Inspection on 16/06/08 for Beechwood House

This is the latest available inspection report for this service, carried out on 16th June 2008.

CSCI found this care home to be providing an Good service.

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

Beechwood House 06/06/06

Beechwood House 07/11/05

Beechwood House 14/04/05

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Beechwood House Beechwood House 40 Beechwood Road Sanderstead Surrey CR2 0AA Lead Inspector Peter Stanley Key Unannounced Inspection 16th June 2008 09:30 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 Beechwood House DS0000062807.V365583.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. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechwood House Address Beechwood House 40 Beechwood Road Sanderstead Surrey CR2 0AA 020 8651 2937 020 8405 2572 beechwoodcare@hotmail.co.uk 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) Mr Hariharen Pavaday Mrs Anjoo Poovadee Pavaday Mrs Anjoo Poovadee Pavaday Care Home 15 Category(ies) of Dementia (15), Old age, not falling within any registration, with number other category (15) of places Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care 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 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 15 Date of last inspection Brief Description of the Service: Beechwood House is a small residential home for older people situated in a quiet residential road in Sanderstead. A bus service is available to access the home. The nearest railway station is Sanderstead. The home is owned by Mr and Mrs Pavaday, and is managed by Mrs Anjoo Pavaday. The house is set back from the road and has a ramp and steps to access the front entrance. There is a large back garden that can only be reached by steps. The home accommodates up to fifteen elderly residents and is registered to admit residents in both the OP (older persons) and DE (dementia) categories of care provision for older people. The home consists of eleven single bedrooms and two double rooms. There is a residents’ lounge and dining room on the ground floor and another, smaller lounge on the first floor. The dining room is next to the large kitchen, with a door leading to the patio and back garden. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This key inspection of the home took place over one day on 16 June 2008. The registered providers, Mr and Mrs Pavaday, were present during the course of the inspection. Mrs Anjoo Pavaday is also the home’s registered manager. The inspector checked out the progress in meeting the outstanding requirements, The inspector examined a wide range of documentation. This included staff and service user records, care plans, complaints, incidents and accidents records, policies and procedures, and documentation relating to health and safety. The inspector also case-tracked the records of four residents who have been admitted to the home within the last year. No complaints have been received within the last 12 months, and there was evidence from review notes and questionnaires of a high level of satisfaction from both residents and relatives. We spoke with a wide range of residents, including two residents who have been admitted to the home within the last 12 months. Both residents indicated that they had settled in well, and that they were pleased with the home and the support provided. The views expressed by residents at this home were, once again, very favourable, with individuals presenting as settled and happy with their environment, and with the care and sport being provided. The outcome of the inspection was generally very positive, with evidence indicating that this is a pleasant, caring and well-run home, and that the commitment to maintaining and raising standards has been sustained. The home is aiming to build on earlier progress, and is evidenced to be achieving excellence in many respects. There is a positive and open atmosphere, with staff presenting as focussed, respectful and enabling in their interactions with residents. While the home has yet to develop person-centred care planning, it is nonetheless person-centred in its approach and aims to meet the individual needs, preferences and interests of residents. This philosophy of care can be further developed and formalised. To this end, the inspector recommends that the registered providers and possibly two senior care workers, apply to undertake training in Person-centred Care Planning. We observed evidence of activities with six residents being engaged in a bingo session during the inspection, this being facilitated by a staff member. The home has been endeavouring to identify individual interests and hobbies such Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 6 as reading, knitting, and gardening, and to encourage residents to participate in daily routines and activities. There was evidence of regular daily activities and flexibility of routines, with residents being able to exercise a high level of choice and control over their day-to-day lives. Residents are being consulted individually and collectively regarding their day-to-day living and routines, and in planning menus, arranging outings and events. We observed staff on duty. Staff presented as caring and skilled in their interactions with residents, this being affirmed by the feedback received from residents. There is evidence of good support and supervision for staff and of a comprehensive and ongoing programme of staff training and development. Both requirements from the previous inspection have been met. From this inspection there are 3 requirements and 5 recommendations, one of which (the need for a comprehensive Development Plan) dates from the last inspection and which remains to be fully met. The home has achieved 2 stars overall, and was assessed as excellent on one section (Complaints and Protection). Provided that the home is able to sustain and build on its’ progress to date, it is capable of achieving excellence in the longer term. Following the home’s decision to seek a change in its’ registration so as to be able to admit residents with dementia, the application was subsequently approved by CSCI on 18/1/08. All staff have subsequently received training in this area. The registered providers have indicated that they are keen to maintain a balance between those existing residents who are physically frail or disabled, and those who have dementia. They have provided the inspector with an assurance that the needs of the existing residents will be fully protected, and that the home would only be looking to admit older persons with mild to moderate dementia, and not those who may have more severe dementia or who may present more challenging behaviour. To this end, the home’s providers will be required to demonstrate over the longer term that they are able to meet the needs of both sets of residents, and that the specific needs of residents with dementia can be successfully managed alongside those of the existing resident group. The home will, for instance, need to look towards developing the skill-base of staff further so that a significant proportion of the care staff (50 plus) obtain an NVQ Level 3. We would like to extend his thanks to Mr and Mrs Pavaday, and staff, for their assistance in helping to facilitate this inspection. He would also like to extend his thanks to the residents at Beechwood for their involvement, and to those individuals who spoke at some length with the inspector. What the service does well: Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 7 Prospective residents are being provided with comprehensive and up-to-date information required with which to make an informed choice regarding the suitability of the home. Both the Statement of Purpose and the Service User Guide have been reviewed and updated. Prospective residents, their friends and relatives are able to visit to assess the suitability of the home. The home is able to demonstrate that it is obtaining full information regarding the health and support needs of prospective residents prior to their admission, and that their needs are being appropriately assessed and met. The home is ensuring that residents’ health care needs are being fully met. Residents are being protected by the home’s medication policies, procedures and training. Residents are being treated with respect and their right to privacy is being maintained. Residents can be assured that, in the eventuality of their death, their wishes will be respected and that they and their family will be treated with care, sensitivity and respect. Residents are being encouraged to maintain contact with their family and friends, with visitors being made welcome at the home. Residents have some opportunities for accessing links with the local community. Residents are being encouraged to exercise choice and control in their day-today activities and routines. Residents receive a wholesome and appealing diet, with choice being offered, in pleasant surroundings, and at times convenient to them. Residents and their relatives can be assured that the home has an appropriate complaints policy and procedure in place, and that their complaints will be listened to, taken seriously and acted upon. The legal rights of residents within the home are being well protected and promoted. Residents are living in a safe, well-maintained environment, with access to safe, sufficient and comfortable facilities. The home has been assessed by an Occupational Therapist and has sufficient aids and adaptations with which to safely meet the needs of the residents. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 8 Residents’ rooms are safe, comfortable and pleasantly decorated, reflecting residents’ personal identities, and being suited to their individual needs. The home presents as being clean, pleasant and hygienic. Generally, residents are being safeguarded by satisfactory staff recruitment policy and procedures. However, copies of birth certificates must be evidenced, together with a full health declaration. Staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of residents. In order to raise staff awareness of the needs of residents who have dementia, there has been recent dementia awareness training. At the present time, the home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s residents, and to ensure their safety. The staffing and skill levels will, however, need to be rigorously monitored, and possibly increased, given the home’s move towards accommodating more residents with dementia. Residents are living in a home that is being competently managed, and run in a way which creates an open, positive and inclusive atmosphere. Through the appropriate supervision, appraisal and support of staff, good practice is being promoted and the welfare and best interests of residents is being protected. The interests of residents are being safeguarded by the home’s record keeping, with records being kept secure, up to date and accurate. What has improved since the last inspection? The home has revised its Statement of Purpose and Service User Guide so as to refer to the changes required by its change of registration, enabling the admission of residents with dementia. Staff at the home have undertaken relevant training in dementia. The home’s policies, procedures and practice are ensuring that residents are being protected from abuse. Statutory training in adult protection has been extended to all care staff. The home has implemented two recommendations for the proper recording and storage of homely remedies, and for the clarification of the home’s procedures for ordering medication. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 9 The minutes of residents’ meetings have been made available in large print for each resident. All staff have undertaken training in infection control within the last 12 months. 5 staff have been undertaking training leading to an NCFE certificate in palliative care. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 10 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 Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 11 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): People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents are being provided with comprehensive and up-to-date information required with which to make an informed choice regarding the suitability of the home. Both the Statement of Purpose and the Service User Guide have been reviewed and updated. Prospective residents, their friends and relatives are able to visit to assess the suitability of the home. The home is able to demonstrate that it is obtaining full information regarding the health and support needs of prospective residents prior to their admission, and that their needs are being appropriately assessed and met. EVIDENCE: Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 12 A comprehensive statement of purpose and service user guide is in place. These are produced in an appropriate and accessible form (using large print) and are made available to all prospective and current residents. Following a change in the home’s registration, so as to enable it to admit older persons with dementia, the statement of purpose and service user guide have been reviewed and updated on 29.1.08. The home’s policy is for prospective residents to be invited to visit the home and to move in on a trial basis for 4 weeks. Following this trial period a review is held with the individual and his/her relatives/advocates. A decision regarding permanent placement is then made. Unplanned admissions are avoided where possible. The home has admitted four new residents within the last year, two of whom spoke with the inspector. The views expressed indicated that the residents concerned felt that they had been fully involved in the process, and that all the necessary information, and support for settling into the home, had been provided. The home issues a statement of the terms and conditions applying to the placement, this being agreed with each resident prior to their admission. The home also ensures that local authority contracts are obtained for those residents who receive local authority funding. There have been four admissions to the home within the last 12 months, all of which are privately-funded placements. The inspector examined the relevant service user files and evidenced the receipt of medical and health care information for two residents who had been admitted to the home following their discharge from the Mayday Hospital in Croydon. New residents are admitted on the basis of a full assessment undertaken by a person who is suitably qualified to do so. This is usually the home’s registered manager. The assessment is completed with the prospective resident, his/her relative or delegated representative, and any relevant professionals that have been party to the referral. The assessment format includes a number of questions relating to the individual’s mental health, with full information being obtained, where necessary, regarding the person’s dementia and mental health history. The home has recently been re-registered so as to be able to provide care for some older persons who have dementia. The registered providers confirmed that it is their intention to maintain a balance in numbers between those residents who are physically frail or disabled, and those residents whose main diagnosis is dementia. They also confirmed that the home would only be admitting older persons who have mild to moderate dementia, and not those who present more severe or challenging forms of dementia. Risk assessments, moving & handling assessments, and dependency profiles are also being completed by the home. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 13 Staff and training records indicate that the home has the range of skills and abilities with which to meet the needs of the residents. There was evidence from residents’ assessments and care plans that specific social and cultural needs are being addressed. The home is able to provide food that meets different cultural tastes and preferences. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 14 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 to 11 People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ care plans, detailing their health, personal and social care needs are being drawn up with the involvement of residents and their relatives. These are being reviewed on a monthly basis. The home does, however, need to develop more person-centred care plans, plans which reflect residents’ wishes and preferences. The home is ensuring that residents’ health care needs are being fully met. Residents are being protected by the home’s medication policies, procedures and training. The home is ensuring that residents are being treated with respect and that their right to privacy is being maintained. Residents can be assured that, in the eventuality of their death, their wishes will be respected and that they and their family will be treated with care, sensitivity and respect. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 15 EVIDENCE: Each resident has a personal dependency profile, which details emergency contacts, details of the person’s GP and social worker, and information relating to the person’s preferences, health or disability. The home maintains a care plan for each resident, for which a photograph of the resident is attached to the front sheet. These are being presented in a structured format, and provide a clear and comprehensive breakdown of residents’ care and support needs and how these are being addressed. We examined a sample of care plans. These detail residents’ health, personal care and social needs, and are drawn up in consultation with the individual and his/her relatives/advocates. The plans are based on information from assessments and are being reviewed on a regular monthly basis. Generally, risk assessments, and manual handling assessments are being completed and reviewed on a regular basis. Two of the four files for recent admissions did not, however, evidence the completion of a risk assessment. We discussed the need for care plans to become more person-centred so as to fully reflect the choices, preferences, likes and dislikes of each resident regarding the content and delivery of their care. Whilst the home is seen to be consulting both individually and collectively with residents, this needs to be reflected in the care plans themselves. As presently phrased these tend to reflect a task-led approach. The home could also extend the person-centred approach by developing individual health action plans with each resident. These would need to be developed in full consultation with each resident, their relative or representative, and with the GP and any relevant health care professionals involved with their health care. To assist this process we recommend that the registered providers, and one or two senior care workers, attend Person-centred Care Planning training with the local authority (LB Croydon). This would assist in developing the home’s awareness of the PCP process and of the ways in which this can be extended and developed. Any training could then be rolled out to staff. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 16 The health care needs of residents are evidenced from records as being generally very well met. The manager advised that there have not been any major health concerns, or any instances of pressure sores having developed. No significant concerns were identified during the inspection, although one lady who had recently been discharged from a long period in hospital, was being closely monitored. The inspector spoke with the resident who indicated that she was being well supported on her return. Daily logs and care plans indicate that residents’ health and physical condition are being regularly monitored, with professional medical help being sought as and when the need arises. Residents’ weight is being monitored on a monthly basis and recorded. No unexplained problems in regard to weight loss have been identified. Any special dietary needs (none at present) are recorded and provided for. The home is covered by a local GP practice, with one resident exercising his preference to retain his own GP. Service user records detail visits from the GP, district nurse and other health and care professionals. Residents attend for hospital visits and other appointments as required, including optician and dental appointments. There are also periodic visits from a chiropodist. Personal and oral hygiene, including the care of dentures, are actively encouraged. The promotion of continence is monitored with advice being obtained from incontinence advisors when this becomes necessary. The home has a medication policy and procedures in place. The home uses the Monitored Discharge system for administering medication. All medications are kept in a locked cabinet in an area adjacent to the lounge. While any resident who wishes to take full responsibility for their own medication is (subject to a risk assessment) able to do so, none is doing so at the present time. Advice is available from a pharmacist concerning the home’s policy on the safe handling and administration of medicines. The home has purchased a small fridge for the storage of eye drops and any other medication that needs to be kept at a controlled cool temperature. This is located in the office. The home last received a pharmacist’s inspection on 26.2.08 from the Croydon Primary Care Trust. The home received a good report, two recommendations from their previous visit on 19.6.07 having been complied with. The first recommendation related to the need for the home to draw up a list of homely remedies in consultation with the home’s GP, and to store all homely remedies in a separate container. The second recommendation related to the need for new guidelines to be put in place for the ordering of medication from the pharmacy, so as to provide clarity in this area. The inspector was able to evidence that the two recommendations had been implemented, and was shown a copy of the last pharmacist’s report. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 17 The manager advised that any controlled drugs that may be prescribed are reviewed at six-monthly intervals by the home’s GP. She also advised that, at the present time, there are no residents at the home who are being prescribed any controlled drugs. The manager confirmed that all care staff who work at the home have received accredited medication training, including a new care worker who started in January 2008. The London Borough of Croydon provides this training. The home adheres to a clear policy and practice with regard to ensuring that the dignity and rights of residents are upheld in all matters associated with personal physical and medical care. Individuals are able to see their GP in the privacy of their own bedroom and without the attendance of staff if they prefer. Residents’ wish to spend time in their own rooms is respected, and staff have been observed to knock on residents’ doors before entering. All residents have a lockable space in their bedrooms for storing personal possessions and valuables. Residents are able to see visitors in the dining room or in the relative privacy of a pleasantly furnished, quiet lounge on the first floor. The inspector spoke with a number of residents. This indicated that relatives and friends are made welcome at the home and that residents are able to see them in the first floor lounge or in the privacy of their own rooms. Relatives are also being encouraged to take residents out for tea or an outing if they so wish. We spoke with a number of residents during the inspection. The views expressed by residents indicate that staff are respectful of residents’ privacy and dignity, and are sensitive to individuals’ needs and rights. One resident said that she could not speak “highly enough” of the staff and that “if any problem arose, this was quickly attended to”. Staff were observed to be engaging with residents in a friendly, kind and respectful manner, and there was every indication of there being good, trusting relationships between staff and residents. Individuals’ and relatives’ wishes regarding the eventuality of death and funeral arrangement are duly noted in each file. Over the last 12 months there have been three deaths at the home, two of which have occurred in hospital. The home tries to ensure that relatives are kept informed of any lifethreatening conditions or illnesses, and to consult with and involve them in any decision-making relating to their subsequent care and treatment. The home has previously accessed training in loss and bereavement. This has assisted staff to develop relevant skills with which to support residents and relatives throughout the bereavement process. Feedback previously received from relatives, through letters, comments and questionnaire returns, indicates that episodes of loss and bereavement are being handled in a sensitive way. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 18 The home is not able to specifically cater for the needs of older people who are terminally ill and who require nursing and palliative care. Five staff have, however, been undertaking NCFE certificated training in palliative care, which they are due to complete in July 2008. The home recognises that residents may pass away unexpectedly whilst in residence and this has happened in the past. The manager and staff are given all the necessary information through policies and procedures if such an event occurs. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 19 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 to 15 People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are being provided with a varied range of opportunities for leisure and social activities. These are in accord with their social, cultural and religious interests and needs. To ensure the inclusion of residents who have limited abilities or dementia, the home will need to develop additional activities that are tailored to their specific needs. Residents are being encouraged to maintain contact with their family and friends, with visitors being made welcome at the home. Residents have some opportunities for accessing links with the local community. Residents are being encouraged to exercise choice and control in their day-today activities and routines. Residents receive a wholesome and appealing diet, with choice being offered, in pleasant surroundings, and at times convenient to them. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 20 EVIDENCE: We spoke to a number of residents and observed activities taking place. This included a bingo session in which five residents were participating, the session being facilitated by a staff member. Inspection of the minutes from residents’ meetings indicated that residents are being consulted as to their interests and wishes. Views expressed individually by residents indicated that there is a variety of organised activities that take place within the home (usually after lunch) and that residents are presented with options as to proposed activities and outings. From the questionnaire returns, residents generally seemed satisfied with the activities being offered though two residents stated that they did not feel able to participate, and one resident expressed a wish for more activities. The home has recently changed its’ registration so as to be able to admit more residents with dementia. Given the differing needs presented by this client group, the home will need to develop activities and therapies in which residents can readily engage and participate. This may include the need for more one-to-one facilitated activity, and the provision of activities such as drawing and colouring, soft handball games, and puzzles. The home offers a varied range of activities, which include a weekly music and movement session, bingo and manicure. Quizzes, including a variation on the game ‘Millionaire’ are held, residents having the opportunity to demonstrate the extent of their general knowledge. Those less able in this regard are supported in other activities. A reminiscence session, which is held every 2-3 weeks, has proved popular. An entertainment, comprising of song, dance and performance, is provided three times a year by a group of entertainers called Troubadour- at Christmas, Easter and at the annual summer garden party to which relatives, friends and visitors are invited. A Christmas party is also held at the home. Many of the residents enjoy reading, a small library being provided with a varied selection of books being provided in the first floor lounge. The lounge provides a pleasant and quiet place for anyone wishing to read. Newspapers are also made available on a daily basis. In line with the home’s wish to extend choice, residents are being encouraged to develop their individual interests and hobbies. Two ladies enjoy knitting, while another resident likes to assist in the garden, and another, with an interest in music, enjoys singing to the residents. Other residents are encouraged to participate as fully as they feel able in daily routines and activities. The home has access to a minibus that it is able to use for outings, with occasional outings to places of interest being arranged. Residents’ views are canvassed, with outings being arranged to places such as garden centres, Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 21 country pubs, tearooms, theatres and concert halls. This has included a popular return visit to the Garden Centre in Warlingham where residents are able to enjoy the plants and partake of tea and refreshments in the tearoom. Visitors are encouraged to visit and maintain contact with residents. From the feedback that has been received, relatives and other visitors are made to feel welcome at the home and are able to go on outings. The inspector discussed the option of starting a relatives group, to meet 3 or 6 monthly, with view to sharing information, extending the scope for relatives’ involvement with the home, and providing the opportunity for mutual support. This is included as a recommendation Links with the community are maintained with a range of visitors to the home. Residents are able to go out to the shops, or elsewhere, providing that they have been risk assessed as safe to do so. One resident said that she would like to go out more as she had always enjoyed walking. Dial-a-ride is available if required. Residents also attend community lunches at the local Church Hall, these being held about three times a year. From the views that have been expressed directly to the inspector, and in questionnaire returns, it is apparent that residents are being consulted regarding their choices and preferences, and that there is flexibility in their daily activities and routines. Where there are expressed preferences of food or activity, the home is endeavouring to meet these. The manager advised that, in line with their wishes, some residents take breakfast, and other meals, in their rooms, when this is their clearly expressed wish. Residents are able to spend time in their rooms as they please, or to arrange to go out with friends, relatives or with a staff member. Residents’ meetings are evidenced as being held on a regular two-monthly basis, with individuals’ views, and details of issues discussed, being recorded. We spoke with a number of residents about the quality of food that is served. The response was very favourable with residents saying how much they like the food. A daily alternative to the main menu choice is provided, all of the food being home-cooked by the home’s cook. The food was felt to be very good and varied, with good portions being served. It was also felt to be accommodating of individual tastes and preferences. Residents are consulted as to their preferred choices in residents’ meetings, with curries having become a popular choice. Whilst any special dietary needs are taken account of, none of the residents have any special needs at the present time. Residents’ are monitored for any unexplained weight loss or gain, with any specific problems regarding their dietary intake being referred to a dietician. We examined menus provided over a three-week period. These evidenced a nutritious and varied choice of food with fresh vegetables and fruit being included in the diet, and with an alternative main course being provided. The inspector observed residents in the dining room at lunchtime. Sat in small Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 22 groups around neatly laid tables, the dining room presented as a very pleasant place for having their meals. However, residents can, if they wish, take meals in their own rooms. The home provides tea and biscuits in the afternoon, and supper at about 5.30, which includes soup, sandwiches and cakes. A hot drink is available before going to bed if required. We toured the kitchen, which is adjacent to the dining room. Storage arrangements were satisfactory, and good standards of cleanliness and hygiene were observed. The cook, who is relatively new to the home, has obtained an NVQ Level 3 in Catering, and she and other staff have completed food hygiene training. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 23 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 to 18 People using this service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be assured that the home has an appropriate complaints policy and procedure in place, and that their complaints will be listened to, taken seriously and acted upon. The legal rights of residents within the home are being well protected and promoted. The home’s policies, procedures and practice are ensuring that residents are being protected from abuse. Statutory training in adult protection has been extended to all care staff. EVIDENCE: Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 24 The home has an excellent record, with no complaints having again been recorded over the 12-month period since the previous key inspection, and none within the last 3 years. The home has an appropriate complaints policy and procedure in place, which residents and their relatives are made aware of. A summary is included in the Statement of Purpose and Service User Guide. The inspector spoke with a wide cross-section of residents during the course of his visit. No concerns were raised, and residents presented as safe and secure, and trusting of staff. The home aims to protect residents’ legal rights by involving family and friends in respect of their contracts, benefits and monies, and in discussing any issues that may arise. Appropriate policies and procedures for protecting residents’ rights and interests are in place. All residents are registered to vote, and are supported to exercise this right, usually by the use of postal vote. There have been recent local elections in which 7 of the 15 residents chose to exercise their right to a postal vote. Any issue that affects the rights and best interests of residents can be discussed either individually with the manager or the person’s key worker, or it can be raised as a more general issue within the residents’ meeting. The home welcomes feedback from relatives, friends, professionals and other visitors regarding any issues or concerns that affect residents, and aims to promote a culture of openness and transparency. Returns from the home’s surveys indicates a high level of satisfaction with the home and its’ care and support of residents. The home has achieved a consistently good record in protecting its’ residents from any eventuality of harm or abuse, no allegations of abuse having been recorded. The home has appropriate adult protection and whistle-blowing policies in place. Apart from two new staff (who are presently on Croydon’s waiting-list), all staff that work in the home have attended statutory training for the protection or ‘safeguarding’ of adults. Throughout the inspection, staff were, once again, observed to be respectful and caring in their interactions with residents. From the observations of the inspector, and the views expressed by residents, it is clear that residents enjoy good, trusting relationships with the management and staff, and that they feel safe, settled and secure within their environment. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 25 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): People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are living in a safe, well-maintained environment, with access to safe, sufficient and comfortable facilities. The home has been assessed by an Occupational Therapist and has sufficient aids and adaptations with which to safely meet the needs of the residents. Residents’ rooms are safe, comfortable and pleasantly decorated, reflecting residents’ personal identities, and being suited to their individual needs. The home presents as being clean, pleasant and hygienic. EVIDENCE: Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 26 The accommodation provided for the home’s residents presents as being safe, warm and comfortable throughout. The home was externally redecorated in 2006-07 with all residents’ rooms having been redecorated. Paving around the home were re-laid and levelled out to improve both appearance and safety. Double-glazing has been installed throughout the home; this has assisted in reducing the external noise of traffic and in reducing heat loss. The garden areas have been re-planted, and there are plans to try to improve accessibility to the large upper garden at the rear of the home. Generally, the home is in a good state of interior decoration and the premises have been well maintained and comply with both fire and health and safety requirements. There has been re-carpeting of the main staircase and corridors on the first and second floors, and both re-decoration and re-carpeting in the dining room and communal lounges. There has also been re-carpeting of most of the residents’ rooms, with ongoing planned re-carpeting of the remaining rooms. The communal areas provide a pleasant, homely environment. There are two lounges, one of which is on the first floor, and which provides a pleasant and relatively quiet place to sit and relax. The downstairs main lounge is not ideal in terms of dimensions, being long and narrow and thus a bit restrictive in terms of the layout of armchairs, being arranged in a row around the walls. The lounge does, however, provide adequate space for the residents to sit, and presents as being warm, comfortable and pleasantly furnished. A widescreen television is due to replace the existing television set, which should improve the viewing of programmes. Together with the lounge, the dining room has been re-decorated and re-carpeted, and provides a very pleasant area in which to take meals. Residents said that they were very happy with their surroundings and with the facilities provided. We looked at a number of residents’ bedrooms, and found these to be pleasantly furnished and laid out, and reflective of the personal tastes and identities of their occupants. There are 11 single rooms and 2 double bedrooms, which meet the requirements for minimum size. While residents’ rooms are not ensuite, the home has sufficient bathrooms and toilets with which to meet residents’ needs. Each floor has its own bathroom and toilet facilities. Both first floor and second floor bathrooms have had new flooring laid down, improving both the appearance and ease for maintaining hygiene. One bathroom contains an ambu-hoist. There are plans to renovate the first floor bathroom so as to include a walk-in shower. All the bathrooms and toilets were observed to have liquid soap and paper towels provided, and to be kept in a clean and hygienic state. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 27 Generally, adaptations have been made to various areas of the home so as to ensure the health and safety of the residents and maximise their independence. One bathroom has an ambu-hoist, and grab rails are in place in the other bathroom. There is a passenger lift in place from the ground floor to the first floor. Handrails are in place on the staircases. Any adaptations or specialist equipment that is needed is assessed by an occupational therapist on an individual basis as and when required. The home was last assessed by an occupational therapist in July 2006, as a result of which the home implemented a recommendation for the installation of raised toilet seats and frames. Central heating can be controlled in each individual room. There is an emergency lighting system. Hot water temperatures are tested daily and records indicate that these are within safety limits. All radiators within the home are either low surface temperature radiators or have been covered with appropriate guards. The home presented as clean and free from offensive odours at the time of the inspection. Since an inspection in 2006, the home has employed a cleaner to cover cleaning duties for at least 18 hours throughout the week. This has assisted in maintaining and raising standards of cleanliness and hygiene within the home, and has enabled care staff to focus more fully on meeting the care and support needs of the home’s residents. All staff within the home, including two new staff, have completed both infection control and food hygiene training. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 28 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 to 30 People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. At the present time, the home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s residents, and to ensure their safety. The staffing and skill levels will, however, need to be rigorously monitored, and possibly increased, given the home’s move towards accommodating more residents with dementia. Generally, residents are being safeguarded by satisfactory staff recruitment policy and procedures. However, copies of birth certificates must be evidenced, together with a full health declaration. Staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of residents. In order to raise staff awareness of the needs of residents who have dementia, there has been recent dementia awareness training. EVIDENCE: Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 29 Staffing levels are in accordance with the original agreement prior to the Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older people. This is subject to adjustment should the dependency of the residents increase or if a crisis occurs that would warrant an increase in staffing levels. With the recent change in the home’s registration, enabling the admission of residents with dementia, dependency levels may increase over time, hence staffing levels will need to be rigorously monitored and increased if necessary. On the day of inspection appropriate numbers of staff were found to be on duty. The home has 10 care staff and 2 ancillary staff (a cook and a cleaner). The inspector examined staff rotas. These indicated that the manager (or person-in-charge) is on duty with two care workers (together with a cleaner and cook) throughout the day, and two care workers (one waking, one sleepin) at night. Since the last inspection two new staff, one care worker and a cook, have commenced employment at the home. The inspector completed checks on staff files and found that evidence of identity and recruitment checks having been completed, including two references and up-to-date CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) certificates. There were, however, two omissions, both of which necessitate a requirement. As detailed in Schedule 2 (2) of the regulations, a copy of the person’s birth certificate is required, a copy of which did not appear on either of the two staff files that were examined. The home also needs to fully comply with Schedule 2 (6) and provide evidence, in the form of a signed health declaration, that the person is physically and mentally fit for the purposes of the work that he/she is to perform. The health declaration needs to be structured so as to detail responses as to whether the applicant has had any of a list of illnesses, infections or diseases, and should also detail any vaccinations. Advice should be sought from the home’s GP or the Primary Care Trust regarding an acceptable format. A checklist, indicating all the checks and documentation required and the date when these have been obtained, did not appear on either of the two staff files. The inspector wishes to see staff files include a list of all the identity and recruitment checks that are required prior to appointment, with the dates being entered for when these have been completed. Inspection of files evidences that staff have the relevant qualifications and skill mix with which to meet residents’ needs. The home currently has 10 care staff, of whom seven have an NVQ Level 2 social care qualification, and two are working towards an NVQ Level 2. The manager advised that one senior care worker has an NVQ Level 3, while two others are currently undertaking an NVQ Level 3. The registered manager possesses an NVQ Level 4, and a senior care Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 30 worker (who deputises in the manager’s absence) has a nursing qualification (RGN). Given that the home is now admitting residents with dementia, it needs, in the longer term, to aim to develop the skill-base of staff further so that a significant proportion of the care staff (50 plus) obtain an NVQ Level 3. This is a recommendation. It was pleasing to note that all staff (apart from two recently recruited care workers) have completed training in dementia awareness (‘Working with people with a dementia ‘). The training, which took place at the home on 21/11/07, was facilitated by an external training provider, and was certificated for each staff member. The home provides a comprehensive programme of induction and foundation training, which is completed within the first three months of the staff member’s start date. A wide range of ongoing training is provided, which includes health and safety, moving and handling, medication, food hygiene, fire safety, first aid and infection control. All apart from two new staff (who are on the waiting list) have completed statutory adult protection training with LB Croydon. All care staff, including a new care worker, have completed accredited medication training, while 5 staff are currently undertaking study for the NCFE Certificate in Palliative Care. Infection control training (with LB Croydon) has been updated within the last 12 months for all staff, the most recent session having been held in February 2008. The training completed and scheduled by each staff member is recorded and monitored on a staff training profile. This was examined by the inspector and found to have been appropriately maintained. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 31 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): People using this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are living in a home that is being competently managed, and run in a way which creates an open, positive and inclusive atmosphere. The home is consulting widely with residents, relatives and other stakeholders, and is beginning to evidence the home’s ability to meet its aims and objectives. The home needs, however, to develop a more detailed and explanatory Development Plan for 2007-08. Through the appropriate supervision, appraisal and support of staff, good practice is being promoted and the welfare and best interests of residents is being protected. The interests of residents are being safeguarded by the home’s record keeping, with records being kept secure, up to date and accurate. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 32 EVIDENCE: The registered providers, Mr and Mrs Pavaday, present as fit and competent persons to run the home. Mrs Pavaday, who is the registered manager, has undertaken studies leading to the award of the NVQ Level 4 and RMA (Registered Managers Award) management qualification, and an AA1 NVQ Assessors Award. The management approach has been evidenced as being open and enabling, and conducive to creating a positive and inclusive atmosphere in the home. Views expressed by residents were again very favourable, with individuals indicating that the home is being run in their best interests. No relatives were available to speak to on this inspection, but previous feedback has been positive. Following the home’s decision to seek a change in its’ registration so as to be able to admit residents with dementia, the application was subsequently approved by CSCI on 18/1/08. All staff have subsequently received training in this area. The registered providers have indicated that they are keen to maintain a balance between those existing residents who are physically frail or disabled, and those who have dementia. They have provided the inspector with an assurance that the needs of the existing residents will be fully protected, and that the home would only be looking to admit older persons with mild to moderate dementia, and not those who may have more severe dementia or who may present more challenging behaviour. To this end, the home’s providers will be required to demonstrate over the longer term that they are able to meet the needs of both sets of residents, and that the specific needs of residents with dementia can be successfully managed alongside those of the existing resident group. The home has been maintaining its quality assurance processes and has completed questionnaires with all residents. Questionnaires have also been completed with the relatives and friends of residents, and with those who visit in a professional or voluntary capacity, including a GP, district nurses, the chiropodist and hairdresser. Following a requirement from the last inspection, the home has compiled a development plan for 2007-08. While the format has been developed, it still needs further revision to provide a more detailed and explanatory format. The Plan should aim to summarise the main findings from the feedback received from questionnaires and other sources, identify relative strengths and shortcomings, and detail the main priorities (and strategies for addressing any Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 33 shortcomings) for the year ahead. The Plan needs to evidence that the home is meeting its aims and objectives and that it is being run in the best interests of its’ residents. While included as a recommendation, this must be given a high priority. The home is able to demonstrate it’s financial viability, the home’s providers having obtained an audited set of accounts for the years ending 2006-07, and a business and financial plan having been put in place. The registered manager ensures that any resident who wishes to control his or her own monies are able to do so. The manager advised that the home does not act as an appointee for any residents, and that either a relative or solicitor fulfils this role where the person is unable to manage their own monies. The home maintains a record of receipts and expenditure on behalf of one resident for whom a solicitor makes periodic payments from the resident’s account. We examined a sample of staff files and evidenced that supervision is being provided on a regular two-monthly basis. A senior care worker has been delegated the supervision of a small number of care staff. The senior care worker did not, apparently, wish to undertake a supervision training course, but has been supported in developing this role by the manager. The manager advised that another senior care worker, who is currently studying for an NVQ Level 3, will, on completion, be assuming a supervisory role. A system of annual appraisal is in place, all staff having last been appraised in March 2008. We examined a wide range of the home’s records, including staff and residents files, complaints, accidents/incidents logs, and records relating to the running and maintenance of the home. These were found to have been satisfactorily maintained, with residents’ best interests being protected. The manager is ensuring that all the home’s policies and procedures are being reviewed and updated on an annual basis, these having been most recently reviewed in February 2008. A checklist is being maintained detailing when these were last reviewed. We were generally satisfied that the health, safety and welfare of residents and staff are being appropriately protected. All staff at the home have completed infection control training, and food hygiene training. Fire and Health & Safety risk assessments were last updated on 28 January 2008, with fire alarm and emergency call system checks being completed (and recorded) by the home on a weekly basis. Health and safety checks, including the inspection of the home’s portable electrical appliances, gas supply, fire equipment and alarms, emergency lighting and emergency call system, have been completed within the last 12 months. Hot water temperature, Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 34 fridge/freezer are being completed on a daily basis, and oven temperature checks on a weekly basis. The home’s lift and hoists are serviced on a 3 monthly basis, the most recent inspection having taken place on 21/5/08. There is one health and safety check, for legionella in the water supply, that is overdue, this last having been completed in March 2007. This needs to be renewed, and a copy of the certificate forwarded to the inspector. A requirement applies. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 35 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 4 3 3 3 4 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 4 18 4 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 2 3 3 3 3 3 Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 36 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19(1)b Schedule 2 (2) Requirement Recruitment checks. As part of the verification of the person’s identity, a copy of the applicant’s birth certificate must be evidenced on the staff file. A copy of the birth certificate must be obtained for all future staff appointments. 2 OP29 19(1)b Schedule 2 (6) The home must provide evidence, in the form of a signed health declaration, that the person is physically and mentally fit for the purposes of the work which he/she is to perform. The health declaration needs to be structured so as to detail responses as to whether the applicant has had any of a list of illnesses or diseases, and should also detail any vaccinations. Advice should be sought from the home’s GP or the Primary Care Trust regarding an acceptable format. Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 37 Timescale for action 30/06/08 30/09/08 3 OP38 13(4)(a) & (c) Health and safety. To ensure residents’ safe use of the home’s water supply, the home must obtain an up-to-date certificated check for legionella. A copy of the certificate must be forwarded to the inspector. 31/07/08 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 OP13 Good Practice Recommendations Relatives’ involvement. The recommends that the home consider starting a relatives group, to meet 3 or 6 monthly, with view to sharing information, extending the scope for relatives’ involvement with the home, and providing the opportunity for mutual support. 2 OP12 Activities. Given the differing needs presented by persons who have dementia, the home will need to develop activities and therapies in which residents can readily engage and participate. This may include the need for more one-toone facilitated activity, and the provision of activities such as drawing and colouring, soft handball games, and puzzles. 3 OP27 NVQ training. Given that the home is now admitting residents with dementia, it needs, in the longer term, to aim to develop the skill-base of staff further so that a significant proportion of the care staff (50 plus) obtain an NVQ Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 38 Level 3. 4 OP29 All staff files should include a list of all the identity and recruitment checks that are required prior to appointment, with the dates being entered for when these have been completed. Quality Assurance. The Development Plan should summarise the main findings from the feedback received from questionnaires and other sources, identify relative strengths and shortcomings, and detail the main priorities (and strategies for addressing any shortcomings) for the year ahead. The Plan needs to evidence that the home is meeting its aims and objectives and that it is being run in the best interests of its’ residents. This was included as a recommendation in the last inspection report, but has yet to be fully implemented. 5 OP33 Beechwood House DS0000062807.V365583.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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