Inspection on 13/06/06 for Beechwood Nursing Home

This inspection was carried out on 13th June 2006.

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

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

Other inspections for this house

Beechwood Nursing Home 08/12/06

Beechwood Nursing Home 11/11/05

Beechwood Nursing Home 05/05/05

Beechwood Nursing Home 02/09/04

Beechwood Nursing Home 20/01/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Beechwood Nursing Home 41-43 Esplanade Road Scarborough North Yorkshire YO11 2AT Lead Inspector Mrs Rosalind Sanderson Key Unannounced Inspection 13th June 2006 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 Nursing Home DS0000027997.V300379.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 Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechwood Nursing Home Address 41-43 Esplanade Road Scarborough North Yorkshire YO11 2AT 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) 01723 374260 9999 beechwood2000@aol.com Mr Tamby Seeneevassen Mr Tamby Seeneevassen Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Age Range 65 years plus Date of last inspection 5th May 2005 Brief Description of the Service: Beechwood Nursing Home is a detached Edwardian building converted over 20 years ago into a care home providing nursing care for up to 32 residents. It is situated in the South Cliff area of Scarborough and close to the Esplanade with views over the South Bay. A passenger lift is available, giving access to communal and private areas of the home. There is a small terrace to the front of the property and a patio area with seating for service users. On street parking permits can be obtained from the home for visitors. The local shops and post office are within walking distance of the home and there is a regular bus service to the town centre. The homes statement of purpose that gives information about the home is made available to all service users and their families in the entrance of the home along with the most recent inspection report. Individual copies are available on request to the manager or person in charge. The scale of charges made at the home range from £442 - £550 with additional charges made for hairdressing, chiropody, personal toiletries and individual newspapers. This information was correct on May 19th 2006. Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process involved seeking the views of service users, relatives and visiting professionals to the home. 81 of service users and 72 of relatives surveyed responded and both healthcare professionals sent a response. The acting manager provided written information about the service in the form of a pre inspection questionnaire. Two inspectors carried out a site visit that lasted eight hours. Records relating to service users, the running of the home and staff were looked. Private and communal areas within the home were looked at. Seven service users, five members of staff and one relative were spoken with. The comments received will be included in this report. The acting manager was available throughout the day. An inspection record was completed by the inspector prior to the site visit summarising all available evidence and was used to plan and focus the site visit in order that all the necessary information was collected. What the service does well: The newly refurbished bedrooms on the ground floor offer pleasant spacious accommodation for service users. Service users enjoy taking advantage of the seating area that has been provided at the side of the home. They are now able to enjoy the fresh air and speak with passers by. The new manager is greatly appreciated by service users and staff members alike. She has an open door policy and service users feel able to approach her and confidant that they are listened to. Some comments received include, ‘Chris has a lot of respect from staff, she is improving things here’, ‘She definitely has the best interests of service users at heart, she pushes the boat out to get us what we need to care for the patients’. Relatives commented, ‘Since the arrival of the new matron things have started to improve’. A healthcare professional said, ‘I am aware that the manager is new in post and is working hard to build up a good system of joint working between the home and the hospital’. The manager encourages staff to undergo training to NVQ level 2 in order to improve service user care. Currently 41.6 of staff have this qualification. Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Although there are a number of issues mentioned in the report, this summary will concentrate on the key issues that require attention in order that the home can improve. Sufficient information must be gathered about service users needs in order that the provider is confident the staff can meet these needs. Care plans and risk assessments must be reviewed regularly to ensure current needs of service users are addressed. So that everybody using the service is aware of how to make a complaint, the procedure must be amended to show that all complaints will be acted upon. In order that service users are protected and cared for by appropriate staff, the registered person must make sure that recruitment procedures are robust, staff are inducted to the workplace and that they receive regular supervision. So that service users have access to bathing facilities on each floor of the home the registered person must forward a plan to show how those bathrooms currently out of use will be re commissioned. A notice was left with the acting manager on the inspection day to require that issues around service users safety be addressed. These issues included risk assessments for bed rails, locking of a door leading directly onto a downward staircase and access to the sluice room where the hot water temperatures were in excess of 43°. The weekly fire alarm tests and emergency lighting had Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 7 not been tested. Written confirmation has been received that these issues have now been addressed. The registered person must make arrangements to visit the home on a monthly basis and complete a report on the visit. This will enable the registered person to monitor the services performance. As the registered provider is often out of the country for long periods, arrangements must be made to ensure the manager has the authority and autonomy to carry on the efficient running of the service in his absence. The registered person has been asked to provide a plan to show how these issues will be addressed. 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 Nursing Home DS0000027997.V300379.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 Nursing Home DS0000027997.V300379.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is poor. People wishing to use this service do not receive accurate information to help them make the decision to live at Beechwood. Insufficient information is gathered about service users needs to fully inform staff so that these needs may be met. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The statement of purpose has not been updated to reflect the management changes. Those bedrooms where it would be difficult to accommodate service users that require the use of equipment such as a hoist have not been identified within the statement of purpose. This means that service users do not receive accurate written information when looking at the services on offer. Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 10 The manager did however say that she gives full verbal information to prospective service users. Pre admission assessments are completed inconsistently and in some cases not in enough detail. In one case information received pre admission was not included in admission documentation. This means that some service users needs may not be identified on admission to the home. Beechwood Nursing Home DS0000027997.V300379.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. Inconsistent approaches to care planning has the potential to place service users at risk. This judgement has been made using available evidence including a visit to the service. EVIDENCE: There was evidence within the plans that service users have access to other professionals so ensuring they are able to receive the best possible care when needed. One service user reported that they had specific care needs and had to wait to come into the home until staff had received training to meet those needs. A domiciliary optician was due to visit the home to see some service users who found it difficult to get out. Medications are now handled and stored appropriately and an audit system is in place to ensure that this continues. Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 12 The care plans that were looked at had been based on what information was available from the pre admission assessment; therefore in some cases this was limited. In one instance important pre admission information had not been put into a care plan for six months when the problem had become evident from day to day observation. The problems should have been identified earlier and plans put in place to manage them. The plans had the necessary risk assessments completed on admission but where it was stated that they should be reviewed monthly this had not been carried out. In some cases this had not been done for three months. This could mean that the current needs of service users are not addressed. Safety issues such as the checking of the suitability of bed rails in use had not been completed. This could lead to them being used unsafely. Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome group is adequate. Service users dietary needs are met. Service users would benefit from a more structured approach to activities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A random inspection that was carried out on May 9th 2006 showed that the problems identified at the last inspection and those highlighted following the visit by the EHO had almost been addressed. The key inspection confirmed that these had now been fully addressed. There is a new, fully qualified cook in post and service users commented how meals are now improving. Comments received included, ‘the food is very good’, ‘there has been improvements lately with the food on offer’. Another commented, ‘Since the new cook has started the food has improved’ and ‘there is always plenty of drinks available’. The newly appointed cook was knowledgeable about the service users dietary needs and explained how she would provide enriched diets for those who needed it. One service user said that she has a special diet and does not have to worry about this as the cook makes sure she gets what Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 14 she should have. Staff were observed helping service users that required help at lunchtime. This was done in a way to promote service users dignity, respect and independence. Recent activities at the home included outings in wheelchairs to the Rose and Italian gardens. The service users had also enjoyed taking advantage of the new patio area. One commented, ‘I sat out on the new patio to have tea and cakes, it was lovely to watch the world go by’. A member of staff said that the key worker system that had recently been introduced enabled staff to be with service users on an individual basis for a period each week. This made sure that service users were given the opportunity to express their individual needs and wishes and that the expectation is that these will be addressed. Service users and staff agreed that they would like to have more opportunities for activities available to them. A service user said, ‘I’m bored and want to do more’. Another said that they would like a TV in their room so that they may watch some world Cup matches. The manager agreed that the activities programme needs to be developed and she hopes to implement a full programme in the coming months. Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is poor Service users are confident they are listened to and action will be taken to address any problems. Policies and procedures need reviewing to ensure that staff are fully informed of their responsibilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The recent complaint that had been passed to the manager to investigate had been dealt with appropriately and the complainant was satisfied with the outcome. This was recorded in the complaints file. Service users said they felt happy to approach the manager and confident she would address any concerns they had. One said, ‘If I had a complaint I would see Chris (the manager) she comes to see me each day and I know she would sort things out for me’. The procedure is clearly displayed in the entrance hall. The complaints policy states that ‘all complaints must be put in writing’ this may prevent some people making a complaint. Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 16 Trained staff spoken with had a good understanding of adult protection procedures and were clear about their roles in identifying and reporting any issues. The nursing staff are planning to cascade their recent POVA training to all staff in order that all staff at Beechwood are familiar with the procedures and service users will be protected. The adult protection policy states that if an allegation is made it must be referred to the National Care Standards commission for referral to the POVA list. This is not correct and needs review and correction so that it is clear. Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 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): Quality in this area is poor. Some elements within the environment may pose a risk to service users. This judgement has been made using available evidence including a site visit to this service. EVIDENCE: The newly refurbished rooms on the ground floor offer pleasant accommodation for service users. These rooms are en suite so further respecting the privacy and dignity of people occupying these rooms. The home was clean and there were no unpleasant odours. Service users commented that they liked their rooms. One said, I like the nice big room’ another, ‘I was able to bring in some of my belongings’. Service users that share a room have screens in place in order that their privacy is respected. Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 18 The bathrooms on the second and third floor are not in use. This means that there are insufficient bathing facilities in the home and those service users on the top two floors do not have immediate access to bathing facilities. The ceiling in the top floor bathroom needs attention before the bathroom is recommissioned. The toilet on the top floor has no adaptations to make it easy for service users to use. The manager said that it was not used. The size and layout of some bedrooms would make it difficult for service users that required the use of lifting equipment to be accommodated in these rooms. Floorboards in room 21 were loose and the carpet required stretching, these issues were a possible trip hazard. Some rugs had been placed next to beds but they had frayed edges and were again a possible trip hazard to service users, staff or visitors. A curtain rail fell down during the inspection and the service user reported that this had happened before. The sluice room was not locked and the water temperature in there was recorded at 53°. Service users could access to this room. The door leading down to the laundry and cleaning rooms was unlocked. This door leads directly to a flight of downward stairs. This is a risk to both service users and staff and there is a note on it saying that it should be kept locked. COSHH substances were kept secure and staff were aware of where the data sheets were kept in the event of an accident. A fire exit door had been left open on the second floor, this was to ‘air’ the room. However it allowed direct access to the home from outside. The fire log showed that the weekly fire alarm, fire door and emergency lighting checks had only been carried out intermittently. Some emergency lights were not working. The acting manager informed the inspector that since her appointment in January 2006, she had arranged for a fire safety survey to be carried out. A report had been received and highlighted some areas for improvement. This had been passed to the provider for his attention in April 2006. The work that needed to be done to the fire escape as recommended in the report from the structural engineer is still outstanding. The fire risk assessment for the home was seen and is satisfactory. Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 19 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 quality in this outcome area is poor. Staff receive sufficient training to enable them to carry out their roles effectively. Recruitment practices may place service users at risk from unsafe staff This judgement has been made using available evidence including a site visit to this service. EVIDENCE: Sufficient staff are on duty to meet the needs of service users in a timely fashion. 41.6 of care staff hold a qualification in care at NVQ level 2. There was no documentation to show that recently appointed staff have received a formal induction to the home that meets the ‘Skills for Care’ standards. The manager did however confirm that induction had been completed for staff employed since she had been in post. Formal induction would enable staff to become familiar with health and safety requirements and the aims and objectives of the home. Staff have received some training since the last inspection and more training has already been planned. Staff confirmed this , ‘I feel that we have had more training lately’ and another said, ‘I need moving and handling training but Chris is aware and it is in hand’ Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 20 The recruitment policy states that all new staff will have the necessary checks carried out prior to starting work. However the records that were looked at showed that some staff had brought a CRB with them or one had been obtained after the employment had started. This may place service users at risk of being cared for by unsafe staff. The acting manager has already made provisions to put in application for these checks to be carried out. Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 21 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): Quality in this area is poor. Service users are benefiting from the input from the new manager but improvements still need to be made in order that service users remain safe and well cared for This judgement has been made using available evidence including a site visit to this service. EVIDENCE: The acting manager is a trained nurse with a number of years experience in care home management. She has been in post since January 2006 and is to make application to become registered manager of Beechwood. She has made a positive impact on the running of the home and staff appreciate her openness. Some comments received include, ‘Chris has a lot of respect from Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 22 staff, she is improving things here’, ‘She definitely has the best interests of service users at heart, she pushes the boat out to get us what we need to care for the patients’. Relatives commented, ‘Since the arrival of the new matron things have started to improve’. A healthcare professional said, ‘I am aware that the manager is new in post and is working hard to build up a good system of joint working between the home and the hospital’. The manager does not have access to a budget in order to manage the home but relies on petty cash. The provider is sometimes away from the country for a few weeks at a time and arrangements need to be made in order that the manager has the authority and autonomy to continue to manage the home effectively in the provider’s absence. Regulation 26 visits have not been completed and these are required in order that the registered person is fully aware of the service’s performance. The manager does not look after any monies for service users. General risk assessments for the home have not been completed so control measures to reduce any risk may not be in place. The quality assurance system is still being developed in order that stakeholders views on the service are obtained. A comment received from a relative was, ‘We found a recent relatives meeting useful and hope that these continue’ Staff supervision needs to be formalised so that staff have the opportunity to discuss their individual performance in line with the homes aims and objectives and their training needs can be identified. Health and safety issues that require attention include: • The last three reports from the lift engineer have highlighted the same issues as requiring attention. • The electrical wiring certificate issued in 2004 stated a re test would be needed in 4 weeks. There was no evidence available that this has been completed. Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 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 X 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X 1 1 X 1 X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 1 X 1 Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 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 OP3OP7 OP8 Regulation 12,13,14, 15 Requirement Sufficient information must be gathered about service users needs in order that the registered person is confident the staff can meet these needs. Care plans and risk assessments must be reviewed regularly to ensure that the current health and social needs of service users are addressed. 2 OP19 13,23 The registered person must: • Make sure that risk assessments are in place for the safe use of bedrails and that these are reviewed as per the homes policy. Make sure that the sluice door is kept locked as the water temperature far exceeds 43° Keep the laundry door locked at all times as per the policy of the home as there is a risk to service users and staff as the door opens directly onto a Version 5.2 Page 25 Timescale for action 13/07/06 13/06/06 • • Beechwood Nursing Home DS0000027997.V300379.R01.S.doc • downward staircase. Make sure that all fire exit doors are kept closed at all times to prevent unauthorised access from the outside. 13/07/06 3. OP21 23 4 OP29 OP30 OP36 18,19 The registered provider must forward proposals including timescales to show how those bathrooms currently out of use will be re commissioned. The registered provider must make sure that recruitment procedures are robust, staff are inducted to the workplace and that they receive regular supervision. For each new member of staff employed at the home the registered provider must obtain a Criminal Records Bureau check prior to them starting work. Previous timescale of 02.09.04, 5/5/05, 11/11/06 and 9/6/06 not met) 13/06/06 5 OP29 18,19 13/06/06 6. OP33 26 7 OP38 23 (4) The registered provider must: 13/07/06 • Arrange for visits to the home to be carried out in accordance with Regulation 26 of the Care Homes Regulations 2001 and a copy of the monthly report be sent to the CSCI. • Make arrangements so that the manager has autonomy and authority to continue to run the home effectively during the provider’s absences. The registered person must 13/06/06 make arrangements for the testing of the fire alarms and emergency lighting to be carried DS0000027997.V300379.R01.S.doc Version 5.2 Page 26 Beechwood Nursing Home 8 *RQN CSA section 31 out. This must be from the day of the inspection and maintained weekly thereafter. The registered person must provide to the Commission an action plan showing how the above requirements will be actioned and how the home will be improved. 02/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations The statement of purpose must be revised to include recent management and staff changes. Information that identifies the rooms where it would be difficult to accommodate service users who require the use of equipment should also be included. It is recommended that the programmes of activities on offer be extended after consultation with service users. This will ensure that individual and collective needs of service users are met. The complaints procedure should be reviewed so that it is clear that complaints do not have to be presented in writing to be considered. It is recommended that a suitably qualified person, including an occupational therapist, undertakes an assessment of the premises and facilities It is recommended that the quality assurance system is further developed to ensure that the views of all stakeholders are taken into account and to inform the homes development plan 2. OP12 3 4. OP16 OP22 5 OP33 Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beechwood Nursing Home DS0000027997.V300379.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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