Inspection on 10/07/07 for The Beeches

This inspection was carried out on 10th July 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

The Beeches 29/07/08

The Beeches 08/06/06

The Beeches 06/01/06

The Beeches 06/07/05

The Beeches 21/02/05

The Beeches 19/07/04

The Beeches 20/01/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Beeches 163 High Street Hanham South Glos BS15 3QZ Lead Inspector Odette Coveney Key Unannounced Inspection 10th July 2007 09:00 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 The Beeches DS0000003332.V338106.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. The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Address 163 High Street Hanham South Glos BS15 3QZ 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) 0117 9604822 0117 9857190 Miss. Julie Alexandra Windows Ms Janet Margaret Windows, Mr. Mervyn Roy Windows Mr Matthew Roy Windows Care Home 23 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (23) of places The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd April 2007. Brief Description of the Service: The Beeches is an extended, detached Victorian building situated in Hanham High Street. There is parking to the front and a small parking area to the side of the house for three or four cars. There is a small garden to the rear with a patio area. The larger of the gardens has been built upon and the former garden has been reinstated. The home is close to local shops and amenities and is also on a main bus route between Bristol and Bath. The home is arranged on two floors. The home has two double bedrooms, both with en-suite facilities and nineteen single bedrooms, seven of which are ensuite. There are two lounges and two dining rooms one of which has a small conservatory leading from it. The home is managed and owned by three generations of one family. The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last key inspection that was undertaken on June 8th 2006 there have been two random site visits, the first was completed on 23rd January 2007 and another visit took place on April 2nd 2007. The January visit found that all five requirements made at the previous inspection had been met, three requirements were made at this visit and one requirement was made following the visit to the home in April 2007. All of the requirements were reviewed at this site visit and all were found to have been met. Information in respect of these is recorded within this inspection report. This unannounced key standard inspection was carried out in two days over a 9-hour period by one inspector for the Commission. This inspection was very positive and overall a judgement of good was made. The purpose of the visit was to establish if the home is meeting the National Minimum Standards and the requirements of the Care Standards Act 2000 and to review the quality of the care provision for the individual’s living in the home. Prior to the site visit the Commission received from the Registered Manager a completed an annual quality assurance assessment (AQAA). The annual quality assurance assessment is a new process that is being used for all regulated services from April 2007. An opportunity was taken to view the home and a number of the records relating to the management of the home and plans of care for two individuals were reviewed. The registration certificate for the home was reviewed at this inspection and the information contained within it was found to be accurate. A number of Comment cards were received prior to the inspection, these were from relatives of those who live at the home, from individual’s who live at the home, and two comment cards were from visiting health/social care professionals who visit individuals at the home. Comments made were reviewed during the visit and these, maintaining individual’s confidentiality, were shared with the registered manager and have been incorporated within this inspection report. The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? All of the requirements made from previous site visits have been met. Residents can have clear information about the terms and conditions of their placement as they are issued with a copy of their contract made between themselves and the home; this document contains clear information about the fees. Residents can feel safer with the knowledge that in the rare situation that the home have staff employed without the full recruitment checks that the home have completed a full risk assessment in order to protect residents during the interim period of awaiting receipt of a Criminal Records Bureau check. Residents can feel confident that all newly appointed staff members are completing a comprehensive induction as the home have obtained a copy of the ‘skills for care induction’ and this is being followed at the home. Residents can feel assured that their right to privacy is respected at the home as the home have ensured that locks are fitted to toilet doors and furthermore the home have ensured that ‘listening’ monitors used at the home are to ensure individuals safety, rather than impinging on their privacy. The residents can be assured of their safety within the home as there is now in place a notice warning people that oxygen is in use at the home and also as the home have replaced a ‘missing’ emergency call bell. Residents are aware of the correct name of The Commission for Social Care Inspection as the home have updated their complaints procedure to reflect this. The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 7 Residents can feel more assured that their money is better accounted for as the home have developed a record of demonstrating when money is taken to purchase items on behalf of residents. 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. The Beeches DS0000003332.V338106.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 The Beeches DS0000003332.V338106.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, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is in place about the facilities and services provided at The Beeches are good, however some minor amendments are needed to the homes statement of purpose. Individuals living at the home can be confident that their needs will be met. Clear contractual arrangements are in place outlining individual’s rights and responsibilities. EVIDENCE: The home has a statement of purpose in place, this outlines the admission procedure into the home, how to raise a complaint and provides information about the services and facilities offered at the home, there were some areas within this document which require some amendment. The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 10 In order that current and prospective residents are provided with clear information it is required that the home update their statement of purpose. A copy of this must be forwarded to the Commission. The inspector viewed the admission documents for two of the most recent residents admitted into the home and saw that the home had completed a full preadmission assessment and had a care plan from the placing care manager, this information, along with consultation with the resident and their family enabled the home to develop a care plan on which to support the individuals and to provide guidance and instruction for staff. A requirement was made at the site visit undertaken in January 2007 that All residents must be issued with a copy of the term and conditions of their placement. Terms and conditions were sampled, four for a publicly funded resident and two for privately funded residents. The breakdown of costs of care were clearly stated and information in place also covered and included: trial periods/termination notices, insurance, fees and what is not covered by the fee, and information about the home’s complaints procedure. The management and some of the staff at the home have worked in the care profession for many years and have a wealth of experience in caring for older people Standard 6; Service users are assessed and referred solely for immediate care are helped to maximise their independence and return home; this standard was not assessed as it is not applicable to this home. The Beeches DS0000003332.V338106.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, 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s health, personal care and social needs are set out in an individual care plan, however the home must ensure that these are kept under review and updated where required. Individuals are treated with respect and systems of medication administration are sound. EVIDENCE: During this site visit the records concerning four residents were examined in depth, others very randomly reviewed in order to examine particular areas. Care plans, which had been developed by the home, record information on how individuals require support in aspects of their physical and emotional care needs and areas of daily living. There was clear information within these plans to show how individuals are supported; however, not all care plans are reviewed on a monthly basis. The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 12 It is required that this is done in order that individuals changing needs are recorded and updated and the support altered accordingly. Daily records are on the whole well written, however, there are occasions where staff have not identified that it is them who have written the entry, it is recommended that staff clearly put their names on reports as these are legal documents and staff are accountable for what they write. The home have in place ‘personal history’s’, for those that have been completed these provide valuable information for staff supporting residents, particularly those who have a diagnosed dementia as staff can use this information as prompts for conversation and enables staff to ‘see the person’, not the task, it is recommended that these are completed for all residents. A requirement was made at the site visit undertaken in June last year that suitable locks must be fitted to toilet doors in order to ensure privacy for residents, these had been fitted. Another requirement made at the June inspection was too ensure that individual’s privacy was not being impacted upon and the requirement was that a risk assessment must be completed in respect of the use of a listening monitor used at the home. These had been developed and written to evidence that All individuals have a manual handing risk assessment in place. Risk assessments were seen in individual’s files, these assessments covered areas such as identified risk and hazards and who is potentially at risk; those seen had been well written. Risk assessments had been completed; Waterlow scoring is used to determine the risk of pressure ulcer occurring and is rechecked on a regular basis. Pressure relieving equipment was in use where stated and is used to prevent pressure ulcers developing. Body mapping is used to show the location of any skin problems and the date noted is recorded. Information seen in daily records, care plans and correspondence showed that residents are supported to access primary healthcare services such as optician and dentist. All residents are registered with a general practitioner and district nurses visit individuals at the home if a specialised nursing need is identified. It was also noted that the home accesses specialist services if required by individuals, an example of this is During this site visit medication storage, recording, administration and staff training were reviewed. A pharmacist who provides medication to the home in a monitored dosage system supports the home. There was also prescribed medication in boxes, which is given by staff. Medication was found to be stored in a locked secure cabinet. There are residents at the home who are supported to take ‘controlled’ medication this was found to be appropriately recorded. The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 13 There are no residents at the home who are able to manage their own medication. All interactions between staff and service users were heard to be kind, polite and respectful. The comments heard included that staff are ‘kind’, the manager was described as ‘nice’, and one of the care assistants was spoken of fondly. The Beeches DS0000003332.V338106.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, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can keep close contact with relatives,friends and the community. Residents are offered a varied and nutritious diet, and are able to take part in a range of social and theraputic activities. EVIDENCE: Information seen evidenced that the individuals living at the home are provided with a variety of social activities and are able to participate or not. This is dependent on the individual’s choice. On the day of the inspection an entertainer came in and played the piano to the residents. Residents were seen singing along and those spoken with said they really enjoyed this performance. Comment cards were received from relatives of those who live at the home all answers were consistent in that all said that staff make them welcome at the home, that they are kept informed of important matters affecting their relative, that there are sufficient numbers of staff on duty and that they are satisfied with the overall care provided at the home. The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 15 The inspector spoke with a visiting relative at the home who said that their relatives health had improved greatly since admittance to the home, their relative was happy, they are kept informed of their wellbeing and help in respect of health issues are responded to promptly. They also added they visited the home most days and meals always looked ‘very tempting’. The home would contact individual’s next of kin should they need to be they need to be informed of issues, which affect the well being of an individual living at the home. At a brief walk around the building residents was seen spending time in their bedrooms and the communal lounges. Daily records of care showed that residents are able to choose when to get up and retire, what to eat/drink and how they were to be assisted with aspects of their life. The inspector observed residents having their meal at lunchtime. The meal was relaxed and residents were given the meals based on the choices they made. A list of forthcoming events is listed in the entrance hall of the home and visitors are welcome to participate. The Beeches DS0000003332.V338106.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, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. There are clear processes in place in which individuals can raise concerns; individuals are protected from potential abuse, however the home must inform the Commission of incidents, which affect the wellbeing of individuals at the home. EVIDENCE: The home has in place procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of individuals; this includes a copy of the South Gloucestershire protection of Vulnerable Adults Policy and the home’s abuse policy. Recruitment practices carried out in the home protect residents from abuse, criminal records bureau and protection of vulnerable adults checks are carried out, and two written references are obtained before staff commence employment. Staff at the home has completed adult protection training. Following the site visit to the home in January 2007 it was recommended that the home update their complaints procedure in order that it reflects the correct name of the Commission, this had been completed and correct information was available should it be needed. The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 17 In order to ensure residents money was being monitored appropriately it was recommended following the visit to the home in January that the home should maintain a record to demonstrate money taken to purchase money on behalf of residents, this had been completed. Prior to the visit to the home and since the last visit to The Beeches the home have forwarded some notification of incidents which had happened, however upon examination of records it was found that there were a few situations in which the Commission should have been informed and some discussion about this took place with Julie Windows for provide clarity. In order to demonstrate that incidents had been dealt with effectively it is required that the home must inform the Commission of incidents, which affect the wellbeing of individuals who live at the home. The Beeches DS0000003332.V338106.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, 22, 23, 24, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a Home that is well maintained and the quality of furnishings are of a good standard and suitable for the needs of residents, however attention must be given to the inner entrance door. EVIDENCE: The Beeches is a spacious residential Home and is furnished to a good standard. The house is a detached property and is situated in Hanham and is close to private houses and a short distance from the local shopping areas of both Fishponds, St George and Kingswood and is nearby to bus stops. This helps ensure residents can be a part of the community. The Home is wheelchair accessible. It was noted upon arrival that the internal front door had a pane of glass, which was loose, it is required that this is given attention in order that it is safe. The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 19 There are adaptations in place throughout the Home and specialist equipment including mobility aid, sensory aids, and specially adapted baths. There is a spacious dining area and two comfortable lounge areas. There is a small ‘domestic’ type kitchen, this was found to be clean and tidy and had benefited from a refurbishment just over a year ago. The home has recently been awarded a five star rating from South Gloucestershire Councils environmental health department for food standards and are to be commended for this. The kitchen is well equipped and looked to be very kept clean and tidy. The garden and patio to the rear of the home are kept safe, tidy and accessible to residents and have plenty of seating available to residents when the weather is good The home has a cleaner on duty each day and the level of cleaning around the home was very good. The home has a handyperson to undertake maintenance work at the home. The home has a fire alarm system, detection equipment and fire extinguishers that are all maintained. Two requirements in respect of ensuring resident privacy were made following the site visit to the home in January 2007; these were that suitable locks must be fitted to toilet doors in order to ensure privacy for the residents, this had been completed, furthermore the home have completed risk assessments do demonstrate the purpose in respect of listening monitors used at night for some residents at the home. Written feedback received from a visitor to the home prior to the site visit recorded that ‘Standards of décor/furnishings in rooms is not always up to scratch’. In the homes AQAA documents which had been completed prior to the homes site visit they had recorded for areas of improvement over the next 12 months would be to: ‘get information and feedback from all in the home on areas they feel need to be updated or changed. Much in the way we have done in the past 12 months. To ensure that areas that have been spotted that need to be updated, fixed or changed are done quickly and in a professional manner. The manager confirmed information that future plans to improve the environment for residents would be to install a stair lift, to replace ‘dated’ bedroom suites to replace the curtains in the lounge, purchase a new shed and an assisted bath chair for residents with mobility difficulties. The Beeches DS0000003332.V338106.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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. The home had sufficient, staff on duty and staff are qualified to provide good level of care. All staff are clear regarding their role in what is expected of them. Recruitment practices safeguard individuals living at The Beeches. EVIDENCE: There is a well- established staff team at The Beeches. During the inspection staff were able to demonstrate a clear understanding and knowledge of the individuals who use the service, and of their role in the home. Staffing provision appeared to be consistent with levels and skills needed due to assessed care needs of the individual’s. The staff team have a varied range of knowledge and skills, they were observed by the inspector to be good listeners, effective communicators and were interested and motivated in meeting the needs of those living at the home. The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 21 Staff spoken with and certificates seen in individuals files provided confirmation that the training had been undertaken and staff that were spoke with were positive about how the training they had undertaken, including National Vocational Qualification and first aid, medication competency Comments received prior to the site visit from relatives of those who live at the home included; ‘I have always found the care service very helpful and my mother has always been treated with the respect she expects’, comments from another relative were that the ‘care is excellent’ A requirement was made at the visit to the home, which was undertaken in January that the home must complete a full risk assessment to protect residents during the interim period of awaiting a Criminal Records Bureau Check. The recruitment and selection documents for three members of staff were reviewed at this inspection; these staff files evidenced that full and robust practices are adhered to at the home to ensure that those appointed have the qualities and skills to work within this care environment. Appropriate adult protection checks are taken to ensure the protection and safety of service users. A recommendation was made at the site visit to the home in January 2007 that the home should obtain a copy of the new Skills for Care Induction, the home had done this and the inspector saw that this document was being used with a recently appointed staff member as a recording tool for what has been completed within their induction. Areas of completion had included; The staff member had well recorded answers and demonstrated a sound knowledge and understanding in these areas. The Beeches DS0000003332.V338106.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, 33, 35, 37, 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a well established management team at the home who run the home in the best interests of residents, there are policies and procedures in place appropriate to this service, however some of these are in need of updating. EVIDENCE: Both Julie Windows and Mathew Windows came across as committed to ensuring that needs of residents were well met and that the home was ran in line with the national minimum standards for care homes. Since the last visit to the home Mathew has completed a NVQ at level 4 in care management and keeps himself up to date with current best practice by accessing care publications and attending training and local care conferences. The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 23 Two recommendations were made following the site visit to the home in January were that the home should obtain a warning notice in respect of oxygen in use at the home and furthermore that the emergency call bell identified at the site visit be replaced, both of these had been dealt with effectively by the home. Records were seen to be stored securely and access was appropriately restricted. In the homes completed AQAA document when they were asked to demonstrate how do they know they give value for money they replied: ‘When we have nice comments from residents, their family and friends and the staff, when we get a good report during our inspection and E.H.O etc… seeing a resident laugh and enjoy living in the home. Seeing staff enjoy spending time with the residents and doing more than they are expected for the residents and the home because they enjoy their jobs. Providing good care for the people in the home, supporting staff and keeping them for many years. Running for 19 years and hoping to be going for many many more in the future by getting a good reputation in the community and helping others’. It was noted that staff meetings are held on a regular basis at the home and these provide an opportunity to discuss issues, to plan ahead and to ensure effective communication and continuity of service for residents. Residents meetings have been held at the home in the past and evidence of this has been seen on previous site visits to the home as there have been no recent meetings with residents it is recommended that these recommence and that records are these meetings are maintained. These meetings will enable residents to have a say about the running of the home and issues, which affect them. There are a number of policies and procedures in place at the home and these are all relevant to the care setting, the staffing at the home and are in line with the support needs of residents, it was noted that a number of these policies and procedures had not been reviewed for some time and contained minor errors within the information provided. There was evidence that the home ensures so far as is reasonably practicable. the health and safety of resident’s staff and visitors. The home has robust policies and procedures in relation to aspect of health and safety. The fire logbook was viewed and was well maintained. The home was completing the appropriate checks on the fire equipments and recording of training and testing of equipments were satisfactory. Staff have attended fire drills to ensure that they have clear knowledge of action to be taken in the event of fire emergency. The Beeches DS0000003332.V338106.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 X 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 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 2 2 3 x 3 3 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 X 3 X 3 X 3 3 The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 25 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. 2. Standard OP1 OP18 Regulation 4(1) c 37 Requirement The home to review and update its statement of purpose. The home must notify the Commission of incidents that affect the wellbeing of residents at the home. Care plans must be reviewed on a monthly basis. Glass in the internal entrance door to be made safe. Policies and procedures must be reviewed and updated where needed. Timescale for action 10/08/07 10/07/07 3. 4. 5. OP7 OP19 OP36 15(2) b 23 (2) b 17(3) 10/07/07 10/09/07 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. 3. 4. Refer to Standard OP32 OP8 OP7 OP7 Good Practice Recommendations Residents meeting should be held more often and these should be recorded. Weight charts for residents must be maintained. Past history information on care plans must be completed Daily records must show who has written the entries. DS0000003332.V338106.R01.S.doc Version 5.2 Page 26 The Beeches Commission for Social Care Inspection South west Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 The Beeches DS0000003332.V338106.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!