Inspection on 05/05/05 for Beechwood Nursing Home

This inspection was carried out on 5th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 13/06/06

Beechwood Nursing Home 11/11/05

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 Anne Prankitt Unannounced 5th May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Beechwood Nursing Home Address 41-43 Esplanade Road Scarborough North Yorkshire YO11 2AT 01723 374260 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Tamby Seeneevassen Post Vacant Care home with nursing 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2nd and 3rd September 2004 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. There is a small terrace to the front of the property. On street parking permits can be obtained from the home. Further building works have just been completed resulting in a decrease in the number of shared rooms, and an increase in the number of single bedroom accommodation. The works have also included a replacement communal lounge from that which previously existed. A passenger lift is available, giving access to communal and private areas of the home. Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over eight hours, and was undertaken by two inspectors, Anne Prankitt and Mary Slattery, with a previous days preparation having taken place prior to the inspection. The manager of the home, Peggy Sly, assisted during the course of the inspection. A full tour of the premises was completed, and staff were spoken to. Time was also spent talking with residents in private, and also in communal areas of the home. The views of three visitors were also sought. Some records were inspected, including care plans of specific residents identified at the time of the inspection. Discussion also took place with the building control officer and fire safety officer about the new building works which have recently been completed. Further joint meetings about the extension have been organised. Another visit has been made to the home since the inspection, to check on the progress that has been made about matters that needed to be dealt with quickly. What the service does well: What has improved since the last inspection? Better information about the home is now available, and is given to people to view. Residents are now each given written information which they keep in their room about the home. Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 6 The manager has been given extra time to focus on managing the home and the staff. Complaints are recorded and explain how they have been resolved. There have been some improvements made about the information kept about residents and their care needs. The new bedrooms and communal area are pleasantly decorated, and new seating has been provided for the main lounge. Bedroom doors are being fitted with proper closers so that residents can have their doors open safely during the day. The manager keeps in contact with nurses in the community who give advice about pressure sores, and two staff have had some training. What they could do better: The improvements made to the records kept about residents, and the care that they need, need to be improved upon further. The manager and staff need to make sure that service users and the building are kept safe, and that all risks to health and safety are minimised. This includes making sure that the control of infection is properly understood, that the building is kept safe from the risks from fire, and that equipment, such as bed rails, is used safely. Residents are not aware that they can choose an alternative from the daily menu, and the lack of space in the dining room means that they cannot choose to sit together to eat. Better records need to be kept about the food that is provided. Staff need to be given more information about how to recognise abusive situations, and what to do if they were ever to have any concerns. The bathing facilities could be improved upon, so that all residents are able to have a bath on the floor where they are accommodated. More stringent checks need to be made before staff are employed, to ensure that they are suitable to work at the home. A number of health and safety matters have been neglected, and must be given serious attention. Due to the large number of outstanding requirements, a decision has been agreed that additional visits will be made to the home on a regular basis, in order to check on progress made in meeting these. Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 7 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 J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 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 standard(s) 1 and 2 Whilst the Statement of Purpose provides sufficient information for service users, the service users’ guide and contract/terms and conditions do not fully inform service users of their rights. EVIDENCE: Since the last inspection, the Statement of Purpose has been amended to provide additional information to assist people in making informed choices about the home. The terms and conditions /contract has also been amended so that service users are better informed about the terms of residency. The document states the fees payable, but does not include: Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 10 • • • by whom the fees are to be paid, for example service user, local authority, relative or another. details of how the free nursing care contribution will be reimbursed to the service user. rights and obligations of the service user and registered provider and who is liable if there is a breach of contract. The manager confirmed that service users or their relatives are now provided with a copy of the terms and conditions. Service users’ rooms now contain a copy of the service users’ guide. The guide omits some information, including a copy of the most recent inspection report, or about how to complain. Service users’ views of the home are not included. Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 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 standard(s) 7,8 and 9 The care planning process is inconsistent. Care plans and risk assessments are not fully implemented, therefore staff are not always provided with the information they need to satisfactorily meet service users’ needs. The systems in place for the administration of oral medication ensured that the needs of the service users are met. However, the failure to maintain equipment in a clean state could potentially place service users at risk. EVIDENCE: Each service user has a care plan. The manager has implemented the improvement of care plans, which now contain more detail than previously. Within the five care plans inspected, there was no evidence available to support that the care plans are drawn up with the involvement of the service user and/or their relative. The social and psychological needs of service users were often not recorded, and their wishes upon death and dying were not included. However, there was information to confirm that advice is sought from the tissue viability nurse, dietician and other community specialists. Following the tour of the environment, discussion with staff, and also examination of the accident book, it was evident that risk assessments were Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 12 inadequate in the case of the use of bed rails, falls, and moving and handling issues. It also remains outstanding that there are no organised activities to promote exercise and physical activity. Review of the care plans was inconsistent. There was evidence to support that the Tissue Viability nurse is involved in the prevention and treatment of pressure sores, and there was a variety of equipment available around the home. Two staff members have completed training. One service user suffered a pressure sore at the time of the inspection. Another service user was recovering from a pressure sore. The service users, who were being nursed in bed, appeared comfortable. However, the written record of the treatment required by staff was of poor quality. One service user spends a large part of their time isolated, as their behaviour is perceived as being sometimes ‘antisocial’. The manager agreed to make a referral to the care manager for a review to ensure that this person’s current needs are fully addressed. The daily records provided only limited evidence of the care recorded as being required over a twenty four hour period. The recording of the administration of medication was improved, with no omissions seen, but the return to pharmacy of controlled medicines was delayed. It was apparent that the medication was no longer required on a regular basis in some cases. This matter must be referred to the General Practitioner for review. The equipment of one service user who is fed via a PEG feed was stored within their bedroom in an unacceptable state. The equipment had not been cleaned. The manager confirmed that the previous practice whereby medication was administered to service users at 7am by night staff has now ceased. Day staff now administer medication. In addition to this, the temperature of the fridge which is used to store medication which needs to be kept cool, is now maintained within normal limits. The décor within the treatment room where medication is stored was poor, and would benefit from redecoration. Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 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 standard(s) 13 and 15 Unrestricted visiting arrangements results in service users maintaining good links with their family and friends. The choice of meals at the home is limited, and does not provide service users with sufficient choice. EVIDENCE: Three visiting relatives were spoken with. Two visited their relative in the communal areas, and one in the service users’ own bedroom. It was evident that visitors are welcomed into the home at any time, and comments included that ‘staff are kind’, and that they felt able to take any concerns to be dealt with to the staff. Written information about visiting is included in the Statement of Purpose. Since the last inspection, written detail of the main meal of the day is posted in the dining area. However, some service users do not access this area. Service users said that they liked the food, but were not aware that they could request an alternative from the advertised meal. The manager needs to devise a daily menu, to include breakfast, lunch and tea time choice of meals. The cook demonstrated knowledge of the dietary likes and dislikes of service users, and provides freshly prepared meals on a daily basis. However, this information is not written down, but rather committed to memory. Neither is there a record Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 14 kept of meals provided, which includes specialised diets such as diabetic and liquidised meals. There was a good supply of cold drinks in bedroom and communal areas, and hot drinks were provided between meals. Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 The home has a satisfactory complaints procedure. Complaints are recorded and acted upon. The lack of training with regard to the protection of vulnerable adults could result in referral of such matters to the correct authority failing, thus placing service users at unnecessary risk. EVIDENCE: The complaints procedure is posted in a public area of the home. It is also included within the Statement of Purpose. It needs to be included within the service users’ guide. Comment made by relatives included that they felt able to continue to air any concerns they may have until such time that they were addressed in full. The manager and one member of trained staff have received training in abuse awareness. However, it remains outstanding that the remaining staff have not been provided with training in abuse awareness, linked to the local authority multi agency policy for the protection of vulnerable adults. Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 16 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 standard(s) 19,20,21,22,23,24,25,26 The physical environment does not wholly meet with the requirements of the people who live at the home. EVIDENCE: There is a small garden area to the front of the building. The newly built or altered areas were being used in the absence of a certificate of completion by building control or the fire safety officer. This matter is being addressed separate to this report. The basement area was used for storage of combustible items. The arrangements were not safe. The manager removed the door wedge from the laundry door immediately, and arranged for the items to be removed. The fire officer was contacted, and information provided pending a fire inspection the following day. The recently commissioned sitting area has new chairs and carpet. The service Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 17 users appeared comfortable, and said that they liked the alternative accommodation. The communal dining room is not large enough to accommodate all of the service at one sitting. They therefore sit in their bedroom, or on the communal areas as well as the dining area at mealtimes. There are five bathrooms. One bathroom was used as a store for linen. The top floor bathroom was non assisted, in need of refurbishment, and not used. Service users who are accommodated on this floor have to be transferred to another floor for bathing. Within the newly commissioned bedrooms, one room was fitted with a walk in en suite shower. Others have an en suite facility. Neither the original premises nor the new extension have been assessed by an occupational therapist. However, one relative said that the wider doors in the newly commissioned area had made a good improvement. A remote call bell system is installed. One service user in the conservatory, and one who occupied their own bedroom, did not have access to their remote call bell, and were therefore not able to alert staff attention. Due to their shape, some bedrooms are difficult to furnish in order to provide room at either side of the bed. The ability to carry out safe moving and handling practice was questioned in one shared room where space to manoeuvre was very limited. The manager must consider alternative arrangements in order that this service user’s needs can be met safely. One bedroom inspected had only one single socket, and a three way adaptor was being used in order that the service user could use their electrical appliances. The adaptor was deemed unsafe, and the manager was required to obtain a safe alternative. Both ceiling lights in the bedroom did not work. The service user, who occupied the room, was relying on a table lamp to light the room. All beds at the home excepting two hospital beds are divan type, which restricts the care that can be provided at the home. Residents’ bedroom doors have not been fitted with a lock. Only newly commissioned bedrooms have been provided with a lockable facility. The carpet to one bedroom in the original part of the home was badly stained, and required attention or replacement. All shared bedrooms were provided with screening. The hot water temperatures tested, and accessible to service users, were all maintained correctly at around 43 degrees centigrade. The heating within one bedroom was out of order. The room was cold, and contained a free standing unguarded radiator. This is unsafe. Following investigation, the manager said that the boiler had ‘gone out’, and confirmed that the room was now warm, and that the radiator would be removed. The communal and bedroom areas were clean. However, one bedroom Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 18 suffered a strong malodour. The sluice room, which contained a sluice disinfector, was dirty. There were unwashed kidney dishes both in the sink, and also on the floor of the room. Following a complaint made prior to the last inspection, the manager confirmed that commode pans are now cleaned regularly by staff. . Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 and 29 There is a satisfactory compliment of staff at the home. The recruitment process is not robust, which potentially leaves service users at risk. EVIDENCE: An interim staffing notice was agreed with the registered provider, on the understanding that, at such point that the home wished to admit over the number of 25 service users, the staffing notice would need to be further negotiated. At this inspection, it was discovered that there were 28 service users occupying the home, and the Commission for Social Care Inspection had not been informed. The manager was unaware of this arrangement, but had increased the staffing available regardless. The registered person must now submit a further staffing proposal to reflect the increase in occupancy. Two staff are currently working towards NVQ Level 2, and one member of staff to NVQ Level 3. The home also employs qualified nurses from overseas, who work as care assistants at the home. The recruitment files of two recently employed staff members identified that insufficient information is gathered prior to deployment. One member of staff had commenced duties prior to either of the written references being received, and a CRB check had been accepted which was carried out at a previous employment. The second file evidenced that the CRB had not been returned at Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 20 the point at which the staff member was deployed, and a POVA First had not been requested. There was only one written reference available. Staff training provision has improved, and the manager was confident that staff receive at least three days training each year. Newly employed staff now receive an induction, provided by an outside body, which meets with TOPSS standards. Further in house induction is undertaken. Additional training, which is pertinent to the needs of specific service users, has also been provided to staff by community services. Further training in the prevention and treatment of pressure sores is currently being sought. Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,37 and 38 The manager has improved the lines of accountability at the home. The health and safety of the home has been neglected in a number of areas, resulting in service users being in danger of unnecessary risk. EVIDENCE: The manager has applied to the Commission to become registered manager for the home. They are continuing studies towards their health and social care award. They have been awarded additional supernumerary time, which will assist them in working towards the large number of requirements that remain outstanding. They have made good progress in defining roles and lines of accountability, and staff and relatives said that the manager was approachable. They have no budgetary control, but stated that there were sufficient systems in place to ensure that they would be able to access services in situations of emergency. Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 22 It remains outstanding that the care plans, which are located in an unlocked filing cabinet in a public area, are not kept locked away. This must be addressed. Some mandatory training has been provided for some staff since the last inspection. During discussion with staff, it was evident that sometimes a service user will be lifted ‘for speed’. This is entirely inappropriate. All staff must be provided with training in moving and handling, and the importance of safe moving and handling practices reinforced. To assist in this process, it is planned that one trained member of staff will undergo a ‘train the trainer’ course in back care. Six staff have completed first aid training. The manager must organise first aid training for sufficient staff to ensure that there is a qualified first aider on each shift. Concerns were raised regarding the staffs’ level of understanding about infection control, with specific reference to the sluice room, and PEG feed equipment as detailed previously. Staff must be provided with suitable training in infection control. Staff have recently undergone training in COSHH. Despite this, it was of concern that the majority of bathroom cupboards, which contained hazardous chemicals, were not locked. With specific reference to the kitchen area, it is important that the manager: • • • devises a cleaning schedule ensures that the temperature of cooked meats is recorded organises for the fly screens to the door and windows to be replaced The manager said that fire training was provided at six monthly intervals. Additional training should be provided for night staff, and new starters should receive training twice within the first month of induction. The fire records evidenced that the last recorded fire alarm test was completed 22nd April 2005. There is currently a programme in progress whereby all bedroom doors will be fitted with magnetic closers. The fire door to one bedroom door was not closing properly. In addition to this, the laundry door was wedged open. The wedge was removed immediately. The manager organised for this to be repaired forthwith. Some fire exit doors are located in service users’ bedrooms. Not all of the remote alarms were switched to the ‘on’ position. The manager stated that it is planned that these will be wired into the mains system. The fire escape from one fire exit door was partially blocked by planks of wood. The manager arranged for these to be removed immediately. The fire fighting equipment was last checked in July 2004. Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 23 As explained in the environmental standards, one bedroom was supplied with only one single electrical socket. A three way adaptor was being used. This was deemed unsafe. Pending refurbishment of the rooms, the registered person must ensure that all such adaptors are replaced with a safer alternative, following the advice of a qualified electrician. . The majority of service users’ beds were fitted with bed rails. There were no records kept to confirm that these were checked on a regular basis to ensure that they were safe and properly fitted. In addition to this, it was established that some of the rails were not compatible with the equipment used on the bed. Also, there were some accidents recorded within the accident book which were attributable to the use of bed rails. The manager was required to immediately: • • check all bed rails and the beds to which they were fitted to ensure that they were safe and compatible identify those service users who have suffered an incident connected with the use of bed rails, and review their risk assessment Within one week the manager was required to: • • • ascertain why the bed rails were fitted update the risk assessments in order to reflect why they were fitted, and the possible risk to service users, and how these could be reduced or eliminated organise a review with the care manager where issues remain outstanding following the in house review There are outstanding matters detailed within the fixed wiring certificate issued in July 2004. The manager stated that these were in the process of being addressed as part of the refurbishment plan. Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 1 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 1 COMPLAINTS AND PROTECTION 1 2 1 1 1 1 1 1 STAFFING Standard No Score 27 1 28 2 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 2 2 x x x x 1 1 Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 5 Timescale for action The service users guide must 30 June include a copy of the most recent 2005 inspection report (timescale of 31.07.04 not met) It must also include a copy of the complaints procedure, including the address and telephone number of the CSCI The terms and conditions of contract must include: Requirement 2. 2 5 30 June 2005 3. 7 15 (i)fees payable and by whom , for example service user, local or health authority, relative or other (ii)details of how the free nursing contribution will be reimbursed to the service user (iii)rights and obligations of the service user and registered provider and who is liable if there is a breach of contract Wherever practicable, the plan of 30 June care must be drawn up and 2005 subsequently reviewed with the involvement of the service user and/or their representative (timescale of 02.09.04 not met) Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 26 4. 7 12,15 Wherever practicable, wishes regarding terminal care and arrangements after death must be discussed with the service user and/or their representative. Details must be recorded within the plan of care (timescale of 30.06.04 not met) The registered person must ensure that service users who are at risk from: (i) falls (ii)weight loss (iii)the use of bed rails have risk assessments and management plans incorporated into their care plans and that these are reviewed on a monthly basis (timescale of 01.04.04 not met) 30 June 2005 5. 7 13 30 June 2005 6. 7 15 The social needs of each service user must be fully explored and and recorded (timescale of 02.09.04 not met) The incidence of pressure sores, their treatment and outcome, must be clearly recorded in the plan of care. The plan must be reviewed on a continuing basis (timescale of 02.09.04 not met) The psychological needs of service users must be fully recorded and monitored (timescale of 31.10.04 not met) Service users must be offered opportunities for appropriate exercise and physical activity (timescale of 31.10.04 not met) 30 June 2005 7. 8 17(1)(a) Schedule 3(p) 30 June 2005 8. 8 12,13 30 June 2005 9. 8 16 31 July 2005 Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 27 10. 8 13 11. 9 13 12. 9 13 13. 15 12,13 14. 15 17(2) Schedule 4(13) Referral must be made to the appropriate care manager for a review of the mental health needs of the service user identified at the time of the inspection The manager must implement systems to ensure that the equipment used to administer PEG feeds is kept in a clean state at all times The fact that some service users no longer require controlled drugs on a regular basis as part of their treament must be referred to the General Practitioner for review The manager must provide the cook with a list of dietary likes and dislikes and requirements, to ensure that nutritional advice from other professionals is clearly understood A record must be kept of the food provided for service users in sufficient detail to enable any person inspecting the record to determine whether the diet is satisfactory, in relation to nutrition and otherwise, and of any special diets prepared for individual servcie users (timescale of 03.09.04 not met) All staff must receive training about abuse (timescale of 01.05.04 not met) The training must be linked with the local authority multi agency policy for the protection of vulnerable adults In the absence of a self closing device authorised by the fire authority, all fire doors, including the laundry door, must be kept shut 31 May 2005 5 May 2005 and maintained thereafter 20 May 2005 31 May 2005 5 May 2005 and maintained thereafter 15. 18 13 30 June 2005 16. 19 13,23 5 May 2005 and maintained thereafter Page 28 Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 17. 19 13,23 The basement area must not be used for the storage of combustible materials The registered provider must consider how appropriate bathing facilities may be provided to each floor Service users must have access to their remote call bells at all times The manager must consider alternative arrangements in the case of the service user occupying the shared room, and where current moving and handling arrangements are unpractical and unsafe The registered provider must, as part of the plan of refurbishment, provide an action plan to the Commission with regard to the provision of additional electrical sockets to bedrooms Each service user must be provided with a lockable storage space (timescale of 31.11.04 not met) The registered provider must, as part of the plan of refurbishment, provide an action plan to the Commission with regard to the provision of lockable facilities within service users bedrooms The badly stained carpet identified at the time of the inspection must be cleaned or replaced The ceiling lights within the room identified at the time of the inspection must be restored to working order 18. 21 23 05 May 2005 and maintained thereafter 31 July 2005 5 May 2005 and maintained thereafter 31 May 2005 19. 22 16,23 20. 23 12,23 21. 24 16 30 June 2005 22. 24 23 30 June 2005 23. 24 16 31 May 2005 5 May 2005 24. 25 23 Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 29 25. 25 23 26. 27. 25 26 13 12,16 28. 26 13 The central heating supply to the room identified at the time of the inspection must be restored and maintained Heaters and radiators must be fastened securely to the wall and guarded The manager must identify the cause of the malodour to the bedroom discussed at the inspection, and must ensure that systems are put into place to assist in it being eradicated The sluice room must be thoroughly cleaned The registered person must submit a further staffing proposal to the CSCI, which considers the amount of staff that will be available when the home is fully occupied The registered provider must obtain a Criminal Records Bureau check before any new member of staff commences work (timescale of 02.09.04 not met) Two satisfactory written references must be obtained and authenticated for each prospective employee before they are deployed to work at the home Care plans must be stored securely when not in use (timescale of 28.04.04 not met) All staff must undergo training in safe moving and handling Sufficient staff must be trained in first aid to ensure that there is a qualified first aider on each shift 5 May 2005 5 May 2005 31 May 2005 29. 27 18 5 May 2005 and maintained thereafter 31 May 2005 30. 29 18,19 5 May 2005 and maintained thereafter 31. 37 17 31 May 2005 31 July 2005 31 July 2005 32. 33. 38 38 13 13 Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 30 34. 35. 36. 38 38 38 13 13 13 Staff must be provided with training in infection control Staff must be provided with training in the Control of Substances Hazardous to Health Hazardous chemicals must be kept locked away With specific reference to the kitchen, the manager must: (i)devise a cleaning schedule (ii)ensure that the temperature of cooked meats is recorded (iii)organise for the fly screens to the door and windows to be replaced 31 July 2005 31 July 2005 5 May 2005 and maintained thereafter 31 May 2005 37. 38 13 38. 38 13,23 Fire alarm tests must be caried out on a weekly basis, and records kept 5 May 2005 and maintained thereafter 39. 38 13 40. 38 13 41. 38 13 All fire exits must be kept clear at all times Following the advice of a 5 May qualified electrician, the 2005 registered person must replace all electrical socket adaptors with a safer alternative The manager must immediately: 5 May 2005 (i)check all bed rails and the beds to which they are fitted to ensure that they are safe and compatible (ii)identify those service users who have suffered an incident connected with the use of bed rails, and review their risk assessment Within one week,the manager 12 May must: 2005 (i)ascertain why bed rails are fitted (ii)update the risk assessments Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 31 in order to reflect why they were fitted, and the possible risk to service users, and how these could be reduced or eliminated (iii)organise a review with the care manager where issues remain outstanding following the in house review The manager must also devise a system whereby staff record that the equpiment has been checked, and of any remedial action taken where the equipment has been found to be unsafe The registered person must provide the Comission with a plan of action which explains how those outstanding unsatisfactory matters detailed within the most recent fixed wiring certificate are to be addressed 42. 38 13 31 May 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. Refer to Standard 1 15 20 22 24 24 Good Practice Recommendations It is recommended that service users views of the home are included in the service users guide. It is recommended that a choice of written menu is offered to service users at each mealtime Consideration should be given to the provision of additional dining space, in order that service users may eat together, should they wish to do so It is recommended that a suitably qualified person, including an occupational therapist, undertakes an assessment of the premises and facilities It is recommended that doors to service users private accommodation are fitted with locks that are accessible to staff in emergencies Priority should be given to the purchase of additional J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 32 Beechwood Nursing Home 7. 8. 9. 10. 28 31 38 38 hospital beds 50 of all care staff should achieve NVQ Level 2 or above by 2005 It is recommended that the manager pursue a qualification in management, and that this is achieved by 2005 It is strongly recommended that the fire exit doors are wired into the nurse call system, in order that staff can be immediately alerted when the exit doors are opened Staff should receive fire training at the following rate, and records kept: Day staff - six monthly Night staff - three monthly Newly recruited staff - twice during the first month of induction Beechwood Nursing Home J53-J04 S27997 Beechwood Nursing Home 223300 040505 Stage 4.doc Version 1.30 Page 33 Commission for Social Care Inspection 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. 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