CARE HOMES FOR OLDER PEOPLE
Bevan House Stackwood Avenue Barrow in Furness Cumbria LA13 9HQ Lead Inspector
Marian Whittam Unannounced Inspection 21st August 2007 10:20 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 Bevan House DS0000035555.V338235.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. Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Bevan House Address Stackwood Avenue Barrow in Furness Cumbria LA13 9HQ 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) 01229 894547 01229 894550 www.cumbriacare.org.uk Cumbria Care Stephen Atwell Care Home 40 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (40) of places Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 40 service users to include: Up to 40 service users in the category of OP (Old age, not falling within any other category) Up to 15 service users in the category of DE(E) (Dementia over 65 years of age) Date of last inspection 25th July 2006 Brief Description of the Service: Bevan House is a care home registered to provide care for 40 older people, 15 of whom may have dementia. The home is in a residential area of Barrow in Furness, close to a local bus route into Barrow, and to surrounding areas. The home has a car park to the rear of the building and there are patio areas for residents to use. All of the home’s 40 bedrooms are single rooms and the home is divided into five units for residents. On the first floor are Langdale, Abbey and Furness units and on the ground floor are Piel and Ramsden units where up to 15 people with dementia live. Each unit has a non- smoking lounge and dining area with a small kitchen attached, a bathroom and 2 separate toilets. The home has a main kitchen and a large ground floor lounge for communal activities. Information is available to prospective residents in the combined Statement of purpose and service users guide; this is available in different formats and displayed in the home. A copy of the last inspection report is also available. The fees charged by the home range from £326.00 to £434.00 per week as at the date of the inspection and an additional charge is made for personal toiletries, newspapers, magazines, also hairdressing and chiropody services and any personal travel expenses, according to information provided during the inspection. Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced site visit, that forms part of a key inspection, took place over five hours. The pharmacist inspector assessed the handling of medicines during the visit through inspection of relevant documents, storage and meeting with the staff and residents. The pharmacy inspection took four and a half hours. Time was spent looking around the home observing routines and staff interaction, talking with residents in the lounges and in their own bedrooms, speaking to the care staff, observing any activities in progress and looking at care plans. Policies and procedures, systems for recording complaints, financial records and personnel and training records were looked at in the afternoon as well as other records required by regulation. Before the visit information was also gathered on the service from records of previous visits, notifications and other regulatory activities including concerns and complaints raised with CSCI by people coming into contact with the service. Questionnaires from people and other agencies, provided by CSCI, were returned before the inspection took place. What the service does well:
The home provides a safe, warm and homely environment where residents feel relaxed and comfortable. Residents spoken to liked living in the home and spoke highly of the staff and the care and support they received from them. One person said “ the staff are always helpful” and several residents said they can raise any concerns they have and feel they will be attended to. Throughout the day the inspector saw that staff and residents got on well together and that residents individuality is respected with staff showing an interest in the residents and in supporting them in daily life The home is kept clean and tidy and people living there are able to bring in their own things from home such as pictures, ornaments and suitable items of furniture to make their rooms more homely and personal. There are robust recruitment procedures for staff and the thoroughness of pre employment checks helps to safeguard the welfare of people living in the home. The service has safe systems for administration of medicines and keeps good records of medicines it receives and those administered to residents. There are good protocols for the administration of some “when required” medication so that they are given only when residents need them promoting their health and well being. Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better:
The service has safe systems for medication administration but it would be an improvement if protocols were in place for administration of all “when required” medicines so that all such medicines are given only when residents need them. The service needs to always ensure that all doctors’ instructions regarding medication are followed so that residents are not at risk from the effects of wrong treatment. All medicines that are refused could be recorded for disposal so that they can be accounted for and provide a clear audit trail. Information on the manager’s qualifications and experience need to be put in the statement of purpose to make sure the information is complete for people thinking of using the service.
Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 7 Information in the care plans is clear and up to date but more consideration should be given to making it clear within personal plans how people living there are being actively involved in creating and developing their care plans. These should reflect and their personal perspectives on how they want to be cared for and supported by staff. The manager should try to develop the use of, and access to, the grounds for residents on the EMI units as this could improve their choice and quality of life. Although the management works hard to maintain safe staffing levels consideration should be given to better planning to ensure staffing is organised to meet clearly identified support needs rather than just basic staffing requirements. Fire training for staff needs to be recorded promptly when given or is forgotten and the records not up to date. 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. Bevan House DS0000035555.V338235.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 Bevan House DS0000035555.V338235.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. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 1, 3and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an effective assessment and admission procedure and relevant information about the home is provided to help people make an informed decision about coming to live there. EVIDENCE: The home has a combined statement of purpose and service user guide, including resident survey views and the most recent inspection report. This document states the home’s aims, information on the environment and service provision. Residents do not have their own personal copy given on admission; the document is kept on display in the entrance hall. Survey responses and conversations with people living in the home indicate that people feel they had enough information about the home to help them choose before they came in. It needs minor updating on the registered manager’s details and qualifications.
Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 10 These documents are also available in different formats, in large print for those with sight problems and it is planned to put it in audio formats too. This would help improve access to the information. Individual care plans show that before coming to live in the home the residents have there personal, health and social needs assessed. Assessments are done by social workers under care management arrangements and by the home manager or senior staff to try to ensure they are able to meet people’s individual needs. This information is used to develop individual care plans for people. Assessments are on going following admission and other agencies are involved in care and assessment. During the visit a district nurse was visiting to attend to some resident’s nursing needs and was involved in requesting reassessment for changing needs. The home has an introductory period that varies in length depending on the individual situation and this is followed by an individual review to make sure needs are being met and the resident is happy to stay. Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a care planning and assessment system in place that gives staff the information they need to meet resident’s individual health, personal, cultural and social care needs. EVIDENCE: All residents have a clear and easily followed individual plan of care and clinical risk assessments, based on their initial assessments before and at the time they come to live there. Each plan sets out the individual’s health, personal and social care needs and this information ensures the staff are aware of the level of care required to meet these different needs. Care plans show that they have been reviewed at least monthly and any identified changes in conditions and assessments have been consistently incorporated into them. It is evident from examining the plans that any changes in the care needs are noted promptly in between the reviews and have been updated to make sure the plan reflects the current situation. This was evident for one person whose
Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 12 condition had deteriorated and a thorough reassessment of care needs had been done to reflect their changed needs. Appropriate equipment to prevent pressure sores is in use, mental health is monitored and effective nutritional screening is being done and weights recorded. Residents say they have been involved in gathering the information in their plans and some people living there make their preferences and views on the running of the home clear themselves. The plans are clear but give information on the care needed largely from the caregiver’s perspective rather than the person receiving the care. For good practice a more individualised approach to a person’s care would be to include the person’s own perspective, where possible, on how they want to be supported, cared for and their independence promoted. Speaking to some residents they felt some of their own perspectives and choices were not always fully taken on board by the staff and manager. However, staff spoken with were aware of residents personal care needs and showed a familiarity and understanding of these. Observation during the inspection, checking of records of care planning and conversations with residents suggests that resident’s are generally treated as individuals although this was not always so evident from their care plans. One local GP who attends the home commented that, “residents are known and treated as individuals with care staff giving excellent continuity”. The service has safe systems for administration of medicines and keeps good records of medicines it receives and those administered to residents. There are protocols for the administration of “when required” painkillers and laxatives so that they are given only when residents need them. This good practice should be extended to all other medicines that are prescribed, “when required”. Residents’ doctors often confirmed changes to medication in writing so that staff had clear instructions and to reduce the risk of errors. These were mostly accurately followed but in one case it was a concern that aspirin was continued for a resident after the doctor had stopped it due to possible side effects and this could place the resident at risk of harm. Medications may still be provided by the pharmacy even after a change has been made by a doctor, as in this case, so the manager should double check discontinued medication when new stock arrives to try to minimise any risk to residents. The manager is aware of the risk of this happening and is seeking ways to overcome it. Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 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. People who use the service have a choice of good quality food and their diverse needs are generally being supported. EVIDENCE: The home encourages relatives and friends to visit and residents say there are no restrictions on when people can visit them. Care plans show information is gathered about people’s preferred social and religious activities and some useful personal profiles indicating, important events, people and interests are in place. This is valuable information that could be used more in promoting a person centred focus on opportunities for recreation particularly for those who have difficulty communicating their thoughts and feelings. The manager is aware of the need to try and do this as they continue develop their activities programme. The home has an afternoon activities programme running over 2 weeks printed in the Statement of Purpose, including those at weekends. Some people confirmed that the activities were put on whilst others were less informed about what was available. Two people said they were not “ not really
Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 14 interested “in the activities but could take part if they wanted. A supervisor oversees trips out as part of her role and a day trip was taking place that afternoon to the coast for ice cream and drinks and included those with dementia who expressed interest. Another such outing was organised for the next day as well. A carer takes responsibility for other organised activities and records are kept on the things done. There is a multi denominational religious service monthly and residents say they have access to their own ministers as well. The hairdresser also visits twice a week. On the individual units staff do support residents, as their work allows at staff overlaps, in more impromptu recreational activities, chatting and listening to what they want to do. Reminiscence sessions incorporating songs and quizzes are also provided and have been popular with some residents. A member of staff was sat reading the newspaper to a poorly resident on one unit. One person attends outside day services broadening their interests and choice in how they organise their days. Other local community involvement is limited although local groups from schools and churches have visited in the past. There is no restriction on people going out to town or to visit friends and family as long as staff are aware of their intentions. Progress is being made on improving the range of organised activities being offered within the home and on having more day trips out. The manager and staff should continue to develop this important aspect of daily life in line with resident’s capabilities, ideas and preferences. There is a 3 weekly menu in place and on the units. The menus have recently been reviewed in consultation with residents and they offer choice and variety at each meal. Menus have been discussed at the residents meetings with the cook and ideas have been taken forward such as themed meals. One person particularly liked the ‘sweet and sour’ and such things as tripe and onions and liver and onions are included on the menu for those who have said they want these. The manager has not been able to recruit a part time cook despite 3 attempts but the permanent cook takes care of the food ordering so supplies are always maintained. Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are able to express their concerns through an accessible complaints procedure and protection is promoted by following adult protection policies and through staff training. EVIDENCE: Since the last inspection the home has referred one adult protection incident and one is still in progress. This is being investigated and addressed by the home manager with other relevant agencies. The home has a complaints procedure and a system for logging complaints for investigation. The complaints procedure is displayed in the foyer along with informative brochures with complaints forms inside and is in the service user guide. This information is also available in other formats on request and appears in large print in the Statement of Purpose. There were no recorded complaints logged since the last inspection. Adult protection procedures are in place and local multi agency guidance available to staff and information on whistle blowing. There are procedures regarding Protection of Vulnerable Adults (POVA) processes. Training is given on adult protection and preventing abuse. Survey responses and comments from people in the home indicate that they are aware of how to make a complaint and they felt that overall staff listened
Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 16 to what they had to say and acted upon it. One person said “ I feel I could speak to anyone if I was unhappy, even one of the cleaners”. Surveys from local GPs indicate the home has always responded to any concerns raised. The home did not deal with any resident’s personal finances only small amounts of spending money for safekeeping and practices and procedures are in place to protect resident’s financial interests. A spot check showed the records to be accurate. Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 17 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 19, 20, 21, 22, 23, 24, and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, safe, and homely and is being generally well maintained for residents and has the equipment they need to promote care, comfort and independence. EVIDENCE: There is a programme of maintenance and improvement for the home. The general improvement budget was withheld last year so slightly affecting the general appearance of the home such as damaged paintwork and wallpaper. This year’s budget will go ahead as planned and a survey of works has been completed and contractors are due to be appointed to carry it out. This includes the redecoration of some bedrooms, communal areas and bathrooms and new carpets for some bedrooms and a lounge. The home does not have a
Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 18 dedicated maintenance person on site and the manager and staff do the safety checks. The grounds are tidy and some residents are able to sit out on the patio. One person living there said they did some potting of plants and these could be seen on the patio. However, some residents with poor mobility and dementia have reduced safe access to the grounds and sitting outside. The manager is aware of this limitation for some due to a lack of ramps and security for dementia residents using the grounds. The manager should try to develop the use of, and access to, the grounds for residents on the EMI units as this could improve their choice and quality of life. All bedrooms are single rooms and vary in size and furnishings with some people bringing in their own possessions to make their rooms more personal and homely. There are separate toilets close by resident’s rooms and lounges and bathrooms with assisted bathing aids. Bathrooms, toilets and showers are sufficiently large enough to allow for the use of equipment There are suitable adaptations inside the home for wheelchair users and moving and handling equipment is in place to make people comfortable and promote their independence. Call bells are in resident’s bedrooms, toilets, bathrooms and communal areas. Adjustable nursing beds are used following an assessment of need. There is sufficient communal space in lounge/ dining areas on each unit for people to relax, see visitors or join in an activity and the large main lounge is used for entertainments when they are put on. The entrance and foyer is welcoming and the supervisor’s office is sited so they are accessible to anyone entering the home. There is a separate smoking room with a fan for smoke extraction. There are infection control procedures in place in the home and staff are given training in this. There is a small laundry and sluice areas and care staff are responsible for doing the laundry and taking it back to residents. The home was generally clean and tidy with no unpleasant smells. Some residents commented that their rooms had not been cleaned everyday which some would prefer. Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 19 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 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. There are satisfactory recruitment procedures being followed to safeguard residents and appropriately trained staff offering care to people living in the home. EVIDENCE: People living in the home expressed general satisfaction with the care they receive and said that staff were usually available when they needed them. One relative said that staff are “very helpful and discuss any problems with us as and when they occur”. The duty rotas are frequently altered making them hard to follow but they indicate the home has experienced periods of staff shortages especially at weekends due to holidays and sickness. The rotas indicate that staff levels are being maintained but are often at capacity with little room for any sickness or holiday cover. The manager and supervisor have managed to cover the shifts by moving staff around the home and getting relief staff and permanent staff to do extra shifts to cover. A lot of time is spent by senior staff on organising the rota to maintain adequate staff and skill levels on all shifts rather than a
Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 20 contingency plan for unexpected absences. The focus of staff planning is on keeping a basic number of staff on duty to keep people safe and meet basic needs. Rotas do not show staffing planned around delivering individual outcomes for people using the service, rather they indicate being led by established routines around staff numbers. Training is being well supported in the home and is being better planned and organised to make sure mandatory training is up to date and individual training needs prioritised. NVQ training courses are well established with 51 of staff achieving level 2 or 3 and several staff are still doing the course. Staff are being encouraged to take more responsibility for their own continuing professional development. There are clear recruitment and selection procedures overseen by the manager. Application forms are completed, references taken up and interviews arranged. Records show that new staff are appointed and begin work only after all the required legal checks have been completed and that they have a period of induction. Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 21 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 31, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is open and there are quality monitoring systems in operation to promote and safeguard the best interests and welfare of people living there. EVIDENCE: The home has a manager in post who registered with the Commission for Social Care Inspection and has completed the Registered Managers Award although he is still awaiting verification of completion. The manager is clear about his role and responsibilities and the ways in which the service can continue to develop and improve for people living there.
Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 22 There are quality monitoring systems and procedures in place in the home and resident and relatives satisfaction surveys form part of this. Regular staff meetings allow staff feedback, there are internal reviews of policies and procedures and staff appraisals and supervision are being done. There is a development plan for the home within the overall organisational plan setting targets and objectives and a strategic action plan. The manager shares targets and objectives with staff and this promotes staff involvement. Policies and procedures are produced and reviewed centrally across the organisation. Residents meetings are being held and topics recorded and some have been acted upon. More trips out were asked for and are now taking place and people living in the home said that food and menus are discussed at their meetings and the cook attends to listen to their views and ideas. Staff spoken with found that the manager was approachable and supported them in their roles. The standard of record keeping and organisation of information is generally satisfactory. Policies and procedures are in place to protect resident’s financial interests and to safeguard spending money given to the home for safekeeping. There are health and safety procedures in place to promote the interests and safety of residents and records of fire and other mandatory training, fire drills, equipment testing and the servicing of equipment and appliances. Although the manager should make sure that fire training is recorded promptly when it is done. Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13(2) Requirement Changes to medication must be implemented accurately to prevent residents receiving treatment that may be harmful or inappropriate. Timescale for action 10/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP7 Good Practice Recommendations The statement of purpose and service user guide should be updated to include the registered manager’s qualifications and experience. Consideration should be given to making it clear within personal plans how people living there are being actively involved in creating and developing their care plans and their personal perspectives on how they want to be supported and their independence maintained. All medicines requiring disposal that have been refused by residents should be recorded so they can be accounted for. The good practice of using protocols for the administration of some “when required” medicines should be extended to all “when required” medication so residents receive these
DS0000035555.V338235.R01.S.doc Version 5.2 Page 25 3. 4. OP9 OP9 Bevan House 5. OP20 only when needed. The manager should try to develop the use of, and access to, the grounds for residents on the EMI units as this could improve their choice and quality of life. Consideration should be given to better planning to ensure staffing to meet clearly identified support needs rather than just staffing number requirements. Fire training records should be completed promptly to show when staff have been give training. 6. 7. OP27 OP38 Bevan House DS0000035555.V338235.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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
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