Inspection on 28/02/07 for Beeton Grange

This inspection was carried out on 28th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beeton Grange 08/01/08

Beeton Grange 15/11/05

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Beeton Grange 50-55 Beeton Grange Winson Green Birmingham West Midlands B18 4QD Lead Inspector Sean Devine Key Unannounced Inspection 28th February 2007 08:40 Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 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 Beeton Grange DS0000064739.V323823.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 Adults 18-65. 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. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beeton Grange Address 50-55 Beeton Grange Winson Green Birmingham West Midlands B18 4QD 0121 554 5559 0121 523 8681 beeton.grange@carepartnerships.com 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) West Regent Ltd Ms Marlene Myers Care Home 24 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (24) of places Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can care for twenty four (24) service users under 65 years of age who are in need of care for reasons of mental health disorder. Accommodation is to be provided in two adjacent units. That two named persons over 65 years of age at the time of admission can continue to be accommodated and cared for in this Home. The home must demonstrate through comprehensive care planning and regular reviews carried out by social services that it is able to meet all the needs of each individual. 15th November 2005 2. Date of last inspection Brief Description of the Service: Beeton Grange is a large building situated in Winson Green close to the number 11 bus route for link to the city centre. The home comprises of two individual sections, which are interlinked and are registered as one organisation. The stated function and purpose of the home is to provide care and support to 24 African, Caribbean or Asian people who are recovering from mental health illness. The programmes of care include encouragement and support in promoting residents independence. Assistance is provided with personal budgeting, shopping, cooking, laundry and the development of individual programmes for each resident. The aim of the home is where possible to rehabilitate residents and help them return to community living. Accommodation constitutes 22 single bedrooms and two flat lets. Each section has a lounge and dining room. There are toilets and bathing facilities strategically located. There is no off road parking facilities. The pre inspection questionnaire completed by the manager recorded that the current fees to receive this service ranges between £447.06 and £1600.00. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was visited on a weekday; it was an unannounced visit by one regulation inspector. Prior to the inspection four residents had returned completed surveys to the Commission about life at the home and the manager returned a pre inspection questionnaire. Comment cards were received from a social worker, two community psychiatric nurses and a consultant psychiatrist The inspector was able to meet and have discussions with many residents. At the time of the key inspection there were twenty-four residents receiving a residential service. How the service provides support and care for four of the residents was fully assessed, including their health and lifestyle and what it is like for the four residents to live in the home. Records about the support and care offered to the residents were seen and staff were at times observed supporting the residents. Records about management such as health and safety practices and quality of the care were also looked at. The inspector had a look at communal areas of the home but at this visit did not look into residents’ bedrooms. Complaints records maintained at the home were seen, there have been no complaints made to the home in the past 12 months and no complaints about the home have been made to the Commission. What the service does well: People are able visit the home before they make a decision on whether they wish to live there, whilst there the home will do assessments and gather more information which helps them decide on whether they can offer a care service. The residents are able to choose how they spend their time and can choose from a wide range of activities in and outside of the home. This often includes attending day centres, Birmingham Industrial Therapy Association, developing and maintaining skills such as shopping, cooking and cleaning. The residents decide upon the food menu and staff also incorporate a healthier option where it is needed. The residents’ personal needs are well met, including choices about dress, toiletries and hairstyles. The staff support the residents to take their medication and will often go with them to health appointments. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 6 The home is “homely” and does not present as an institution, how it is decorated reflects a warm and relaxing atmosphere. There are at all times good numbers of staff on duty to support and care for the residents. They are safely recruited, which includes making checks on their backgrounds. The staff are provided with a lot of training, both in health and safety and also to meet some of the personal needs of residents. The manager has regular meetings with each member of staff known as supervision where important issues such as how they are getting on and where they can improve are discussed. The manager was found to have a good deal of knowledge about the support and care each resident requires, and is highly valued by residents. She ensures that the home is well organised and that the health and safety of all people in the home is a high priority. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that they do include the prospective resident in making a decision on whether the home is suitable to meet their needs and expectations. The majority of residents believe that their choices and preferences are considered as part of the assessment process and that support is offered according to their wishes. EVIDENCE: There was a good range of evidence that indicated that residents are actively involved in deciding whether or not to live at the home, this included surveys forms, records maintained at the home and admission policy and staff practice. The care records of residents seen and conversations with staff and manager included reference to residents having trial visits to the home and to residents having been provided with information about the home. There were records of assessments conducted by the home to explore the current care and support needs of prospective residents and information provided by referring agencies such as social workers from hospitals. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not fully demonstrated that the individual needs and choices of residents although having been assessed are satisfactorily met. There is a lack of evidence that residents are involved in planning and reviewing their care, which may lead to misdirected support and increase frustration about making important life decisions. EVIDENCE: A social worker commented, “Beeton Grange is an especially welcoming unit, which caters very well for service users individual needs. Cultural needs are well recognised and catered for”. Comments from residents included “sometimes I need help from the staff to go shopping” and another commented “I enjoy cooking for myself on a daily basis”. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 10 Residents had some written care plans, yet some identified risks and required a risk assessment and management plan. For one resident there were no care plans about chosen lifestyles, although assessments had considered these needs, no support was planned for hobbies, family, social life, education and occupation. Some residents had signed to say they agree with the support written in the care plans yet many other residents had not. The care plans were regularly reviewed yet there was little evidence residents are involved in the review and nearly all reviews recorded “no change” and no information was recorded about whether or not the care plans had been effective to meet the objective of the care plan. There were risk assessments available for residents. These did not always fully take into consideration personal risks relating to age, lifestyles and mental health. As with the care plan reviews many of the risk assessment reviews recorded “no change”, there was little evidence residents had been involved in the review and how effective or otherwise the risk management plan had been. At the time of the visit the inspector met a visiting community psychiatric nurses who commented, “it’s a good home, they do contact the team at the earliest sign of relapse”. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it does have the ability to support residents’ choices about their lifestyle, including their aspirations, promoting independent living and cultural identities. There are good resources and opportunities, which require some further planning to help guide staff. EVIDENCE: The pre inspection information recorded some of the recreational and educational facilities available to the residents at the home and in the wider local community. These included computer skills, cooking skills and woodwork, football, snooker, day trips and holidays, cinema visits, Birmingham Industrial Therapy Association and the local leisure centre. There is a weekly plan of activity available to residents, this planner is completed four weeks in advance and is varied to meet the cultural, religious Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 12 and domestic needs of residents. Examples of activity available includes; communal meals, Asian videos, computers, food shopping, karaoke, dominoes, table tennis, cooking assistance, hair and nail care, bingo, Asian ladies daycentre, Indian cooking afternoon, music, a pub night out, church, mosque and temple visits. Residents have daily records and activity records, which confirmed they do participate in many of these activities. In discussion with staff and residents it was evident that there is a structure to the support residents receive. There are two distinct sides to the building (phase one and phase two). Phase one supports residents who require more staff involvement and phase two is for residents who are more independent and who require reduced support from staff. This is reflected in the staff allocations, and residents confirmed there is always lots of staff available to help them if needed. Each resident was found to have a life history completed as part of the assessments of need this also recorded information about family, friends and relationships. As recorded in individual needs and choices a resident had no written care plans about their chosen lifestyle. All residents had care plans about leaving the home as an objective, these were comprehensive and often mentioned daily life arrangements and community support. Three residents in discussion with the inspector commented that they did enjoy the meals, one resident pointed out that he cooked his own food when he was hungry and was able to cook at any reasonable time of day. The monthly food menu was seen and included many of the choices of residents and supported their cultural heritage and backgrounds, it also allowed for eating out at pubs, restaurants or for takeaways. The menu did not always advertise an alternative meal, yet residents and staff advised that this is available should the resident’s wish for something different to eat. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it does have the ability to meet the personal and healthcare needs of residents, yet there are areas that require improvements to ensure that it is well planned and that residents attend health appointments, if not residents may not have all their needs met and may suffer ill health. EVIDENCE: The residents all had an assessment of their ability to meet their own personal care needs, for one resident a risk assessment about severe personal neglect had been completed. For another resident, a care plan had been written, this was seen to need improvements, as it did not inform staff about the support needed and did not record monitoring. Three residents advised that they choose what they wear and shop for their own toiletries, one commented that this was normally with the staff. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 14 Comment cards from health professionals, included comments about healthcare such as “excellent working partnership” and “caters well for the clients needs”, there were no negative comments. The residents all had a record, for health appointments and visits. Mental health teams are actively involved in the residents’ care, including social workers, community psychiatric nurses and psychiatrists. There was evidence of chiropody visits where this was needed, yet no mention of how blood sugar levels are monitored within a care plan for a resident who is diabetic. For some residents their chosen lifestyle may well put their health at risk, for these residents risk assessments are written; yet they do not describe the support they receive such as education and health monitoring. In discussion with the manager and two residents it was clear that residents do receive their health appointment letters; including outpatients at hospitals, dental and opticians, yet the residents do not always inform the staff team of an appointment and it is likely that some health appointments are missed. There has been one reported medication error since January 2007, the staff were quickly alerted to this as the resident presented drowsily. Appropriate actions were taken, including contacting the doctor and the rehabilitation and recovery mental health teams for guidance. Positive actions have been taken to improve staff competencies. For each resident there was a photo, a medication administration record (MAR), a copy of the GP’s prescription and where known a record of allergies. Stocks of medication for residents were sampled and found to be accurate. The MAR had been fully completed for when medicine had been received and administered to residents. Homely remedies are provided and there is a policy and guidance; the guidance had been signed by the GP describing medication, what for, how much and how often. The home has a contract with a chemist and a pharmacist undertakes regular audits. All medication is appropriately stored including refrigeration where needed. A training record confirmed that the majority of staff have attended medication training. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has fully demonstrated that it has the processes and skills to effectively managed concerns and complaints in the best interests of the residents. The complaints policy is clear and concise and resident’s views are listened to and acted upon. EVIDENCE: Pre inspection information from residents, manager and visiting healthcare professionals recorded no complaints. Residents confirmed they knew who to talk to should they be unhappy and three indicated that they did know how to make a complaint. The home does have a complaints record; this confirmed that there had been no complaints about care, support and services for residents. Three residents who had discussions with the inspector were positive about how the home supports them; they felt the staff were good and provided them with a nice home to live in; they had no complaints. The home does provide a service for residents to have their money put in a safe and maintains accurate records. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 16 The training records provided by the manager indicate that all current support staff, administrator and managers have received training in adult abuse protection (POVA). Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it has the capacity to provide the residents with an environment that is homely, clean and which meets the group and individual needs of residents. This will help protect and increase the health and well being of the residents. EVIDENCE: The residents surveys all indicated that the home is kept clean and tidy and pre inspection information recorded that since the last inspection some repainting and redecoration of bedrooms, lounge and kitchen had been undertaken. An environmental health officer visited the home on the in February 2007 and provided a report, which was very positive about cleanliness and good standards of hygiene in the kitchen, the manager advised that the recommendations had been addressed. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 18 A tour of the communal areas of the home was undertaken; the home is divided into two sides, phase one and phase two. Phase two, has a large lounge with many two seated settees, the manager advised that these were due to be replaced. The carpet in the lounge had some small stains, yet there was evidence it is cleaned on a regular basis. The dining area is annexed from the kitchen and residents can smoke in this area, one resident commented “we ask people if they mind us smoking when they are eating, if they do we move somewhere else”. There is a bathroom on the ground floor, with a toilet and good hand washing facilities; the flooring in the bathroom is damaged and needs repair or replacement; the manager advised that this has been reported on and repair and refurbishment is to be completed in March 2007. The bathroom has a pull cord to activate the call system; it was seen to need repair, as many residents could not reach it. The Laundry is on the ground floor. Residents have set days for their laundry, but do use it on other days when needed. There are two washing machines and there are two tumble dryers. The floor and walls were clean and there are facilities for ironing clothes. The laundry is kept locked and the manager advised that staff usually stay with residents when they are using the laundry. Upstairs on Phase two there is a shower room, the manager advised that the refurbishment as with the bathroom is due in March 2007. The upstairs toilet was not clean and had stained paintwork, this was cleaned at the time of the visit. Phase one also has a large lounge area, with several settees. There is a call system in the lounge area. Many residents use the dining area during the day, and briefly had a conversation with the inspector; they confirmed that the staff always provide them with privacy in their rooms. The bathroom as with the other bathing and shower facilities was seen to require refurbishment; again the manager advised that this was due in March 2007. There is a large rear garden, with sheds for the maintenance person, which also provides for a work area. The rear of the building has large areas of paintwork that is chipped or worn away and needs repainting. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it has the ability to ensure that residents are supported by staff who have been safely recruited, who are well trained, available in good numbers and who are regularly supervised. This ensures resident’s benefit from a skilled and competent workforce with their individual and communal needs being effectively met. EVIDENCE: The residents’ surveys and health professional comments all indicated that the staff team are competent and skilled. One resident recorded “staff are very supportive” and all health professionals indicated that the home communicates well, that there is always a senior member of staff to consult with and that staff clearly understand and demonstrate a good knowledge of the residents needs. The pre inspection information provided by the manager recorded that no staff members had left since the last inspection. That 17 of the 28 care staff had achieved NVQ level 2 or above and that the training plan from 2006 through Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 20 2007 included all mandatory training such as food hygiene, health and safety and first aid and also included specific training such as POVA, medication, epilepsy, risk assessment and communication. Two staff training files provided confirmation that new staff complete a full induction. At the inspection the manager provided an extensive training needs analysis for all staff. It was evident that all staff are well trained in health and safety and to meet the specific needs of the residents. Rotas and support workers on duty at the time of inspection indicate that staffing levels are satisfactory to meet the needs of residents during the day and at night. The recruitment files for the two most recently employed staff were seen, it was evident that all required checks are completed including two written references, criminal records bureau disclosures and a health check prior to staff commencing duties. Both staff had completed an application form and they had been interviewed. The supervision records were available for both staff. These meetings were frequent and provide support for staff to ensure they can meet the needs of the residents. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, 42 and 43. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it does have the ability to ensure that the management and administration is run in the best interests of the residents, that its operation has a focus on choice, inclusion and promoting the health and safety of all persons in the home. EVIDENCE: It was the view of the residents that they like the manager and that she spent a lot of her time out on the units and was always available for them, this was confirmed as residents were seen regularly coming into the office to see the manager and the administrator to talk about what they were doing, collect money and to ask questions. Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 22 The manager advised of her own current training and development including study on an IT course and recently completing a four-day health and safety course. She also commented that the recent transfer of ownership had gone smoothly, that the new paperwork and policies had quickly been accepted and put into practice. The home does have a quality assurance system, which ensures that regular audits and monitoring takes place. It is evident that residents and relatives are involved and their views and opinions are sought; yet there does not appear to be a report available for residents and other interested parties. Maintenance records were seen, including service and tests of utilities and equipment. These are well maintained. There is a fire risk assessment and staff regularly attend fire training and drills. The fire system and equipment is well serviced and regularly tested. However one emergency light according to records and the maintenance person has not worked for 2 months. The fire officers’ report of May 2005 advised of improvements of which the manager confirmed have all been addressed. The records of hot water temperatures in the kitchen were seen to be low, regularly recorded at 44°C. The call system is serviced annually, at present three are not working and this has been reported to the engineer for repair. The home has current public liability insurance cover. Beeton Grange DS0000064739.V323823.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 Adults 18-65 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 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 3 28 3 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 3 X X 2 3 Beeton Grange DS0000064739.V323823.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 YA6 Regulation 15(1)(2) Requirement The registered person must ensure that written care plans are completed for residents where a need is identified such as lifestyles and health care arrangements and that residents are involved in the planning and review of the care plans; ensuring that staff are all aware of the residents choices and of how to support and care for residents. The registered person must ensure that care plans reviews with residents consider and record on whether the care plan has been effective to meet the assessed needs of residents. This will enable appropriate changes to be made. Timescale for action 31/05/07 Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 25 2 YA9 13(4)c The registered person must develop and implement risk assessments that are specific to individuals needs. Previous timescale of 31/12/05 not met, this requirement is carried forward. The registered person must ensure that the risk assessments have a detailed management plan that advises staff what they must do to alleviate or reduce risks, and that residents are involved in the planning and review of the risk assessments. 30/04/07 3 YA19 The registered person must ensure that risk assessment reviews with residents consider and record on whether the management plan has been effective to reduce or manage the assessed risks of residents. This will enable appropriate changes to be made. 12(1)(2)(3) The registered person must 13(4)(c) ensure that residents attend health appointments, where residents decline to share the details of appointments with staff a risk assessment must be implemented after consulting the resident and relevant other healthcare professionals. This may ensure residents attend health appointments and will alert the homes concerns to the residents and healthcare professionals and may improve the health of the residents. 30/04/07 Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 26 4 YA24 5 YA29 6 YA42 23(2)(b)(d) The registered person must ensure that the external rear brickwork to the building is kept in a good state of repair and is reasonable decorated. This will help promote the health and welfare of the residents. 23(2)(c) The registered person must 13(4)(c) ensure that the call system is fully operational and that residents can reach pull cords should they need assistance from staff. 23(4)(c) The registered person must (iii)(iv) ensure that all emergency lighting is operational and will work should there be an emergency to allow safe evacuation of all persons from the building. 30/06/07 30/04/07 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beeton Grange DS0000064739.V323823.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beeton Grange DS0000064739.V323823.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. Re-publishing this information is in breach of the terms of use of that website. 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