Inspection on 07/11/05 for Beechwood House

This inspection was carried out on 7th November 2005.

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

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

Other inspections for this house

Beechwood House 21/06/07

Beechwood House 06/06/06

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Beechwood House Beechwood House 40 Beechwood Road Sanderstead Surrey CR2 0AA Lead Inspector Peter Stanley Unannounced Inspection 7th November 2005 9:30 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.V262506.R01.S.doc Version 5.0 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.V262506.R01.S.doc Version 5.0 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 anjupavaday@yahoo.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 Old age, not falling within any other category registration, with number (15) of places Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A variation has been granted to allow one specified service user in the Dementia - over 65 (DE(E)) category to be accommodated until such time as the needs of the service user can no longer be met or until such time as the placement ceases. 14th April 2005 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 changed ownership in March 2005, and is now managed by Mrs Anjoo Pavaday. The registered provider is Mr Hariharen Pavaday. The house is set back off 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 fifteen elderly residents and is registered in the category of care provision for older people. The home consists of eleven single bedrooms and two double rooms. There is a smoking lounge on the first floor and a smaller lounge on the ground floor. The dining room is next to the large kitchen, with a door leading to the patio and back garden. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unnanounced inspection of the home took place over six hours on 7 November 2005. 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 progress in meeting outstanding requirements and spoke to a number of service users and staff. Care records and other documentation were examined. This small home is generally evidenced to be managed in a caring and competent way, many positive comments having been received from the home’s service users. Five requirements remain outstanding from the previous inspection. These are highlighted in bold print in the requirements list. The home’s care staff must attend statutory adult protection training, and training in manual handling must be evidenced. From this inspection a further seven requirements, and five recommendations are made. The inspector would like to extend his thanks to Mr and Mrs Pavaday, and to staff and service users at the home, for their cooperation and assistance in completing the inspection. What the service does well: While service users are generally being provided with the information, which they require, to enable an informed choice as to where they would like to live, the relevant documents need to be reviewed and updated. The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. The health care needs of service users are being fully met. The home’s medication policy and procedures are providing protection for service users. Service users are being treated with respect and are having their right to privacy upheld. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 6 Service users are being assisted to exercise a significant degree of choice and control over their day-to-day routines and decision-making. The home’s policy and procedures indicate that the views and wishes of service users and their relatives, regarding the eventuality of the service user’s infirmity or death, are being respected. Staff are being provided with the necessary induction and training with which to competently perform their work duties; there is, however, a need for updated training in the care of older adults. Service users’ financial interests are being safeguarded. The health, safety and welfare of service users and staff are being appropriately promoted and protected. What has improved since the last inspection? Following a requirement from the last inspection the home has obtained the necessary care management assessments from social services for all recent admissions. A photograph of the service user is being included on all service users’ files. Accredited medication training is in the process of being extended to all care staff. The home has acted on a recommendation for a checklist to be compiled and kept on service users files, detailing all the documentation obtained in respect of service users who have been referred for admission to the home. A lockable facility for storing personal monies and valuables has been provided for service users in their rooms. With the recent improvement in completing the required staff recruitment and criminal records checks, the home is able to assure service users that they are being appropriately protected. Following a recommendation, the registered manager has put in place a recruitment-vetting checklist. This is placed on the front of the staff file and details all the recruitment checks required, and the dates when these have been completed. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 7 The home has put in place satisfactory supervision and appraisal arrangements for staff. The home has received an up-to-date health and safety inspection. Up-to-date servicing of the home’s hoists has been completed. All staff have completed infection control training. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 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 DS0000062807.V262506.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): While service users are generally being provided with the information, which they require, to enable an informed choice as to where they would like to live, the relevant documents need to be reviewed and updated. Service users are not currently being provided with a copy of the home’s terms and conditions at the point of moving into the home. The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Care management assessments and care plans are now being obtained. EVIDENCE: Standards 1 to 4 were inspected. The home does not provide intermediate care (Standard 6). A comprehensive Statement of Purpose and service user’s guide is in place. This is made available to all prospective and current service users. Both these documents need, however, to be reviewed and revised as necessary, and must Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 10 be dated and signed. Service users and the CSCI must be notified of any revisions within 28 days, and revised copies of the SOP and SUG distributed. The inspector evidenced contracts from Croydon Council on the files of service users recently referred by the authority and admitted to the home. While the homes refers to terms and conditions in the Service User’s Guide, a separate and specific Statement of Terms and Conditions also needs to be agreed by the home with each service user prior to their admission. This needs to be written in plain English and must include reference to all the criteria detailed in Standard 2.2. This statement must be signed and dated by the home’s manager, the service user and his/her relative or representative. Where care is purchased privately this will be in the form of a contract. The inspector examined a sample of four service user files relating to recent admissions. The home completes assessments, risk assessments and service user plans that are kept for easily accessible staff reference on a separate file in a staff area of the home. Following a requirement from the previous inspection, a copy of all assessments and risk assessments are being included on the main service user files located in the first floor office. A copy of the service user plan is not, however, being included, hence a requirement applies. The service user plan must be reviewed at least once a month and updated to reflect any changing needs or circumstances. One care management review, recorded as being held on 3/8/05, is awaiting a copy of the minutes from the care manager. This must be followed up and the review evidenced. New service users are admitted on the basis of a full assessment undertaken by a person who is suitably qualified to do so. The assessment is completed with the service user, relative or delegated representative and any relevant professionals that have been party to the referral. Following a requirement from the last inspection the home has obtained the necessary care management assessments from social services for all recent admissions, this being evidenced on the service users’ files. The home has acted on a recommendation for a checklist to be compiled and kept on service users files, detailing all the documentation obtained in respect of service users who have been referred for admission to the home. This includes details of when care management assessments and care plans have been received, details of any specialist assessments, and details of when the home’s initial assessment, risk assessments and service user plan have been completed. The registered manager was able to demonstrate the home’s capacity to meet the assessed needs of individuals admitted to the home. The inspector spoke to a number of service users who expressed their positive satisfaction with the home and the care provided. Service users presented as well cared for and Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 11 supported. There was evidence from the service user plans that specific social and cultural needs are being addressed. Staff and training records indicate that the home has the range of skills and abilities with which to meet the needs of service users. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): While service users are having their health, personal and social care needs set out in an individual plan of care, service users’ care plans, and their monthly review, must be evidenced on service users’ files. The health care needs of service users are being fully met. While service users are being protected by the home’s medication policy and procedures, their protection also requires the extension of accredited medication training to all care staff. Service users are being treated with respect and are having their right to privacy upheld. The home’s policy and procedures indicate that the views and wishes of service users and their relatives, regarding the eventuality of the service user’s infirmity or death, are being respected. EVIDENCE: Standards 7, 9, 10 and 11 were inspected. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 13 The inspector inspected a number of service user plans. As previously detailed, service user plans are kept on a separate file in an area easily accessible to care staff. A copy of the service user plan is not, however, being included on service user files. It must be evidenced that the service user plan has been reviewed on at least a monthly basis and updated to reflect any changing needs or circumstances. A requirement applies. The standard on medication was examined in detail on the last inspection. Satisfactory policy and procedures were found to be in place. Following a requirement, the home has entered an arrangement with Ruskin College to provide care staff with accredited medication training. This is currently underway and the time-scale for meeting this requirement has been extended until 31/12/05. The standard on privacy was almost met at the last inspection, the privacy of service users having been found to be well respected in this home; this was again confirmed from the inspector’s observations. A lockable facility was, however, required for all residents in their rooms. With the exception of three service users, whose wishes have been recorded, all service users have agreed to the provision of a small lockable safety box for storing any personal monies or valuables. 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. The home recognises that service users 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. Service users and relative’s wishes in the event of death and funeral arrangement are duly noted in each file. The inspector discussed the sense of loss felt by both service users and staff following the deaths of two service users in recent months, both occurring following their admission to hospital. The inspector recommends that the home access training in loss and bereavement so as to assist staff to develop coping strategies, and acquire relevant skills with which to positively support service users throughout this process. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users are being assisted to exercise a significant degree of choice and control over their day-to-day routines and decision-making. EVIDENCE: Standard 14 was inspected. This section of standards was generally well met at the last inspection. The inspector found that service users are assisted to exercise a fair degree of choice and control in their daily routines. Feedback from a number of service users indicate that they feel supported in exercising choice in their daily routines and activities. The participation of service users in decision-making within the home was not, however, being evidenced at the last inspection. A requirement was made, relating to the need for service users’ meetings to be held and minutes maintained. The inspector examined these and evidenced that while meetings are now being held, these are not being arranged on a sufficiently regular basis. A meeting on 14 July was next followed up with a meeting on the 29 September 2005, a period of about ten weeks. The manager was advised that meetings should be held every six to eight weeks and no longer than two-monthly. The minutes indicated good attendances by Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 15 service users with a wide range of issues being discussed. A requirement applies. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): While the home’s policies and procedures are helping to ensure that service users are safeguarded from abuse, their protection also requires that statutory training in adult protection be extended to all care staff. EVIDENCE: Standard 18 was inspected. The home has appropriate adult protection and whistle-blowing policies in place. No adult protection concerns have arisen since the last inspection in April 2005. There is an outstanding requirement from the last inspection for care staff to undertake statutory adult protection training. Due to a long waiting list for places, no care staff have so far undertaken this. An extension of the timescale (to 31/03/06) for meeting the requirement has, therefore, been agreed. The manager advised that summaries of Croydon’s adult protection policy and procedures have been made available to all staff. The registered manager has, however, completed this training and is intending to undertake the Croydon ‘Training for Trainers’ course. This would enable her to cascade the statutory training to new staff. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not inspected. All standards met at the last inspection. Since the last inspection there has been some upgrading of the home with recarpeting in the reception areas and corridors on the ground floor and some repainting of internal doors and surfaces. Some external decoration and maintenance has also taken place. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home has appropriate recruitment policy and procedures in place. With the recent improvement in completing all the required recruitment checks, the home is now able to assure service users that they are being appropriately protected. Staff are being provided with the necessary induction and training with which to competently perform their work duties; there is, however, a need for updated training in the care of older adults. EVIDENCE: Standards 29 and 30 were inspected. Whilst appropriate recruitment policy and procedures are in place, the previous inspection evidenced shortcomings in the completion of the home’s recruitment checks. The inspector completed checks on staff files and found that all the necessary recruitment and identity checks are now being completed. CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks were found to be in place. Following a recommendation, the registered manager has put in place a recruitment-vetting checklist. This is placed on the front of the staff file and details all the checks required, and the dates when these have been completed. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 19 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, food hygiene, first aid and infection control. The inspector identified a need to develop a training profile for each staff member to detail all training completed and training that is scheduled or currently unmet. A requirement applies. The inspector also identified a need for care staff to update their knowledge and access training relating to the social and care needs of older adults, and how these are met; a requirement applies. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): While the home is developing its quality assurance processes, these need to be extended so as to demonstrate that the home is meeting its aims and objectives and that it is being run in the best interests of the service users. The home needs to demonstrate that it is being safeguarded by it’s accounting and financial procedures. Service users’ financial interests are being safeguarded. Staff are being appropriately supervised, and a system of appraisal is being developed. The health, safety and welfare of service users and staff are being appropriately promoted and protected. EVIDENCE: Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 21 Standards 33 to 36, and 38 were inspected. The home needs to demonstrate that it is being run in the best interests of service users, and that it is meeting its aims and objectives. Service users and staff are able to communicate their views to management in service user and staff meetings. Whilst views expressed to the inspector from service users and staff are generally very positive, the home needs to evidence its performance and develop its quality assurance processes. Following a requirement from the last inspection, the home has completed questionnaires with all service users. Questionnaires have also been developed for relatives and friends of service users, and for those who visit in a professional or voluntary capacity. These still need to be distributed for completion. Hence the requirement is partially, but not fully met. The time-scale for meeting this requirement has again been extended so as to allow the new owners to institute an ongoing quality audit system. In line with a further requirement from the previous inspection, the home must put in place a development plan for 2005-06 to evidence that the home is meeting its aims and objectives and is being run in the best interests of service users. This must include feedback from all sources of information, including the surveys, and must evidence a cycle of planning, action and review. The results of the surveys must be publicised and the report made available to current and prospective service users, their relatives or representatives and other parties including the CSCI (Commission for Social Care Inspection). The home needs to demonstrate its financial viability and submit a set of audited accounts for the year ending 31/03/05. A business and financial plan also needs to be put in place, and then reviewed annually. Employers liability insurance to the value of £5 million is in place. The registered manager ensures that service users who wish to control their own monies are able to do so. The manager advised that the home does not act as an appointee for any service users in the home, and that either a relative or solicitor fulfils this role where the service user is unable to manage their own monies. The home maintains a record of receipts and expenditure on behalf of one service user for whom a solicitor makes periodic payments from the service user’s account. The inspector examined this record, which was being appropriately maintained. Following a requirement from the previous inspection, a new supervision format has been developed; this still requires some further revision so as to provide more space for agenda items and issues discussed. The supervision record is being signed and dated by the supervisor and supervisee. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 22 The inspector examined supervision records and found that supervision is being held once every eight weeks. Whilst the care standard states that supervision should be provided at least six times a year, good practice would be for new and less experienced staff to be supervised on a more regular basis. A recommendation applies. Following health and safety requirements from the previous inspection, an up to date health and safety inspection of the home was completed on 23/06/05, this being evidenced with an inspection report. Actions required have been addressed. Up to date servicing of the home’s hoists has also been addressed, this being evidenced as having been carried out by the maintenance contractor on 8/7/05. The registered manager advised that training in moving and handling for all care staff has been held (on 7/9/05), but that certificates to evidence this have not yet been received; a requirement, therefore, applies. Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 2 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 1 3 3 X 2 Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 24 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 OP1 Regulation 6(a) & (b) Requirement Timescale for action 31/01/06 2 OP2 5(1)(b) & (c) 3 OP3OP7 17(1)(a) (b),3,No1 4 OP9 12(1)a b,(13),2,6 Both the Statement of Purpose and Service User’s Guide must be reviewed and revised as necessary, dated and signed. Service users and the CSCI must be notified of any revisions within 28 days, and revised copies of the SOP and SUG distributed to all service users. 01/12/05 The registered manager must ensure that a statement of terms and conditions is agreed with each new service user at the point of moving into the home. This must include reference to all the criteria detailed in standard 2.2, and must be signed and dated by the registered manager, the service user, and his/her relative/representative. The registered manager must 01/11/05 ensure that a copy of the homes service user plans are kept on service user files. These must be reviewed at least once a month. The registered manager must 31/12/05 ensure that accredited medication training is updated for all staff. DS0000062807.V262506.R01.S.doc Version 5.0 Page 25 Beechwood House 5 6 OP14 OP30 12(2) & (3) 18(1)(a) & (c) 7 OP30 18(1)(a) & (c) 8 OP34 25(1), (2) & (3) Service user meetings must be held every six to eight weeks and no longer than two-monthly. A training profile must be developed. This must provide a comprehensive list of all the training that is required to be undertaken, and indicate (for each staff member) the dates when training was last undertaken. Training must be provided for all care staff regarding the social and care needs of older adults in residential care, and how these are met. The home needs to demonstrate its financial viability and submit a set of audited accounts for the year ending 31/03/05. A business and financial plan must also be put in place, and then reviewed annually. A quality audit system must be in place to assess whether the aims and objectives of the home have been met. The registered providers must ensure an annual development plan is implemented for the home and send a copy of the plan to the CSCI, local office. Up to date training in moving and handling must be evidenced with certificates for all care staff. The registered manager must ensure that all staff have attended a (statutory) one day course in adult protection. 30/11/05 31/01/06 31/03/06 31/03/06 9 OP33 24 (1)(a) & (b) 24(1) 31/03/06 10 OP33 31/03/06 11 12 OP38 OP18 12(1)a b,13(4)c 12 (1)a b,18 (1)a 31/12/05 31/03/06 Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP11 OP18 Good Practice Recommendations The inspector recommends that training in loss and bereavement is provided for all care staff. The new providers should attend an accredited training course on adult protection such as ‘Training for Trainers’ a recognised course which can be cascaded down for the benefit of all staff. Whilst the care standard states that supervision should be provided at least six times a year, good practice would be for new and less experienced staff to be supervised on a more regular basis (4 to 6 weekly). The supervision proforma requires some further revision so as to provide more space for agenda items and issues discussed. The inspector recommends that the manager and deputy manager undertake staff appraisal training to assist in facilitating this process. 3 OP36 4 5 OP36 OP36 Beechwood House DS0000062807.V262506.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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