Inspection on 05/06/06 for Beechy Knoll

This inspection was carried out on 5th June 2006.

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

Beechy Knoll 19/05/08

Beechy Knoll 24/05/07

Beechy Knoll 10/11/05

Similar services:

Abbey The

Snydale Care Home

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 Beechy Knoll 378 Richmond Road Sheffield South Yorkshire S13 8LZ Lead Inspector Sue Turner Key Unannounced Inspection 5th June 2006 8:30 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 Beechy Knoll DS0000065505.V298111.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. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechy Knoll Address 378 Richmond Road Sheffield South Yorkshire S13 8LZ 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) 0114 239 5776 0114 264 6063 beechyknoll378@yahoo.co.uk Pearlcare (Richmond) Ltd. Mrs Wendy Barnes Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The minimum numbers of care staff on duty must comply with that required by the `Residential Forum - Care Staffing in Care Homes for Older People`. 10th November 2005 Date of last inspection Brief Description of the Service: Beechy Knoll is a forty-bed home providing personal care for older people of both sexes. It is situated in a residential area of Sheffield, close to local amenities and bus routes. The home is built over two floors, all areas of the home are accessible to service users and a passenger lift is provided. 33 of the homes bedrooms are single and 3 bedrooms are double. 22 bedrooms have ensuite toilet facilities. The home has communal lounges and a communal dining space. Appropriate bathing facilities are provided. A central laundry and kitchen serve the home. Seating is provided in the homes gardens. The home has a car park. A copy of the previous inspection report was available for anyone visiting or using the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. The manager confirmed that the range of monthly fees from April 2006 were £303 - £335 per week. Additional charges included newspapers, hairdressing, dial-a-ride and private chiropody. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection, which was unannounced and took place over 7 hours from 8.30 am to 3:50 pm. Prior to the site visit the manager completed pre inspection information and five service users returned questionnaires sent out entitled ‘have your say about…’. At the site visit, an inspection of the environment was undertaken. Records were examined, including: 4 care plans, complaints, staff recruitment and training, menu and fire records. All of the Commission for Social Care Inspection (CSCI) key standards were checked. Interactions between staff and service users were observed. The inspector spoke with a proportion of the staff on duty (8), and 8 service users. Discussions with the homes manager and the provider’s representative also took place. Four relatives and a district nurse visiting on the day of the inspection were also spoken to. What the service does well: What has improved since the last inspection? The homes record of complaints had been expanded and detailed the outcome of any complaints received and any action that had been taken to resolve any issues. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 6 A copy of local multi-agency adult protection procedures was available at the home for the staff to read and refer as necessary. The providers representative was visiting the home several times each week to offer the manager support and help her to become familiar with her management duties and responsibilities. An audit of the staff training needs had been carried out and where gaps had been identified training had been arranged and facilitated. Staff spoken to said that they were receiving formal one to one supervision from their line manager, on a six weekly basis. What they could do better: At the previous inspection it had been highlighted that the care plans required more specific detail to ensure service users needs were being met. This requirement had not been actioned and is therefore carried forward to this report. Other requirements carried forward to this report relate to service users being consulted about further activities, particularly outside of the home and staff recruitment files that need to contain photographs, proof of identity and evidence that gaps in employment history have been checked. A number of issues relating to the health, safety and well being of the service users are highlighted in this report. These include: • Shortfalls in the safe recording and handling of medications received into the home. • The medicine trolleys were very unclean with spillages • Not all staff had received training in adult protection, infection control, food hygiene and moving and handling. • A discrepancy in one service users financial records that necessitates increased measures to safe guard finances • Substances that could be hazardous to health left in unlocked cupboards and fire doors that should be kept locked left unlocked. • One service user was observed to be moved and handled in an unsafe way. • A substantial number of window restrainers were broken and water was running very hot from one tap. There are a number of environmental improvements would make the home more pleasing and help to achieve a more homely impression. Some carpets were stained and marked and the home was generally untidy, with bathrooms, toilets and the laundry used for storage. The furnishings in the conservatory were looking particularly worn and tired and unpleasant odours were in two bedrooms. There should therefore be a review of the ancillary staffing hours to ensure that the home is kept clean and tidy. The homes quality assurance systems require further development so that the manager and provider can monitor the homes performance and take any appropriate action required. Relatives and visitors should be more involved in this process so that their views and concerns are heard and actioned. The variety of food served did not meet all of the service users needs and preferences and service users should therefore be consulted about this. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 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. Beechy Knoll DS0000065505.V298111.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 Beechy Knoll DS0000065505.V298111.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments prior to admission took place and trial visits to the home were encouraged. This enabled staff to be aware of service users needs to ensure that they could be met. EVIDENCE: Staff spoken to said that assessments were undertaken prior to admission to ensure the service could meet prospective service user needs. The home’s manager or senior staff carried these out. Copies of care management assessments were seen on the files checked. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 10 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): 7, 8, 9, 10 and 11. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Not all care plans had sufficient recorded information to ensure that the service users health, personal and social care needs were truly reflected and could be met. Service users were not assured that their wishes were known and would be considered at the time of their death. Care plan reviews had not highlighted changes to the service users needs. Service users privacy and dignity was in the main respected, ensuring that their rights were upheld. The homes medication practices do not fully protect the service users from being administrated inappropriate medications. EVIDENCE: Four care plans were sampled. These contained varied information on aspects of personal, social and health care needs. The plans contained detail of health care contacts and the home supported access to these to ensure health was maintained. The plans did not include information on the staff action required to ensure assessed needs were met. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 11 The quality of information in the care plans was not adequate. The manager was given examples of where information recorded in sections of the plans was not fully completed or appropriate. The care plans seen did not have the service users wishes regarding death and dying. The inspector believes that a full ‘pen picture’ of the service user cannot be established from reading the care plans. All four care plans checked had been signed by staff stating that they had been reviewed each month. The reviews verified that no changes were required to be made to the care plan. For one service user this was over a four-year period. The manager, when asked, said that the service users needs had changed in that four year period and agreed that the care plan should have been amended in this period. A district nurse visiting on the day of the inspection was spoken to. She said that she visited the home twice each week and more often if necessary. She said that she always found the service users well dressed and cared for. Staff were helpful if she needed assistance with dealing with the health needs of the service users and she had no concerns about the pressure care provided by staff at the home. The inspector observed a team leader giving out medications. Service users were offered water and the inspector observed the staff member being very patient. In the main the home used blister packed medications, however there was also a substantial amount of medications in boxes and bottles. The trolleys used to store the medications were very unclean with spillages and stains. Medication records were checked and a number of issues were identified. • One medication balance did not tally with records • Medications, which were not in blister packs, were not being booked in appropriately • A system to check the stock of medication was not in place. Staff were observed respecting privacy by knocking on doors before entering. The interactions between staff and service users appeared respectful and caring. Service users spoken to said the staff were ‘kind’ and ‘helpful’. One service user questionnaire raised concern about ‘ I do not like the fact that they have a tights pool, I buy 10 pairs a month and never see them again when they go in the wash’. The manager was asked about this and said that if tights went to the laundry without nametapes on they were put in a box and then used for anyone. The inspector pointed out the inappropriateness of this practice. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were able to make choices about daily living and social activities. Service users would benefit from a further programme of activities, which would suit their individual capabilities and preferences. The home had an open visiting policy, which assisted in maintaining good relationships with service users family and friends. The meals provided did not meet all service users individual needs and preferences. The comments received from service users need to be considered and actioned in order for the service users to feel valued and listened to. Service users would enjoy being served fresh fruit on a more regular basis. EVIDENCE: Service users spoken to said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. One service user spoken to said that they preferred to go to bed late and get up late and this wasn’t a problem for the staff. One service user spoken to said ‘staff always ask me what I want to wear, they never chose for me’ The home employed an activities worker for three days each week. Service users spoken to and comments received from questionnaires varied regarding Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 13 the quality and quantity of the activities available. Some service users said they were ‘happy’ with the activities programme, however a number of service users and two relatives said that activities were not sufficient. They said trips out of the home were ‘few and far between’. One service user questionnaire said that because they were blind they could only join in ‘a few activities’. The home did not have a formal activities programme that could be monitored and evaluated by the manager to establish if the activities available were suitable and if individual preferences were being met. Two relatives spoken to said they were able to visit at any time and one relative said they were always made to feel welcome. Service users opinions of the food provided at the home also varied. Comments made by them were ‘I’ve no complaints about the food’, ‘the food is very good’, ‘ there’s not enough fresh fruit and vegetables’, ‘there’s enough but the choices are very poor’, ‘ meals are very repetitive, there’s too much sausage and pasties’, ‘I am on a liquid diet and get fed up with soup at teatime’. Relatives and service users commented that they used to have fresh fruit in the lounges but this was no longer available. Lunch on the day of the inspection was either braised steak or quiche. One service user spoken to had ordered quiche and salad, but all service users were served quiche with mashed potato, vegetables and gravy. The inspector noted that at the previous service users meeting, service users had asked not to be served quiche with potatoes and vegetables. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 14 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): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes record of complaints was accessible and evidenced that appropriate action was taken following any concerns raised. Not all staff had not been provided with essential training in adult protection procedures to ensure service users were safe, and to inform staff of the procedures to follow if an allegation was made. EVIDENCE: The homes complaints policy was on display in the entrance area of the home. It contained relevant information and informed the reader who to contact external to the home, should the complainant wish to do so. The home had a record of all complaints made to the home. The manager said that there were no outstanding complaints. Since the last inspection CSCI had not received any complaints about the service. Staff spoken to were aware of their responsibilities in reporting any complaints or allegations to the appropriate person. The homes adult protection policy included information on local procedures. Staff spoken to said that they would report any allegations of abuse to their senior manager. Some staff spoken to said they had not received any training in adult protection procedures, however they were able to describe types of abuse that service users could be susceptible to. The manager stated that all staff had been allocated a place on the adult protection training course. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 15 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): 19, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate facilities, aids and adaptations were provided to meet the service users needs and maximise their independence. Homely touches had been provided to create a comfortable environment. The environment within the home was not maintained to an adequate enough standard and was not free from offensive odours. EVIDENCE: The homes location and layout was suited to its stated purpose. The home was in the main well maintained. Appropriate aids, hoists and adaptations were provided to meet the needs of the service users. All areas of the home were accessible to the service users. Homely touches had been provided to create a comfortable environment. In the main communal areas were well maintained, and service users bedrooms were personalised. All Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 16 service users spoken to said they were pleased with their rooms and that they had ‘all they needed in them’. The inspector carried out a full environment check and found a number of areas within the home to be in need of decoration, cleaning and tidying. Observations of the environment were: • Walls and skirting boards around the home were damaged and marked • A substantial number of carpets in bedrooms and communal areas were stained and marked • The medication trolleys were in need of a thorough clean • The laundry was extremely untidy. Clean laundry was seen placed on the floor before being folded • The ground floor bathroom floor was stained and marked • Bathrooms and toilets were used to store broken furniture and were generally untidy • The upstairs toilet had no curtain or blind fitted to the window and no toilet seat • Two bedrooms were odorous • The conservatory looked untidy, the roof was dirty, paintwork was marked and chairs were showing signs of wear and tear. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care staff were employed in sufficient numbers to meet the service users needs, however the ancillary staffing numbers were not ensuring that the home was kept clean, tidy and free of unpleasant odours. Recommended levels of NVQ trained staff had been achieved, however not all staff had undertaken mandatory training which would ensure that staff had the competencies to meet the service users needs. There remained a number of shortfalls in the details held and recorded in staff recruitment files, therefore not ensuring the protection of service users. EVIDENCE: The homes rota indicated that agreed levels of care staff were being maintained to meet the needs of service users. Service users and relatives spoken with felt that enough care staff were provided. The inspector spoke to three ancillary staff who said that the aim was that three staff worked each morning but this often fell down to two due to holidays and sickness. One domestic also worked for two hours during the evening. Two relatives spoken to said they felt that cleanliness at the home had recently decreased. The inspector also believes this to be the case as evidenced in the environmental standards. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 18 Of the 28 care staff, 18 staff had achieved NVQ level 2 in care, a further 4 staff were undertaking the training, which met the recommended 50 of the care staff trained to NVQ level 2 in care by 2005. Three staff records were checked. In the main the files contained the required information, CRB’s had been completed. There were shortfalls in the information seen on file, photographs were not present and gaps in employment records had not been explored and explained. The manager had undertaken a review of staff training, which had identified a number of shortfalls. Not all staff had completed training in food hygiene, infection control, adult protection, health and safety and safe moving and handling. The manager had initiated a planned programme of mandatory training. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35, 36 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager’s leadership approach benefited service users and staff. The lack of quality assurance audits means that the home cannot be run in the best interests of the service users. The system used to record monies held for safekeeping was inadequate and susceptible for misuse. Staff received formal supervision at the frequency required to ensure their development, training needs and care practices were being monitored. The health, safety and welfare of service users were not fully promoted due to the number of concerns around health and safety. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 20 EVIDENCE: All of the service users, staff and relatives spoken with said the manager was approachable and supportive. Recorded quality assurance visits by the regional manager had been undertaken and the reports forwarded to the CSCI. The manager said that she had recently sent out questionnaires to the service users to ask their opinions of the home and the care provided. These had been returned but no action had been taken regarding any comments made. Service user meetings had occurred, but service users spoken to felt that very little action had been taken following these. The inspector looked at the minutes from several service user meetings and found that action points had been carried over from month to month and appropriate action had not been taken swiftly, following the issues raised at the meetings. Two relatives spoken to said that they felt that the service provided by the home had recently declined. The manager stated that no relative’s meetings had taken place. The inspector believes it is essential that a full quality assurance audit be carried out so that everyone concerned with the home can feedback their views and any concerns they may have. The personal accounts of three service users were checked. For one there was a discrepancy in the records and the money held for the service user. Money held for the service user was substantial and neither the regional manager nor the registered manager was able to clarify the discrepancy. Following the inspection the manager contacted the inspector to confirm that the discrepancy had been rectified. Staff spoken to said that they had received formal supervision from the manager, which they had found useful and informative. Fire records were up to date and stated that weekly testing of the fire alarm system and fire practises/drills had occurred. The fire drills had not been reported in full with the detail required. During the inspection the inspector observed a number of concerns relating to the health, safety and welfare of the service users: • Two doors with signs stating ‘Fire door keep locked shut’ were open. • The water from a sink in the small sitting room was very hot. • A substantial number of window restrainers, fitted to first floor windows were broken. • A bathroom cupboard that contained hazardous substances had been left unlocked. • A service user was seen being transferred from wheelchair to chair. The service user was none weight bearing and staff did not use a hoist. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 3 3 2 STAFFING Standard No Score 27 2 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 3 X 1 Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 15 Requirement Care plans must contain specific detail on the staff action required to ensure service users identified needs are met. (Previous timescale of 31/01/06 not met) Information within all care plans must be reviewed and updated to reflect each service users current health, personal and social needs. There must be arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. Medication trolleys must be thoroughly clean and hygienic. Service users clothes must be solely for their purpose and not used by others. Service users wishes regarding dying and death must be sought and recorded in their care plan. Service users must be consulted regarding the variety of activities offered. Further activities and trips out of the home must be provided. DS0000065505.V298111.R01.S.doc Timescale for action 01/09/06 2. OP7 15 01/09/06 3. OP9 13 05/06/06 4. 5. 6. 7. OP9 OP10 OP11 OP12 13 12 15 16 05/06/06 05/06/06 01/09/06 01/08/06 Beechy Knoll Version 5.2 Page 23 8. OP15 16 9. 10. OP18 OP19 18 16 23 11. OP26 16 23 12. OP27 18 (Previous timescale of 31/01/06 not met) Service users must be consulted regarding the variety of food. Appropriate action must then be taken to ensure adequate quantities and suitable and wholesome food is available as required by the service users. All staff must be trained adult protection procedures. All areas of the home must be well maintained, clean and tidy and free from offensive odour therefore: The marked and scratched skirting boards and walls must be redecorated. All carpets and floors must be cleaned to eradicate marks and odours. Where this is not possible, the carpet must be replaced. Bathrooms and toilets must not be used for storage and must be kept clean and tidy. The upstairs toilet must be fitted with a curtain or blind and a new toilet seat. The cause of offensive odours must be established and appropriate action taken. The conservatory roof must be cleaned, paintwork must be redecorated and chairs must be cleaned, re-upholstered or replaced. Clean laundry must not be placed on the laundry floor. The laundry must be kept clean, tidy and hygienic. A review of the number/hours worked by ancillary staff should be undertaken to establish if they can fully meet the needs of the service users and keep the home clean, tidy and free from unpleasant odour. Appropriate DS0000065505.V298111.R01.S.doc 01/08/06 01/09/06 01/08/06 01/08/06 01/09/06 Beechy Knoll Version 5.2 Page 24 13. OP29 18 14. OP30 18 15. OP33 26 16. OP33 24 17. 18. OP35 OP38 13 13 action must then be taken. Staff files must contain all of the required information, including: Proof of identity; Photographs; Dates of all previous employment; Evidence that gaps in employment history have been explored. (Previous timescale of 31/01/06 not met). All staff must receive statutory training, records must be accessible and organised so that information can be easily retrieved. Service user and relatives meetings must be held. When issues are raised appropriate action must be taken promptly. The homes quality assurance system must be developed further. The performance of the home must be monitored against the Statement of Purpose and The Care Homes Regulations. Any identified patterns or issues requiring action must be dealt with appropriately. Adjustments to improve the service must be made if necessary. Increased measures must be put in place to ensure service users finances are safeguarded. The health, safety and welfare of all service users must be promoted and protected at all times, therefore: All substances that may be hazardous to health must be securely stored at all times. Where agreed with the fire authority all fire doors must be kept locked shut. All service users must be safely moved and handled. All moving and handling techniques must be DS0000065505.V298111.R01.S.doc 01/08/06 01/09/06 01/08/06 01/09/06 05/06/06 05/06/06 Beechy Knoll Version 5.2 Page 25 recorded in service users individual plans of care. All water temperatures must be checked and appropriate action taken where necessary. All window restrainers must be in working order. 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 OP15 Good Practice Recommendations Fresh fruit should be offered to service users on a regular basis. Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Beechy Knoll DS0000065505.V298111.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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