Inspection on 22/05/07 for Beechwood House

This inspection was carried out on 22nd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beechwood House 06/10/09

Beechwood House 14/07/09

Beechwood House 13/10/08

Beechwood House 19/06/08

Beechwood House 25/07/06

Beechwood House 04/10/05

Beechwood House 22/09/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Beechwood House Front Street Earsdon Whitley Bay Tyne & Wear NE25 9JU Lead Inspector Jackie Burke Key Unannounced Inspection 22 –24 May 2007 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 DS0000061572.V338222.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 DS0000061572.V338222.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechwood House Address Front Street Earsdon Whitley Bay Tyne & Wear NE25 9JU 0191 252 4840 F/P 0191 252 4840 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) Redcote Homes Limited Vacant Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2006 Brief Description of the Service: Beechwood House is a residential care home for older people situated in the village of Earsdon. There are two public houses in the village and a local bus service. Accommodation is provided over two floors. Access to the first floor is via a passenger lift. There are 27 bedrooms, none of which are en suite. Toilets are located throughout the building and commodes are provided in bedrooms overnight. There are five bathrooms three of which have assisted baths and one incorporates a roll in shower. There is a mobile hoist available in the home. Beechwood House has a large lounge and conservatory on the ground floor and two dining rooms. The home is pleasantly decorated and furnished throughout and there is a private garden to the rear. Nursing care is not provided at Beechwood House. The cost of services provided by Beechwood House range from £361 to £385 per week. Information, including inspection reports, is provided for service users to enable them to make a decision about moving to Beechwood House. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report is of an unannounced key inspection. The inspection took place over three days between the 22nd and 24th May 2007. The manager completed a pre- inspection questionnaire and submitted it to the Commission for Social Care Inspection. This key inspection took 9.5 hours. Time was spent talking with service users, visitors and staff. Observations of staff and service users also took place. Time was spent talking to the acting manager and the provider. Care plans, accident records, medication records and daily records were looked at during this inspection and this was linked to observations and discussions with service users. Staff files and training records were looked at to ensure that recruitment and employment practice follow policies, which are in place to safeguard service users. Beechwood House has experienced staffing changes since the last inspection. A manager was appointed in August 2006 but has not yet registered with CSCI. In April 2007 the manager moved to another home within Redcote Homes Ltd and an acting manager was appointed. The acting manager has since been offered the post of manager at Beechwood House. The owner has agreed to apply to register both managers with the Commission for Social Care Inspection. What the service does well: Beechwood House provides a pleasant homely environment for people who live there. Families and friends are encouraged to visit. Caring skills and positive attitudes of staff were demonstrated during the inspection when a resident took ill in the dining room. Staff showed that they had skills and were caring toward another resident who was recently discharged from hospital by staying with her and giving her reassurance. Residents have a pet cat and are supported to care for it. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Assessment of needs should contain accurate information regarding the needs of each individual and this should include relevant information regarding medication needs and risk assessments. Some staff members showed that they lacked awareness regarding good practice in care and failed to provide appropriate support and care. A resident who was unwell and distressed following her discharge from hospital was left in her room with her breakfast out of reach and placed on a bedside table next to a container of bodily fluid. Care practice training should be provided to all staff to ensure that consistent quality is maintained within the home. Attitudes of some staff and the way they speak about residents in some cases shows disregard, lack of awareness & lack of respect. Some staff showed that they lack knowledge in safe moving and handling techniques and the use of specialist equipment. An anomaly in the medication ordering system was identified during the inspection. Staff should not make changes to the MAR chart as this could lead to potential medication errors. Family members provide culturally specific foods for one resident. Work should be done to develop ways in which the home can meet dietary needs for this service user. The smoking policy within the home should be reviewed in line with current smoking legislation to ensure that the rights of other residents are not affected by the location of the designated smoking area. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 7 Work has been underway at Beechwood House to improve the environment however curtains and carpets in some rooms are shabby and need to be replaced. Beds in some residents rooms are worn and fabric torn and should be replaced. An environmental audit should take place as part of a quality assurance system to develop and improve standards within Beechwood House. Staff should be reminded to lock the door of cleaning cupboards and to hang the keys out of reach on the hooks provided to ensure the safety of service users. The new manager of the service requires support to develop her management skills and should receive regular supervision and mentor support from a peer and should be given support to achieve NVQ level 4 and the Registered Managers Award. The new manager is aware that she must register with the Commission for Social Care Inspection. Supervision should be provided to all care staff at least 6 times per year. Quality assurance systems should be further developed within Beechwood to determine the views and opinions of service users. This may include manager’s daily rounds, meetings with service users families and staff and handover meetings with staff as well as a comments and suggestions book 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 DS0000061572.V338222.R01.S.doc Version 5.2 Page 8 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 DS0000061572.V338222.R01.S.doc Version 5.2 Page 9 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): Standard 3 Quality in this outcome area is adequate Service users needs are assessed before moving into Beechwood House so that the manager knows that identified needs can be met by the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care files were looked at during this inspection. Care files have been changed within the service since the last inspection. Assessment documents are included within each individuals care file. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 10 A care manager in the local authority requesting care from this service carries out an assessment for each person and this is supplemented by the manager’s assessment of needs. In some cases where people are paying for the service privately the manager carries out a separate needs assessment. Assessment information includes physical needs, a personal profile and risk assessment. One file looked at contained inaccurate information regarding a falls assessment. Assessment documents do not contain information regarding medication however a statement is included to refer to the medication administration record. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 11 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): Standards 7,8,9 & 10 Quality in this outcome area is adequate. Care files contain some information regarding the needs of people who use services so that staff may provide health and social care. There is a policy for dealing with medication, which safeguards service users. People are on the whole treated with respect and their privacy is safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care files were looked at during the inspection and time was spent in the lounge with residents and staff to gain insight into daily life in Beechwood House. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 12 Care plans have been changed since the last inspection however information contained in care plans during this inspection was incomplete and failed to give a full picture of residents needs. Care files contain some information on needs assessment and how needs will be met; however this is not complete. Care files are not fully used as a working document by staff members and instead a daily file has been developed which includes daily records and relevant information for all residents. Discussion took place with the acting manager as to how care files may be used as active documents. Discussion also took place regarding confidentiality issues in the use of the daily file. Care plans are not reviewed or evaluated and changes in residents needs are not fully recorded. Records show that referrals are made on behalf of residents to GP’s and to District Nurses. Observation of service users and staff showed that some staff are very caring in their approach toward residents and that they are aware of the needs of individuals. On the first day of inspection a resident was taken ill and staff supported her in a caring and respectful way offering reassurance and calming her fears. On day two another resident was unwell and anxious and a member of staff reassured her and supported her whilst undertaking the medication round. Staff demonstrated care and affection toward a resident for whom English is a second language by using hand signals and nonverbal communication to greet him in the corridor. Some staff members showed that they lacked awareness regarding good practice in care and failed to provide support and care in one instance by leaving breakfast out of reach of a frail unwell resident and by placing a container of bodily fluid on a bedside table in that person’s room next to her breakfast. Some staff showed that they lack knowledge in safe moving and handling techniques and the use of specialist equipment. There are medication policies and procedures are in place at Beechwood House. An audit of controlled medication during the inspection confirmed that records are maintained and medicines are stored appropriately. Senior staff who administer medication within the home are trained to do so and the medication policy within the home is followed. Observation was made of the way that medication is administered within the home and showed that staff are aware of the medication policy and that support and reassurance was given to service users. Medication, which is no longer required, is returned to the pharmacy. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 13 An anomaly in the medication ordering system was identified during the inspection whereby three residents medication is received from the pharmacy one week behind other service users. Staff write in the dates on the Medication Administration Record to achieve consistency, which could lead to potential medication errors. There is a fridge in the medicine room, which is used to store eye drops. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 14 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): Standards 12,13,14 & 15. Quality in this outcome area is adequate. Beechwood House fails to provide a good standard and variety of activities. This means that the environment is not stimulating for people who live there. Links with families, friends and the community are encouraged. People are able to exercise limited choice in their lives. Beechwood House provides a balanced diet for residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Activities are not routinely provided within Beechwood House, as there is not a designated activities coordinator. Nail care, board games and limited armchair exercise are provided when staff members are available. The social environment is compromised by care needs, which take precedence within the home and by staff shortages. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 15 Residents spoke of choosing where they liked to sit and what time they liked to go to bed and to get up. One person said that some of the staff were very good and that they will help when you ask. One person said that she had concerns that there were no activities available for residents and that there were social events at the local church in the village but residents were not given the opportunity to attend. One resident currently smokes at Beechwood House and some work has been done following guidance from the Fire Service to provide him with a safe place to exercise his choice to smoke. The area designated for smoking within Beechwood House is the small dining room. Visitors were observed to come and go freely during the inspection days and service users and visitors confirmed that they were welcomed to Beechwood House. There is a pet cat living in the home, which provides companionship and affection to a number of people. There is a communication plan in place for a service user whose first language is not English. This includes translations of phrases, which have been written on cards and laminated, to promote effective communication between staff, other service users and the individual. There is a new cook at Beechwood House who hopes to spend some time developing new menus based on the likes and dislikes of residents. Meals are provided on the premises and are cooked fresh daily. Residents are given a choice of cooked lunch and alternatives may be provided as requested. Choices are offered at teatime and suppertime and tea and coffee is provided during the day and evening. Cold drinks are available and fresh fruit is available on request. Special dietary requirements may be catered for including diabetic diets and low fat options for people with high cholesterol levels. Family members provide specific cultural foods for one service user. The kitchen staff have not as yet developed a menu, which takes account of the cultural dietary needs of service users in Beechwood House. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 16 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): Standards 16 & 18 Quality in this outcome area is adequate. There is a complaints policy in place and service users complaints are dealt with and people are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a new complaints policy and procedure at Beechwood House. Three complaints have been recorded since changes have been made, two of which has been dealt with appropriately following the complaints procedure. The outcome of one complaint had not been fully followed up by the manager. Residents spoken to say that they would speak to the manager if they had a complaint. One complaint has been made about the way in which Beechwood House dealt with the review of a service user and poor care standards. The local authority is involved and the home is undertaking an investigation. No record has been made of this complaint within the complaints procedure. One person commented that the changes in management were unsettling but acknowledged that improvements had been made in the home which she hoped could be sustained. One person said that she had asked for improvements to be made in her relative’s room furniture but was not confident that anything would be done to improve this. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 17 There is some awareness in the home of the protection of vulnerable adults. POVA training has not been provided to all staff and the acting manager has made a commitment to arrange training for remaining staff members. Recruitment policy and practice within the home safeguard the best interests of service users. Vacancies are advertised in the local press and job centre and interviews for staff are done by the manager. Four staff files were examined during the inspection and confirm that written references are requested and Criminal Record Bureau checks made. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 18 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): Standards 19, 21 & 26 Quality in this outcome area is adequate Work is underway to ensure that service users live in a safe well-maintained environment. There are sufficient bathrooms available. The home is not clean, pleasant and hygienic. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are five bathrooms in Beechwood house one of which is a combined bath/shower facility. Four bathrooms are now available for use by residents Carpets in some rooms need to be replaced as they are soiled and worn. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 19 Carpet in the dining room has already been replaced but must be changed again as the material was not durable enough for a communal area in daily use. Furnishings in some bedrooms are shabby and worn and in one room the bed base is torn, dirty and unsightly. Curtains need to be replaced within the home to include appropriate tracking. On the first day of inspection there was an unpleasant smell within the home from commode pots, which had not yet been emptied. A programme of refurbishment and redecoration is underway and the provider is committed to making changes necessary to improve standards in Beechwood House. A cleaning cupboard door was left unlocked with the key in the door during the first day of inspection. COSHH guidelines are displayed on both storage cupboard doors and cleaning materials are clearly marked and correctly stored. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 20 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): Standards 27,28,29 & 30 Quality in this outcome area is adequate There are sufficient numbers of staff provided to meet the needs of service users. Staff training is required to ensure that all service users are in safe hands at all times. Recruitment policies and practices are in place to support and protect service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the days of inspection there were three care staff and the manager on duty, one cleaner and two kitchen staff. Shifts are covered: 8am-3pm Manager Senior Care Two care staff 3-10pm Senior Care Two care staff 10pm-8am Two care staff There remain some vacancies within the home, for which recruitment is underway. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 21 There have been some management changes recently within Beechwood House, which have had an impact on the way that the service is run. The deputy manager is currently acting up as manager and during the inspection visits made the decision to take the post as manager offered to her by the provider Mrs Sitharanjan. There is a vacancy for deputy manager for which the manager hopes to recruit a replacement There is a commitment to training and development within Beechwood House however there have been some difficulties with training providers. Staff files show that 80 of staff have achieved NVQ level 2, however there are a number of staff who have yet to complete their NVQ training. Moving and handling training has not yet been arranged for staff despite this being an outstanding requirement from a random inspection undertaken in February 2007.Observation of staff transferring service users showed that they were unclear as to safe moving and handling procedures and the use of specialist equipment. Senior staff have had Safe Handling of Medication training from the Primary Care Trust. A training audit is underway to identify gaps amongst staff in training, skills and knowledge. Discussion with staff and observation of practice during the inspection showed that some staff have care and attitude training needs. Some staff showed that they had a positive caring attitude toward residents whilst a minority demonstrated a patronising attitude, speaking of residents as “like little kids” and of needing to be “coerced into doing things that are good for them”. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 22 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): Standards 31,33,35,36 & 38. Quality in this outcome area is adequate People at Beechwood House live in a home, which is managed by a person of good character, who is fit to be in charge. The service does not always operate in the best interests of service users .The financial interests of service users are safeguarded. Staff are not appropriately supervised. The health, safety and welfare of service users and staff is not fully promoted and protected. This judgement has been made using available evidence including a visit to this service. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 23 EVIDENCE: There have been some management changes recently within Beechwood House, which have had an impact on the way that the service is run. The deputy manager is currently acting as manager and made the decision during the inspection process to take on the post of manager. During the inspection she demonstrated commitment to improve standards within Beechwood House and toward developing her skills as a manager. She is nearing completion of NVQ level 3 and has agreed to work toward NVQ level 4 and the Registered Managers Award. The new manager is aware that there is a requirement that she register with the Commission for Social Care Inspection. There is a quality assurance system within the home and the views of residents and families have been sought via questionnaires but have not been evaluated or an action plan developed to improve quality within the service. Policies relating to the financial interests of service users are in place and records relating to individuals financial transactions maintained. Staff records show that staff have not received regular supervision and that changes in management within the home over the past year have led to some resignations and staff changes. Four staff files were looked at and showed that supervision had been provided to two staff members and records kept. There is not enough evidence to show that supervision has been provided consistently to all staff. Policies and procedures are in place to safeguard the well being of people who live in the home. The health and safety of service users has not been fully maintained, as there are some gaps in the provision of mandatory training, risk assessment and record keeping. Fire records confirm that equipment checks are up to date and testing is undertaken on a regular basis. Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 3 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 3 2 Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP3 Regulation 14 (1) Timescale for action Service users should be admitted 01/08/07 on the basis of a full and accurate assessment of needs Care plans should be developed 01/08/07 which reflect the assessed needs of service users The medication ordering system 01/07/07 policy should be reviewed and staff trained in MAR recording procedures. Work must continue to improve 01/09/07 the range of activities on offer and to enable people to exercise choice and control Outstanding Requirement 04/10/05 Service users should be enabled to make decisions in all aspects of their daily lives. Personal autonomy and choice should be maximised. 01/09/07 Requirement 2. OP7 15 (1) 3. OP9 OP30 13 (2) 18 (1) c i 16(1)(2) m, n 4. OP12 5. OP14 12 (2) (3) 6. 7. OP14 OP16 16 (2) (m) 22 (3) The smoking policy for the home 01/07/07 should be reviewed in line with changes in smoking legislation. All complaints should be 01/08/07 recorded and dealt with promptly DS0000061572.V338222.R01.S.doc Version 5.2 Page 26 Beechwood House 8. OP19 23 (2) (b) (c) and effectively Routine maintenance and renewal of the fabric and decoration of the building should be implemented and records kept. Outstanding Requirement 25/07/06 Keys to locked areas should be stored appropriately and not left in doors. The premises should be kept clean and free from offensive odours. Systems should be in place to prevent the spread of infection. A comprehensive staff training programme should be developed which ensures that staff fulfil the aims of the home and meet the needs of service users. Accredited Manual Handling training should be provided to all staff. Outstanding Requirement 02/02/07 01/10/07 9. OP19 12 (1) a 01/07/07 10. OP26 16 (2) (j) (k) 01/08/07 11. OP30 18 (1) a c i 01/10/07 12. OP31 8 (1) (a) A manager should be appointed 01/09/07 who is qualified competent and experienced to run the home and to meet it’s stated purpose, aims and objectives. The manager should be registered with CSCI. Outstanding requirement 25/07/06 Effective quality assurance and monitoring systems should be developed. A copy of quality assurance reports should be forwarded to CSCI Outstanding requirement DS0000061572.V338222.R01.S.doc 13. OP33 24(1) (a) (b) 01/10/07 Beechwood House Version 5.2 Page 27 25/07/06 14. OP36 18 ( 2) Staff should be provided with formal supervision at least six times per year. Outstanding requirement 25/07/06 The Registered Person should ensure the health, safety and welfare of service users and staff. Outstanding requirement 25/07/06 01/10/07 15. OP38 12 (1) (a) (b)13 (4) (a)((a) (b) 01/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP4 Good Practice Recommendations The cultural, and social needs of specific minority ethnic individuals should be understood and met by providing for specific cultural dietary needs Beechwood House DS0000061572.V338222.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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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