Inspection on 20/06/07 for Elmcroft Care Home Ltd

This inspection was carried out on 20th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elmcroft Care Home Ltd 20/11/08

Elmcroft Care Home Ltd 27/05/08

Elmcroft Care Home Ltd 04/07/06

Elmcroft Care Home Ltd 07/02/06

Elmcroft Care Home Ltd 17/08/05

Elmcroft Care Home Ltd 22/03/05

Elmcroft Care Home Ltd 04/02/05

Similar services:

Claremont House

Coopers Mill Ltd

Sun Court Nursing Home

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

15 Bramble Close

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

CARE HOMES FOR OLDER PEOPLE Beckingham Court Brickhouse Road Tolleshunt Major Maldon Essex CM9 8JX Lead Inspector Pauline Dean Unannounced Inspection 20th June 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beckingham Court DS0000063361.V343802.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. Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beckingham Court Address Brickhouse Road Tolleshunt Major Maldon Essex CM9 8JX 01621 893098 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) jean@festivalcare.com Elmcroft Care Home Limited Vacant Care Home 54 Category(ies) of Dementia - over 65 years of age (1), Learning registration, with number disability (1), Learning disability over 65 years of places of age (1), Physical disability (28), Physical disability over 65 years of age (54), Terminally ill (6) Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. Persons of either sex, aged 18 years and over, who require nursing care by reason of a physical disability (not to exceed 28 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 54 persons) One named person, aged 40 years and over, with a learning disability, who requires nursing care by reason of a physical disability. One named person, over the age of 65 years, with a learning disability, who requires nursing care by reasons of a physical disability. One named person, over the age of 65 years, who requires nursing care by reason of dementia. The total number of service users accommodated in the home must not exceed 54 persons. Persons of either sex, aged 50 years and over, with a terminal illness (not to exceed 6 persons) 4th July 2006 Date of last inspection Brief Description of the Service: Beckingham Court Rehabilitation and Specialist Nursing Centre which provides nursing and personal care with accommodation for up to 54 younger adults and older people. The home also provides rehabilitation. Beckingham Court is owned by a private organisation, named Elmcroft Care Home Limited. The home is located in a rural location near to the village of Tolleshunt Major, Maldon. The home comprises of a purpose built building which was opened in 1989 and new additional accommodation which opened in 2007. There are 28 bedrooms of which 3 are double rooms in the original building and 26 single bedrooms in the new accommodation. All rooms have en-suite facilities. The home has extensive views across open countryside and the surrounding gardens are attractive and accessible to wheelchair users. Beckingham Court is accessible by road and rail and the nearest station is in Witham, a short drive away. Parking is available in the large car park of the home. The fees range from £457.00 -£750.00 weekly. Additional costs apply for physiotherapy, chiropody, toiletries, hairdressing and newspapers. This information was provided to the CSCI on 20/06/07. Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 5 Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit of Beckingham Court was carried out on 20th June 2007 lasting 8.5 hours. The inspection involved checking information received by CSCI since the last inspection in July 2006, looking at records and documents at Beckingham Court, and talking to Ms Kerri Nicholls, manager, Mr Robert York, Responsible Individual (RI) for Elmcroft Care Home Ltd., care staff, domestic and laundry staff and catering staff. Questionnaires were left with the manager for distribution to all of the people living at Beckingham Court and one completed survey was returned to the Commission for Social Care Inspection (CSCI). In addition questionnaires were left for distribution to family and friends and four completed surveys were returned to the Commission. This enabled them to give theirs views about the service directly to CSCI. Mr Nicholls, the newly appointed manager was present during the site visit, as was the RI for part of the visit. They and care staff, domestic, laundry and catering staff were spoken with and all were able to provide detailed information about the services provided, procedures, policies and working arrangements. During the site visit three people who live at Beckingham Court were spoken with. All were happy about way they are supported and assisted by the staff. Two visitors to the home were also spoken with and they too were positive with regard to the welcome they received and the care their relative received. What the service does well: What has improved since the last inspection? Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 7 An increase in social activity hours has shown a slight improvement in the provision of social care at the home. One person spoken to at the site visit, related 1:1 contact with the activities co-ordinator, which they had found very enjoyable. Medication and administration was found to be well managed. We were told of improvements and additions to record keeping to ensure good auditing and monitoring practices are followed. 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. Beckingham Court DS0000063361.V343802.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 Beckingham Court DS0000063361.V343802.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): 3 and 6. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A comprehensive admissions process ensures that people who come to live at Beckingham Court are assured that their needs are assessed. Intermediate care is not offered at Beckingham Court. EVIDENCE: The admission process and paperwork was sampled and inspected for two people who live at Beckingham court. Risk assessments were in place covering such issues as falls, moving and handling, continence and physical and social needs. As highlighted at the last inspection, whilst some Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 10 consideration is given to the individual’s physical and social needs on admission this is not carried through in care planning. Folders containing a revised Statement of Purpose and Service Users’ Guide and the last inspection report are available new admissions to the home. Beckingham Court does not offer intermediate care. Beckingham Court DS0000063361.V343802.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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Overall care planning documents were comprehensive detailing health and physical care needs, thus ensuring that the people who use the service receive the care they wish and require. However, people who use this service cannot be assured that their social care needs are met, for they are not considered in the care planning. Management of medication was well managed ensuring that the people living at Beckingham Court are safeguarded and protected. People who live at the home can be expect to be treated with sensitivity and respect. EVIDENCE: Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 12 Three people who live at Beckingham Court were involved in the case tracking exercise conducted at the site visit. As stated previously detailed assessments are completed on admission and a care plan is created. All three care plans had detailed physical care needs identified and records clearly detailed the action taken. Whilst there was some reference to social care needs in daily activities records seen alongside the individual’s care plan, but only one of the three had reference to social care needs in their care plan. Overall, daily record keeping was comprehensive and clear covering both day and night and some reference was seen to these records when making changes to an individual care plan. Within the care planning records sampled there was evidence of healthcare professional visits and appointments attended. Records and monitoring charts were seen as instructed by consultants and specific communication sheets detailed action needed to be taken by care and nursing staff. Records were seen of visits by GPs, dentists, opticians and chiropodists to the home. Medication administration, storage and dispensing was sampled and inspected at the site visit. Medication for three people who live at the home was sampled and inspected. It was found to be well managed. The practice and procedure used by the home for the ordering of medication was discussed and good practices are followed. Medication was stored in a clinical room in a storage trolley that was secured to the wall. A controlled cabinet and two controlled drug registers were in use. This record keeping was found to be in good order. A drugs refrigerator was located in this room and records are kept of temperature checks completed three times a day. Records detailing medication held, administered and returned to the pharmacist were seen. These were well managed, for there were both daily diary notes of medication kept in the home and a monthly order logbook was completed. As found at the last inspection however, the staff list of signatures authorised to give medication needs to be updated. During the day we were able to observe staff going about their duties and as they approached and spoke with the people living at Beckingham Court, it was pleasing to see that they were both respectful and sensitive to their needs. Staff were seen to ensure that bathroom doors were closed when they were occupied and they were seen to knock and wait to be asked to enter before entering a person’s bedroom. One person living at the home said that they did feel that staff did treat them with respect and their privacy was maintained. Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 13 Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 14 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. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The daily routine and activites in the home were flexible and optional, with people who live at Beckingham Court being encouraged to make choices with regard to their social, cultural, religious and leisure activities. Family contact and visiting arrangements were open and relaxed, with family links encouraged and promoted. Beckingham Court provides a varied and nutritious menu for individuals to select from. EVIDENCE: Beckingham Court has an activities co-ordinator who works 25 hours a week. At the site visit, we were able to speak with them. They spoke enthusiastically Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 15 about their work, obviously enjoying the interaction they were able to have with the people living at Beckingham Court either in a group or individually. A range of activities had been devised and developed in the home including armchair exercises, craft activities and group discussions on a selected topic. A programme of activities offered to the large group was posted in the main lounge where these activities took place. As well as group activities, 1:1 activities are offered. These include hand massage and manicures or just a chat. Records are kept by the co-ordinator of the activities held and who took part. Whilst it is seen that there has been some improvement in this aspect of care, more thought and consideration is required by the home. As was highlighted at the last inspection, there is a need for formal training in the development of social and therapeutic activities in the home. Person-centred care plans are required to ensure that meaningful and appropriate activities are offered to all people living at Beckingham Court. Visiting arrangements are detailed in the Statement of Purpose and the Service Users’ guide. One visitor spoken to said that they were able to visit as they were able and could meet with their relative in their room. They confirmed that there were no restrictions on visiting and they were always made very welcome with refreshments offered. The manager said that people who live at Beckingham Court are encouraged to manage their own monies. This is usually managed with the assistance of relatives, friends and appointed independent persons. Additional costs not covered by fees are invoiced to the appropriate parties. Evidence was seen on the three care plan files sampled of an inventory of personal possessions agreed and brought into the care home. Beckingham Court operates a 4-week rotation menu. The breakfast menu is normally based on cereal, toast and grapefruit, whilst at lunch the main meal of the day has six choices offered. At supper both hot and cold dishes are served. The management of food deliveries and suppliers was discussed with the cook on duty on the day of the site visit and throughout the week the home receives deliveries of fresh, frozen and dried good supplies from wholesalers and local shops and supermarkets. Nutrition Record keeping relating was considered and discussed with the cook and this detailed planned menus and food eaten. Special diets are considered and this was evidenced in the record keeping relating to the diabetic requirements of people living at Beckingham Court. The likes and dislikes of the people living at Beckingham Court and are also considered and it was Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 16 evident that catering staff had a good understanding of people’s preferences. This was further evidenced in a response from a service user survey, who had commented that ‘Cook usually takes notice of what we say and usually takes care of our needs if we want something different.’ The only negative comment received regarding the meals served at Beckingham Court was from a completed survey from a relative. They said that ‘the food appears wholesome, although lacking in imagination at teatime.’ Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 17 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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at Beckingham Court can expect to be well treated and listened to, with complaints and adult protection procedures in place. EVIDENCE: Beckingham Court has a complaints procedure held on a central file in the office and within the Statement of Purpose. Appropriate timescales for responding to complaints was noted in the procedure and planned actions noted. An ongoing complaints log was inspected. The newly appointed acting manager had picked up the ongoing complaints and records were kept of the action taken and to be taken. Survey work completed by the Commission had resulted in the return of one survey from a person living at Beckingham Court and four surveys from relatives, carers and advocates. The one survey received from the person living at Beckingham Court had said that they would ‘speak to the manager if I Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 18 have any concerns.’ Within the four surveys completed by relatives there was a mixed response. Two said that they knew how to make a response and the felt that the care service had usually responded appropriately. One said that they did not know how to make a complaint and only sometimes had the care service responded appropriately when concerns had been raised. A fourth survey completed by a relative said that they did not know how to make a complaint and when they had raised complaints with the previous manager they felt that it had been ‘talked away.’ With new management in place the need to heighten the profile of how to raise a complaint and instigate more communication avenues with relatives and the people who live at Beckingham Court is clearly required. One of the survey forms completed by a relative, requested that the inspector contacted them and at the time of writing this report, this was done. We were pleased to hear that following a feeling of dissatisfaction with the lack of communication and information, the newly appointed acting manager had met with the relative and communications had improved. The home had a protection of vulnerable adults policy and procedures and a whistle blowing policy. Two staff spoken with were aware of the procedures to be followed in the event of an allegation and had a good understanding of the different types of abuse. Prior to this site visit an allegation of abuse had been made to the home by a relative. Both the home and the Police have notified the Commission for Social Care Inspection (CSCI) of this and we are awaiting an update. The home has assisted the Police with their investigations making records readily available as required. Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 19 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 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Overall, Beckingham Court provides a safe environment that is accessible to the people who live at the home. It is homely and meets individual needs. EVIDENCE: A tour of the premises was completed at the site visit and a partial inspection of individual and communal accommodation was made. Since the last inspection, an additional wing has been constructed at Beckingham Court. This offers twenty-six bedrooms all with en-suite facilities. This accommodation had been opened and brought into operation for a short period, but staff shortages Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 20 had resulted in its closure. With ongoing staff recruitment it was hoped to bring this accommodation into use once again in the near future. Accommodation within the original building comprises of twenty-eight bedrooms, three of which are double bedrooms. At the site visit, one of these double rooms was being used as a single room. Bedrooms were seen to be personalised with evidence of photographs, pictures and personal items to make their rooms homely. The home is surrounded by landscaped gardens with ample parking for visitors. These grounds were tidy and well maintained as was the premises, for was light and bright. The home was clean and hygienic throughout with no odour problem evident on the day of the site visit. This was confirmed by survey work conducted by the Commission when a relative stated that they found the premises clean and well cared for. However, another relative felt that the ‘interior decoration needs improving, paint work very shabby, carpets need cleaning or replacing’ and another relative commented on ‘poor decorative state… the carpet is shabby and stained’ and a chair used by their relative was ‘very worn’. As only a partial inspection of the premises took place at the site visit, these issues were not found, but they are obviously matters the new acting manager and management need to consider. Beckingham Court has an in-house laundry service, which was found to be clean and well organised with appropriate equipment in place. A laundry assistant was able to clarify laundry procedures and systems in place. In spite of only recently being appointed, they had a good understanding of the management of laundry in the home. Survey work completed by the Commission complimented the home on their laundry service saying it was ‘exceptional’. Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 21 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. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff were roistered in sufficient numbers to ensure the people who live at Beckingham Court are safe and their individual needs are addressed. Beckingham Court has a good staff team and the people who live at the home are protected by the home’s recruitment practices. People who use this service cannot be assured that they will be cared for by appropriately trained staff without the development of a training programme. EVIDENCE: On the day of the site visit, twenty-five people were living at Beckingham Court. Staffing levels were as was found at the last inspection: AM – 2 registered nurses 5 care assistants PM – 1 registered nurse 4 care assistants Night 1 registered nurse 2 care assistants Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 22 The manager said that consideration had been given to the assessed needs of individual residents and the felt that these levels were appropriate to meet their needs. Comments seen in the survey work completed by the Commission were either in agreement with this or contradicted this. One relative spoke of residents waiting ‘a considerable period before they are attended to’ and another said that they thought their relative would benefit from having a staff member talking to them and ‘staff don’t seem to have the time for this.’ One person living at the home however, said that the staff comes when they call. The manager confirmed following the site visit, that 43/7 of care staff have the minimum of National Vocational Qualification (NVQ) level 2 in care. Three of these staff have NVQ level 3 in care. Staff recruitment practices and paperwork were sampled and inspected for three care staff. Overall the record keeping and practice was seen to be in good order. Evidence was seen of an application form, minimum of two written references and ID. Confirmation of Criminal Record Bureau (CRB) Enhanced disclosures were located and set by the acting manager following the site visit. At the site visit, the acting manager was unable to find evidence of an induction training programme and training records on sampled files. At the time of writing this report, no clarification has been received as to the position regarding induction training and training records. Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 23 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, 33, 35 and 38. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service can be assured that the home will be managed well. People who use the service need to be assured by the development of a quality assurance and quality monitoring system to ensure that the home is run in the best interests of those people living in the home. Safe working practices are promoted through ongoing training. Health and safety certification and insurances promotes a safe working environment. Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 24 EVIDENCE: Prior to the site visit, the Commission had been informed that the registered manager and her deputy manager had left the employment of the care home. An acting manager – Kerri Nicholls had been appointed. Ms Nicholls said that she is considering becoming the register manager of Beckingham Court. Clearly these sudden changes in management had unsettled the home. Mr Robert York, the Responsible Individual for the company – Elmcroft Care Home Ltd. visited the home on the day of site visit. He acknowledged that these changes had been unsettling for all, but spoke of staff recruitment and management/staff support being offered by the company in these times of change. Survey work completed by the Commission clearly reflected the uncertainty and concerns felt by relatives of people living at Beckingham Court. One relative spoke of the lack of information around these changes and said that they thought ‘there should be regular meetings between the manager and relatives’ and another said that they thought the home could improve by ‘informing clients/relatives of any changes being made’. Quality systems were in place at Beckingham Court. Whilst this was difficult to evidence at the site visit, as the newly appointed acting manager had problems locating the files, confirmation has since been received that Management Operational Procedures, Clinical Service Procedures and Hotel Service Management Procedures are at the care home. Both the Finance and Administrative Procedures and the System Manual Procedure were said to be in the process of being reviewed and updated. The acting manager spoke of the need to introduce relative meetings and conduct quality assurance survey work. Clearly from the small sample of surveys received by the Commission this would be valuable, for closer communications would appear to be beneficial to all concerned. As stated earlier in this report, monies for the people who live at Beckingham Court are not managed by the home. Residents, relatives/advocates are involved in this task. Records held on behalf of residents were kept up to date and stored safely in secure facilities in a locked office in accordance with the Data Protection Act 1998. Records viewed at this inspection included: care plans, activities records, health care records, medication records, Statement of Purpose, Service User Guide, accidents/incident records, fire alarm checks, an Electrical Installation Report dated 03/05/05 with a lifetime of five years and a passenger lift Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 25 certification completed 02/03/07. In addition Regulation 26 visits/reports completed by the company were found on file and the most recent visit had taken place on 18/06/07. Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 27 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 OP19 Regulation 23(2)(d) 16(2)(j) Requirement People who use the service must be assured of a homely, comfortable and safe environment through the introduction of a planned maintenance and decoration programme. People who use the service must be assured that all staff have experience and skills through the introduction of a training and development programme. An effective quality assurance and quality monitoring system must be introduced to ensure a through review of the care and services offered in the care home. Timescale for action 31/08/07 2. OP30 12(1)(a) (b) 18(1)(a) (c) 13(4)(c) 24(1)(a) (b), (2)(3) 31/08/07 3. OP33 31/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 28 No. 1. Refer to Standard OP7 Good Practice Recommendations People who live at Beckingham Court should be assured that their care plans include a plan for social care. This is a repeat recommendation. 2. 3. OP9 OP12 The staff list of signatures authorised to give medication should be reviewed and updated to ensure that it is correct and up-to-date. People who live at Beckingham Court should be assured that the activities co-ordinator should receive training on the provision and variety of social activities needed in the home. This is a repeat recommendation. 4. OP16 People who live at Beckingham Court and their relatives should be made fully aware of the home’s complaints procedure and how to raise complaints. People who live at Beckingham Court should be assured that 50 care staff have undertaken NVQ level 2 or equivalent. This is a repeat recommendation. 5. OP28 6. OP31 People who use the service must be assured that the home has clear communication links between management, the people who use the service and relatives. Beckingham Court DS0000063361.V343802.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 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