Inspection on 21/08/07 for Edgbaston Beaumont

This inspection was carried out on 21st August 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 but made no statutory requirements on the home.

Other inspections for this house

Edgbaston Beaumont 14/02/07

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Edgbaston Beaumont 32 St James Road Edgbaston Birmingham West Midlands B15 2NX Lead Inspector Kath Strong Unannounced Inspection 09:30 21 August 2007 st 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 Edgbaston Beaumont DS0000069247.V336508.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. Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Edgbaston Beaumont Address 32 St James Road Edgbaston Birmingham West Midlands B15 2NX 0121 440 0421 0121 446 3333 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) Barchester Healthcare Homes Ltd Mrs Diane Karen Bland Care Home 28 Category(ies) of Dementia - over 65 years of age (28), Old age, registration, with number not falling within any other category (28) of places Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That one named person, who is under the age of 65 years at the time of admission can be accommodated and cared for in this home. 14th February 2007 Date of last inspection Brief Description of the Service: The home is well established and situated within the boundaries of Birmingham city centre with easy access to community facilities. Edgbaston Beaumont provides nursing care for up to twenty-eight persons above the age of 65 years who may suffer from dementia. Accommodation is provided in single en-suite rooms situated on the ground and first floors. A shaft lift provides assisted access to each floor. The home has a range of equipment to assist staff in making safe transfers of people who have restricted mobility. Different types of equipment are used on chairs and beds when required, to prevent people from developing pressure ulcers. Communal toilets and bathrooms are strategically located on each floor, which include assisted bathing facilities. There is a lounge situated on the first floor as well as a main lounge, restaurant, conservatory and a further lounge located on the ground floor. These rooms are of a high standard, well appointed, furnished and maintained. There is a pleasant enclosed garden, which residents frequent during warm weather. There are close care accommodation within the grounds and the nursing home building. These are not registered as part of the nursing home and therefore have not been inspected. There is ample parking available at the front of the premises. The spacious reception area is staffed during office hours Monday to Friday, and beverages are freely available to visitors and residents. The scale of charges for the home is: £700 - £950. Items not included in the charges were: hairdressing, newspapers, chiropody and transport. These charges were relevant to the previous inspection and were not discussed during this inspection. Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home did not know that the fieldwork visit would be carried out, this is to enable the inspector to obtain a true picture of the standards of the services provided. On the day of the visit, the home had 26 people living at the home. Assistance was provided throughout the visit by the manager. At the conclusion feedback was given to the manager. No Immediate Requirements were made. Information was gathered from speaking with people who reside at the home, relatives and staff. Care, health and safety and the arrangements for medications were inspected. Staff personnel files were checked and staff were observed whilst performing their duties. A partial tour of the premises was carried out. Two of the five care plans reviewed were case tracked. This involves obtaining information about individuals’ experiences of living at the home. This is done by meeting with or observing people, discussing their care needs with staff, looking at care plans and focussing on outcomes. Tracking peoples care needs and how the care is delivered helps us to understand the experiences of those people. Prior to the visit the home had completed the annual quality assurance assessment and sent it to CSCI. The information within the document advised of what the home does well, improvements made during the last 12 months and what the home would like to further improve. This provided details that contribute to the inspection process and highlights areas that may be explored during the fieldwork visit. Another inspector spent time in the lounge carrying out an assessment about how staff and other people spend time with people who live in the home. It included how staff and others communicate with them, what they did and how it affects the daily lives of people. This is referred to in the body of the report as SOFI (short observational framework for inspection) in the section concerning daily life and social activities. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is based upon the outcomes for people who live in the home and their views about the services provided. This process considers the care homes capacity to meet regulatory requirements, minimum standards of practice and aspects of service provision that need further development. Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: A carry forward system needs to be incorporated into the medication process to enable the home to demonstrate that correct stock levels can be determined. Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 7 People commented that the morning activities “don’t happen” and there was no evidence of one to ones during the visit. People may not be adequately physically and mentally stimulated. It is recommended that this aspect of activities is reviewed. Two requirements remain outstanding from the previous inspection and need to be addressed as a matter of priority. 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. Edgbaston Beaumont DS0000069247.V336508.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 Edgbaston Beaumont DS0000069247.V336508.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): 1, 2, 3, and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supplied with written details about the services but not staff and training details for them to make an informed decision about living in the home. The contract of terms of residency details peoples rights whilst living in the home. The home gathers information to enable senior staff to determine if the home is able to meet all of the assessed needs. EVIDENCE: The home has a comprehensive statement of purpose that contained all of the required information about the services supplied. It was noted that the document was in need of updating regarding current staff and their training. The document indicated that it had been updated August 2005, this means that the home has not addressed the requirement made at the last inspection on 14th February 2007. This should be treated as matter of priority. Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 10 The content of the service user guide provides good information for people who may use the service. Both documents are available in large print as well as audiocassette following a short period of notice to obtain them. The home gives a welcome pack to all new residents, which provide lots of useful information and a copy of the last inspection report. The contract of terms and conditions of residency contains all relevant information for people to understand their rights whilst living in the home. The pre-admission tool includes appropriate sections for completion to assist senior staff in making a decision about offering a placement. Other useful information that may be gathered are mental health status, mood/behaviour, communication, activities and hobbies, sleep pattern and specialist equipment. Such recordings will provide essential information about the person to permit time for staff to prepare for the placement to begin. The pre-admission assessment of the latest admission was reviewed and found to provide good information. The home does not provide intermediate care. Edgbaston Beaumont DS0000069247.V336508.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): 7, 8 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The delivery of care is good and this is supported on the whole by comprehensive care plans. Although people are being given their prescribed medication accurately the system for recording retained medications needs to be improved. Staff practices ensure that people dignity and privacy needs are being respected. EVIDENCE: Each person has a written care plan. This identifies the assessments carried out and staff guidance for how care needs to be provided. Senior staff also carry out regular monitoring of peoples health status and review the care plan to ensure that it is still appropriate for individuals needs. Five care plans were sampled to look at. They supply detailed assessments and clear and comprehensive staff guidance about the persons care needs. The recordings made for reviews were good. The additional information told a story about the person so that whole picture of the persons illnesses and Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 12 needs were easily identified. The standard of care plans were very good and suggest that peoples health and personal needs were being well met. The files also contained peoples personal preferences such as how often a person would like to bathe and whether this should be by shower or bath. The staff instructions were very detailed for such things as how and when hair should be washed and how often the person wishes to visit the hairdresser. There were pictorial aids for staff on how to clean hearing aids and instructions for use. This is viewed as being good practice. Only two shortfalls were found. A care plan regarding staff instructions for strict assistance to be given was dated 23rd December 2006. There was no evidence that the close care is still required. The person who was residing at the home for a short period of time did not have care plans in place for her health and personal care needs. This was brought to the attention of the manager and deputy manager. People gave the inspector positive feedback about their care, “Staff seem to cope with peoples sever difficulties, staff help me to get dressed every morning they do it well, staff are very good”. The process for ordering, receipt, storage, administration and disposal of medications were found to be satisfactory. This indicates that people are receiving their medications as prescribed to promote good health. Although medications received from the pharmacist were being audited staff were not using a carry forward system of recordings for medications that are to be carried on being used the following month. This shortfall prevents medication checks to be carried out for those medications. It was noted that the fridge temperature was erratic and not within acceptable limits. This may result in unstable medications that are to be administered. The problem was brought to the attention of the manager. She advised that a new fridge had been ordered. Staff were observed to be providing discreet assistance and spoke to people in a sensitive and respectful way. Staff practices ensure that peoples dignity and privacy are being maintained. Edgbaston Beaumont DS0000069247.V336508.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): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The range of recreations provided assist people in maintaining an interesting lifestyle. Meals are balanced and nutritious for the enjoyment and wellbeing of the people who live in the home. EVIDENCE: The home has an activities organiser who has been in post for several years. This enables good continuity and knowledge of peoples’ preferences. She is able to work flexible times and days to ensure that activities are widely available. There was evidence that staff also help with recreations on a day to day basis, this assists with the home being able to carry out one to one sessions. The weekly programme was reviewed, which is based on Monday to Friday and appears to provide a physically and mentally stimulating range of recreations. On the day of the visit advise was given that the people living in the home had told staff that they would prefer a different activity to the planned one. This request was complied with; people appeared to be comfortable with the decision. The close care bungalows situated within the grounds also has an activities organiser. People from both units are invited to join in with each others programmes. Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 14 People are offered outings such as visits to garden centres and a visit to an old time musical in Dudley was being arranged. Birthdays are celebrated and external entertainers go into the home on a regular basis to provide additional stimulation. Each person has a personal record and they provide information about participation and level of enjoyment. This information can be used to monitor the programme of activities and where changes are needed. It was noted from the recordings that there was very little one to one stimulation offered. The majority of the comments were ‘sat in lounge or stayed in bedroom’ and there was little evidence of one to ones having been offered or taken up. Some comments were given about the activities and choices, “I don’t think there were any activities which makes me feel despondent, I choose what I want to do”. It is suggested that a review of the programme should be carried out to check that overall satisfaction in maintained as far as practically possible. The short observational Framework for inspections (SOFI) was carried out in the lounge of the ground floor and the findings are as follows: The majority of staff interactions observed were good, however most interactions were a result of tasks being performed. Observed no signs of ill being. XX scored highly regarding engagement, this was a result of her still having her breakfast in the lounge, the person then spent time playing around with cup and saucer. XX was coughing at one stage, quickly observed by staff and reassured. Engagement for YY was re watching TV, looking at magazine, having a drink. Engagement for YY was really just watching what other people were doing. Had a cup of tea in front of her for 25 minutes, she was asleep for part of this time so the drink was going cold. When the drinks trolley came back round she said she did not want it. Periods of time when staff were not in the room, but frequently staff walking past lounge or in office with glass window to rear of room to aid observations of peoples wellbeing. General observations, drinks trolley had choice of drinks. The arrangements for meals were good, the daily menu was on display and a range of choices were provided. Lunch is the main meal of the day and offers three choices for the first and second courses and two for the desert. The evening meal consists of soup, sandwiches, salads, light cooked meals, and a Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 15 sweet. This suggests that people are offered a varied, healthy and interesting diet. The organisation is very supportive of providing training for kitchen staff. This is reflected in the high standards of the meals provided. Special diets needed for reasons of health are provided. Serving of the evening meal was observed. The cooked food looked appetising and included fresh salad. The cold foods were attractively presented. It was noted that one person preferred to have breakfast cereal and this was provided. Good comments were received during the visit, “The meals are very acceptable, I enjoy them, good choices and healthy diets are prepared, the meals are very good, the meals are always very tasty and I choose what I want”. Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 16 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): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are confident that their views are listened to and that any complaints made will be dealt with effectively. Most of the arrangements for the protection of people from abuse are good. EVIDENCE: A copy of the complaints procedure was on display in the reception area of the home. The contents of the document indicated that people who wished to make a complaint were provided with clear guidelines and how it would be dealt with. No complaints had been received by the home since the last inspection carried out February 2007. The home retains a log and good documentation of complaints received during 2006. A complaint was received by CSCI August 2007 shortly prior to this fieldwork visit. The issues raised were surrounding the period of February 2006. The allegations concerned poor standards of care. These were investigated as far as practically possible, but due to the timescale some aspects could not be fully reviewed. It was determined that there was either no evidence or insufficient evidence to support the allegations therefore the home had not breached the Regulations. Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 17 The adult protection policy was checked; it was noted to be dated September 2005. This means that the requirement made at the last inspection had not been met and should be treated as a matter of priority. Section 1.15 of the document states that the Regional Operation Director if appropriate will inform other relevant agencies. The organisation is reminded that all cases of suspected abuse must be reported. The manager advised that any concerns would be reported but the document needs to give staff clear guidelines to follow. Staff had received training in adult protection and the records indicate that regular refresher training is provided. This is viewed as being good practice. There had been no issues of concerns since the previous inspection. Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 18 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): 19, 20, 21, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are provided with high standard, comfortable and homely accommodation within a safe environment. EVIDENCE: The home is decorated and furnished to a high standard. The internal environment was bright pleasant, well maintained and very hygienic. The reception area is staffed during Mondays to Friday office hours. The home is very inviting and some areas are age appropriate in design and layout, which provides an appealing place for people to live. The reception also has a supply of beverages and comfortable seating where people who live in the home and visitors can sit. The overall effect is welcoming, homely and attractive. There is a lounge on each of the ground and first floors. These are tastefully furnished and include pictures, a piano, television, radio and other soft Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 19 furnishings. The first floor lounge includes a balcony where people can enjoy the warm weather. The enclosed garden is shared with people who live in the close care units. This appears to work well and people socialise well. There are a range of toilets and assisted bathing located throughout the home. This ensures that people can exercise choice about the way in which and when they would like to bathe. Bedrooms were spacious and had been personalised in the way in which the occupant preferred. The home has a small library where people can sit or borrow a range of books. People who live in the home were observed freely accessing any areas and entering offices to receive advice. Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 20 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): 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. Staff are allocated in sufficient numbers to meet the needs of the current client group. Recruitment practices are robust; this protects people who live in the home from risks of harm. Staff receive the training they need to meet the specialist needs of people living in the home. EVIDENCE: Review of the staff rota indicated that adequate trained and care staff are rostered to meet the health and personal care needs of the people living at the home. The deputy manager works part of the time in the clinical area to oversee the standards of practices of other staff. This ensures that peoples’ needs are identified and met. Comments received included, “The staff are very pleasant and do their best for you, staff are very good, I like that nurse very much”. The home enjoys a low staff turnover. This provides continuity of care and enables people who live in the home to develop relationships with staff. Review of some staff personnel files including the latest recruit suggested that good practices are carried out. Relevant checks are carried out and two written satisfactory references are obtained before a post is confirmed. This protects people who live in the home from risks of harm. Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 21 Newly appointed carers are expected to undertake an induction programme that reflects the contents of the Skills for Care package. This provides them with the basic skills to work within the care sector. In excess of 50 of care staff have successfully completed NVQ level 2 training. There was ample evidence that staff have completed mandatory training in Health and Safety, Moving and Handling, Challenging Behaviour and Fire Safety. Other courses such as Dementia Care are provided that help staff in caring for peoples specialist needs. This is viewed as being good practice. Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 22 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): 31, 32, 33 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is experienced and possesses the knowledge and skills to oversee the day to day running of the home. The quality assurance programme suggests that the home is making continuous improvements for the benefit of people who live in the home. Arrangements are in place to protect people from the risks of injuries. EVIDENCE: The manager has a wealth of experience and displayed ample skills in managing the home. It was also observed that she has a good relationship with the deputy manager who also carries out management duties. The deputy manager also works with other staff to ensure that the standards of care delivered by them remains consistent. A relative who freely admitted Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 23 that he would be willing to criticize when necessary made positive comments about the home. The home has a good quality assurance system in place. Audits are carried out of personal care, professional practices, medications, health and safety, nutrition, infection control, documentation, the environment, activities and customer care. The results are analysed and developed into an annual report. This will include good aspects of the services and shortfalls that need attention by whom and when. This indicated that the home is constantly making improvements. The home does not hold any monies on behalf of people who live in the home. The accident records are good and there was evidence that further action was taken when required. All relevant checks and servicing of equipment are carried out to ensure that they are fit for purpose. The fire alarm and emergency lighting were being regularly checked and the findings recorded to protect people from harm in the event of an emergency situation. Regular fire drills were being carried out and the names recorded of those staff who had participated in order to capture all staff within a twelve month period. The arrangements appear to protect people who live in the home and others form the risk of injury. Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X N/A X X 3 Edgbaston Beaumont DS0000069247.V336508.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 4 Requirement The statement of purpose must be updated in relation to current staffing and to clearly state that complaints may be referred to CSCI at any time. This is necessary for the home to provide people with up to date information about the services to assist them in making decisions about living in the home. Timescale of 01/06/07 has not been met and therefore needs to be treated as a priority. 2. OP9 13(2) A carry forward system must be developed for medications that are not returned to the pharmacy. This is needed for the home to demonstrate that there is a clear audit trail for all medications held within the home. 3. OP18 13 (7,8) The registered person must make the required amendments to the written policy regarding protection of vulnerable adults. DS0000069247.V336508.R01.S.doc Timescale for action 30/10/07 30/09/07 30/10/07 Edgbaston Beaumont Version 5.2 Page 26 This is needed to give all staff clear guidelines in respect of action to be taken when abuse is suspected. Timescale of 30/06/07 has not been met and therefore needs to be treated as a priority. 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 OP12 Good Practice Recommendations A review of the methods deployed for offering people one to one sessions should be reviewed and any shortfalls identified addressed. Edgbaston Beaumont DS0000069247.V336508.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 Edgbaston Beaumont DS0000069247.V336508.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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