 1st ensure that the assessment of September the service users needs is kept 05 under review and revised when necessary regarding any change of circumstances. Ensure all care plans are up to 1st date and reviewed regularly. September THIS IS AN OUTSTANDING 05 REQUIREMENT WHICH MUST BE MET TO AVOID ENFORCEMENT ACTION. Ensure that medication 1st administration record is signed. September THIS IS AN OUTSTANDING 05 REQUIREMENT WHICH MUST BE MET TO AVOID ENFORCEMENT ACTION. Ensure all staff training is up to 1st date in relation to mandatory September training requirements. 05 Ensure that service users are not 1st at risk from hot surface September temperatures of radiators. 05 Requirement 2. YA2 14]2]a] 14[2][b] 3. YA6 15, 17 4. YA20 12, 13, Medicines Act 5. 6. YA32 YA 42 18 13[4] Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 25 7. YA42 13[4] 8. YA42 13[4]16 The water outlet temperatures in communal bathrooms toilets and service users rooms must be regulated to 43 degrees. Ensure fire risk assessments are carried out and documented as required by the fire authority. 1st September 05 1st September 05 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. 6. 7. 8. 9. 10. 11. Refer to Standard YA6 YA6 YA6 YA7 YA7 YA15 YA 16 YA17 YA15 YA19 YA19 Good Practice Recommendations Review the current format of care plans. Include the service users prefered term of address in care plans. Include issue of keys within the care plan format. Ensure the reason for use of the monitor alarm is fully documented in the individuls care plan and any other service user who may be effected by its placement. Update the service users road safety assessment/programme. Expand the special people and birthday card list to all plans. Review the risks involved in service users being accompanied on holiday with one staff member. Provide a vegetarian option on the menu. Review the catering arrangements to minimise food having to be reheated. Include documentation in care plans to ensure that service users have an annual well person check, smear tests and other checks as applicable. Use seperate running records to ensure that chiropody, dental, optician and other rouitine healthcare checks are completed, and use in the evaluation of healthcare within care plans. Archive any old, uneccesary information in care plans. Transfer accident data to individual plans such as for falls evaluation and where care plans need to be implemented. Add a section on the weight record for action taken regarding weight gain/loss. 12. 13. 14. YA19 YA19 YA19 Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 26 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. YA19 YA20 YA20 YA21 YA22 YA23 YA32 YA32 YA37 YA35 YA42 YA42 YA42 YA42 Include medication profiles within care plans which provide information of medication review dates and changes of medication and consent documentation. Include a prompt for staff on the Drug errors policy for staff to inform CSCI of any drug errors. Staff who administer medication should have accredited training, and the manager should undertake competency assessments periodically. The wishes of srevice users for the end of their life should be obtained. Update the complaints policy to read CSCI. Ensure all staff undertake training in adult protection. Improve on the time taken to recruit staff after notices are given. The manager should work supernumery to have sufficient time to undertake his responsibilities of registered manager. Training for staff in learning disabilities autism specific should be provided for all staff. Risk assessments should be undertaken for all safe working practices within the home. A security review should be undertaken and include the provison of window retsrictors to ground floor windows. Complete the Health and Safety poster. Ensure that records of water outlet temperatures are accurate, and where they reach above 43 degrees the records indicate what action has been taken to rectify and evidence a retest. Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Edegely House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. Extracts may not be used or reproduced without the express permission of CSCI Beechwood Care Home C53 C03 S2245 Beechwood V231174 070605 stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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