Inspection on 10/06/09 for The Beeches

This inspection was carried out on 10th June 2009.

CQC 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 CQC 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 23/06/08

The Beeches 06/06/07

The Beeches 07/09/06

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 15/11/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Beeches 6 Brunswick Terrace Wednesbury West Midlands WS10 9DA Lead Inspector Linda Elsaleh Key Unannounced Inspection 10th June 2009 09:00 DS0000066611.V376242.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Address 6 Brunswick Terrace Wednesbury West Midlands WS10 9DA 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) 0121 556 0435 Asha John Mr Dennis Valentine John Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd June 2008 Brief Description of the Service: The Beeches has been in operation as a care home since 1985 but in May 2006 came under new ownership. It is situated in a cul de sac close to Wednesbury town centre. Local amenities include library, churches and a varied of shops. The service provides predominately long stay accommodation but has offered some short-term care in the past. The house is a large traditional property that has been extended in the past to its present size and layout. All bedrooms and bathrooms (including assisted facilities) are sited on the first floor and can be accessed by a shaft lift. There are a number of toilets on the ground and first floors. The lounge, dining room, kitchen, laundry and office are all located on the ground floor. Ramped access is available to the rear of the property providing access in and out of the home and to the garden. The manager should be contacted for information about the fees charged for this service. The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that people who use this service experience good quality outcomes. We looked at the information we have received about the service since our last visit and sent surveys to people who live in the home, their relatives and health and social care professionals asking them to tell us about their experience of the service provided. We received responses from 75 per cent of the people we surveyed. The comments were mainly positive and have been included in this report. The service is required to complete an Annual Quality Assurance Assessment (AQAA). This provides us with information about service including facts and figures about what has happened during the last 12 months. This unannounced inspection was carried out by one inspector on 10th June 2009. We spoke to the manager, staff and met three people who live in the home and three visitors. We looked two people’s care files and two staff files in detail as well as other records and documents kept by the service. This was to help us to assess the quality of life experienced by the people who live in here and the service’s overall performance. The atmosphere in the home was relaxed and friendly. A tour of the building showed us it was clean and tidy and a programme for the re-decoration and refurbishment is still in progress. People we met appeared healthy and well looked after. Comments made by the people we spoke with and their relatives were generally positive about the service. “Good general care in a friendly atmosphere”, “The care and attention given is first rate” and “A happy and caring environment” were some of the comments we received. What the service does well: People who live at the home continue to be treated with respect and their right to privacy is respected. The service has made progress in its approach to care planning and consulting with individuals about their care. They are being involved in risk assessments carried out by the service and strategies are put in place for them to maintain their independence and to protect them from harm and/or abuse. People are cared for by a staff team that are aware of needs and preferences. Visitors are welcomed into the home. People may receive their visitors in private if they wish. Opportunities are provided for people to visit the service The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 6 and spend a trial period in the home so they can make an informed choice about where they wish to live. Appliances and equipment are regularly serviced to ensure the health and safety of people living at the home is protected. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 7 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 DS0000066611.V376242.R01.S.doc Version 5.2 Page 8 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 5 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are given the information they need to make an informed choice about where to live. Arrangements are made for them to visit the home and move in on a trial basis. There are procedures for assessing people’s needs. However, in order for them to be fully confident their needs will be met the service needs ensure the process is consistently applied for all. EVIDENCE: Information about this service is provided in the form of a Statement of Purpose and Service User Guide. Both documents have been reviewed and produced in an easy to read format. Copies are on display in the reception of area. Two people we spoke to and those who responded to our survey tell us The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 9 they were provided with good information about the service. One person said “I originally wanted to come here but there wasn’t a bed available. I have settled in and it was a good move for me.” Relatives also told us they were pleased with the service being provided. We looked in detail at the files of two people who had come to live in the home since our last visit. One person’s file shows us the assessment carried out by the service covered her/his physical and social needs, risk assessments associated with daily life and their capacity to make their own decisions. A copy of a letter from the service confirming it is able to meet the person’s needs is also available on their file. The second person’s file contained a copy of the Care Management Assessment carried out by the funding authority. The service had recorded interim care arrangements on her/his daily notes. Two staff told us they felt they had not been provided with sufficient information about this person’s emotional needs. The manager said staff had spoken to her about this and regular discussions were being held with the relevant health agency. The manager is advised to ensure a consistent approach is taken to assessing people’s needs and identifying how these will be met by the service. The service provides opportunities for people to visit the home prior to moving in. One person told us she and her sister had visited the home on separate occasions and it was “homely” and “friendly”. This was followed by arrangements for their relative to visit and share a meal with people who were living in the home. She also said a meeting was held a few weeks after her relative moved in to “check s/he had settled in”. The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has continued to improve its care plans to ensure people’s health, personal and social care needs are being met. Risk assessments are carried out to enable them to maintain their independence, where possible, and protect them from harm. Systems are in place for the safe handling and administration of medication. However, to ensure people’s health care needs are appropriately managed a written procedure for dealing with errors should be produced and the shortfall identified in record keeping addressed. People are treated with respect by staff and their right to privacy is upheld. EVIDENCE: The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 11 The care plans detail how the people’s physical, emotional and social needs are to be met. This includes tasks the person is able to carry out independently and the level of support to be provided. For example one person requires support to get in and out of the bath but is able to bathe unsupported. Another person has limited mobility and requires support with to reduce the risk of developing pressure sores. Where applicable, risk assessments have been undertaken to ensure people’s safety is maintained. Two staff we spoke to showed us they were familiar with people’s care plans and where close monitoring was required. The daily records show people’s plans are being followed and amended, where applicable. Two of the comments received from people living in the home were “I always receive the care and support needed” and “Staff are always available when needed”. However, a care plan for one recently admitted person had not been produced. Details of the care to be provided were identified in her/his daily notes. There is concern that this information could be overlooked. We discussed with the manager and advised that each person has a care plan that easily accessible and understood by the person and the staff. People are registered with a local GP of their choice. There is a system for recording information about people’s health care needs, forthcoming appointments and visits made from/to health care professionals such as GP, community nurses, chiropodist, dentist and opticians. Records show the service seeks their advice where any concerns are raised about a person’s well being. One person told us a member of staff was arranging an additional appointment for them with their dentist. A community nurse visiting the home told us the service had made her client very welcome and was working closely with them to ensure the person’s needs were being fully met. Medication for people living in the home is managed on their behalf by senior members of the staff team that have been trained to do so. Training certificates and records of individual staff competency checks are kept available in the home. The deputy told us her duties include monitoring and auditing medication. She explained the process for receiving medication into the home and returning unused medication to the pharmacist. She was familiar with the action to be taken to deal with any errors. Information provided to us by the service shows it reviewed its medication procedures in March this year. However, a written procedure for dealing with errors is not included. This was brought to the manager’s attention and she told us this would be addressed. We looked at how medication is stored in the home. It was locked and the contents are kept in an orderly manner. However, the manager is advised to consider identifying a more suitable location for keeping medication when not in use. We looked at the medication administration record (MAR) sheets for three people. There were no gaps in the records and codes had been entered on occasions when medication had not been administered, for example if someone refused or were sleeping. The medication for one person is under The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 12 regular review by the prescribing practitioner and the service is keeping records of the person’s reaction in order to provide accurate information for each review. The service consults with the GPs before administering homely remedies, such as paracetomol. A member of staff told us she does not administer medication; however does apply prescribed creams when supporting people with their personal care. She reports this to the senior person in charge of medication so s/he can update the person’s MAR sheet. This practice is not in line with procedures and the person applying creams or ointments should also be completing these records. People we spoke to said they were satisfied with how the service manages their medication. One person commented “staff are very good at managing my medication and making sure I have it on time”. A visiting relative said she was very confident in the way the home manages my mom’s medication and happy with the way they contact the GP to discuss any concerns”. The service respects people’s right to privacy. A portable handset for the telephone is available so people can make and receive telephone calls in the privacy of their own room. We saw staff knocking on bedroom and toilet doors before entering. One person commented “They (staff) leave us in peace to do what we want to do”. The Beeches DS0000066611.V376242.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are supported to maintain their independence and follow their preferred routines. They are able to receive visitors at the time they choose and meet with them in private. However, staffing levels should be kept under constant review to ensure people have good opportunities to participate in a range of activities in and outside the home. Meals and mealtimes are arranged to meet the dietary needs and likes and dislikes of people living in the home. However, for people to be fully satisfied with the menus and catering arrangements these should be kept under regular review. EVIDENCE: The files we looked show people are consulted about their preferred routines, such as the time they like to get and retire to their room. We spoke to one person returning from an outing s/he told us “I have been out shopping” and “I am going to my club tomorrow. Another person told us they like reading the The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 14 daily newspaper and some group activities. The records show exercise games and sing-a-longs are popular group activities. Photographs are on display in the hall showing people enjoying activities and parties with relatives and staff. A member of staff told us “the residents” like to participate in activities in the afternoon/early evening. Two staff said staffing levels sometimes restricts them from organising activities at this time of the day and providing people with opportunities to go out “but we try to do this whenever we can”. The rota shows two members of staff are on duty during the afternoon/early evening, one of whom carries out catering duties. We discussed this with the manager who agreed to review the deployment and staffing levels more regularly to ensure people’s needs and interests are being met. Throughout the day we saw people spending time in lounge and going to their rooms. One person said “I like spending time in my room but prefer to go to the dining room for meals”. We also saw visitors arriving to see relatives and friends. One person was pleased when a visitor turned up unannounced. All visitors were made welcome by the staff. This shows the service continues to operate an “open” policy for people to enjoy visits at anytime. One visitor told us “I always feel welcome” and another said “The atmosphere in the home is very friendly”. The records show the service consults with individuals about how they wish to be supported to maintain their independence for example opening their own mail and managing their own finances. The service is not responsible for the finances for anyone living in the home. However, it does manage a small amount of personal allowance for some people. There are procedures for staff to follow and records are kept of all transactions made on a person’s behalf. Risk assessments are carried out to ensure people’s best interests are safeguarded. People we spoke to told us they occasionally meet as a group to discuss issues such as the meals and activities. Changes have been made to the dining room and lounge following a discussion held at one of these meetings. The dining tables were suitably laid for the mid-day meal with condiments and napkins. The choice of meal was chicken pie or stew. However, an alternative meal is provided on request. One person told us “Sometimes I have breakfast in the dining room and dinner and tea in my room”. A cook is employed to provide breakfast and mid-day meals fives days a week. A member of the care staff team is identified to carry out catering duties at other times. The cook was not working on the day of this visit. An additional member of staff was on duty to cover these duties. We looked at the basic food hygiene certificates which tells us all staff who handle food have been trained to do so. The cook has recently completed the National Vocational Qualification (NVQ) Level 3 in Catering and a course in the prevention and control of infection. A four-week menu and records of people’s dietary needs, The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 15 likes and dislikes are available in the kitchen. Records are kept of cleaning tasks that have been carried out to ensure the kitchen is kept clean and monitoring records are kept of fridge/freezer and food temperatures to ensure food is stored and served appropriately. The Environmental Health Services issued the service with a Silver Award for the kitchen during its last visit. We received a mixed response to meals in the surveys that were returned. Comments included “usually like the meals” and “I suppose sometimes the meals could be a little better”. A visitor commented their relative tells them s/he enjoys the meals. Comments received from staff included “employ more than one cook” and “improve menus”. The Beeches DS0000066611.V376242.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home and their relatives are aware of the service’s complaints procedure. They feel staff listen to their concerns and are satisfied with how these are addressed. Policies and procedures are available to protect people and training in safeguarding people from harm and abuse is provided to staff. EVIDENCE: Information provided by the service tells us it reviewed its complaint and safeguarding procedures in March. The manager confirmed that no concerns, complaints or safeguarding issues had been reported since our last visit. People who live in the home and relatives/representatives who responded to our survey said they know how to make a complaint and who they would speak to if they had any concerns. A book is available in the reception for people to enter any comments they have about service. People told us they are confident that any issues raised will be listened to and addressed. The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 17 Staff told us they are confident the manager would deal appropriately with any concerns they have about people’s well being and safety. Certificates are available on staff files to show they have attended adult protection training. One staff member told us a refresher course had been booked for her. The manager said she and the deputy had recently attended update training and this was being arranged for all staff. We, the Care Quality Commission (CQC), have received no concerns, complaints or safeguarding issues since our last visit. The Beeches DS0000066611.V376242.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has made improvements to environment and further work will ensure people live in a comfortable, safe and well maintained home. EVIDENCE: The service is continuing to make improvements to the premises and a housekeeper and handy person have been employed since our last visit. The work carried out includes the replacement of floor coverings, re-decoration of the corridor, toilets and some bedrooms. There are two bathrooms on the first floor. One bathroom has been refurbished and the other continues to be out of use. It needs to be refurbished before it can be accessed by people living in the home. Aids, such as grab rails, are fitted throughout the building. The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 19 Bedrooms are situated on the first floor and can be accessed via a shaft lift or staircase. We looked at five bedrooms of which three had recently been redecorated and new flooring covering fitted. The majority of worn commodes previously seen in bedrooms have now been replaced reducing the risk of infection. The rooms are personalised with photographs and ornaments and two people told us they like to spend time in their rooms watching television or listening to music. There is a lawn and flowerbeds for people to enjoy in fine weather. Ramps are fitted to the side exit to provide easy access. The service is completing work on an extension for a further three en-suite bedrooms, lounge and patio. One person who enjoys spending time in the garden and tending to plants told us they will be moving into one of the new bedrooms once it has been registered by us. The manager told us further improvements to the environment is being planned and will include the re-decoration of at least one bedroom a month and suitable safe storage facilities for staff. There is a small laundry area to rear of the premises. A supply of protective clothing and equipment, such as disposable gloves and aprons are available to staff. Records show training has been provided in the prevention and control of infection. People we spoke to commented that the home is “fresh and clean” and they were pleased with the work being carried out. The Beeches DS0000066611.V376242.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People needs are met by a staff team are provided with training. Recruitment practices had been improved to ensure people are more fully protected. However, staffing levels need to be regularly reviewed to ensure people’s needs are being fully met at all times. EVIDENCE: The staff team is made up of people of different ages and life experiences and there have been fewer changes within the team since our last visit. The rotas show there have been regular changes made to the staffing levels. The manager told us this was due to meeting the changing needs of the people living in the home. Positive comments were made by staff and people living in the home about the appointment of the housekeeper and handy person. the following comments were received about staffing levels “provide additional staff” and “Possibly, as the home develops, extra staff will be employed”. At present two staff are on duty during the afternoon/evenings, one of whom is responsible for carrying out catering duties. The manager has been advised to review this to ensure all people’s needs, including social interaction and the support with activities, are being met. The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 21 We looked at the recruitment records for two staff. These contained references and receipts to show satisfactory PoVa First (Protection of Vulnerable Adults) and CRB (Criminal Record Bureau) checks had been obtained. This shows the service is following more robust recruitment practices to ensure people are more fully protected. Staff told us newly appointed staff members are supervised on shift by a senior member of staff who keeps a record of their progress. New staff are also provided with a copy of the service’s Employee’s Handbook and Health & Safety Handbook. Information provided by the service show 33 of the staff team hold a National Vocational Qualification (NVQ) Level 2 or above. The manager is working towards increasing the number of trained staff within the team to a minimum of 50 in order to meet the national minimum standards. The Skills for Care Induction and Foundation training is completed by all newly appointed staff before being registered for NVQ training. One member of staff told us she attended training included in induction programme and is completing the NVQ Level 2. Certificates of training are kept available on staff files. The manager has produced a training matrix to show which courses have been completed by individual staff, training required and when update training needs to be undertaken. This allows her to produce training plans that meet the needs of the people who are living in home. The Beeches DS0000066611.V376242.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. An experienced manager has been appointed to manage the service. However, for people to be confident the home is being run by a person fit to do so an application for registration should be submitted. A comprehensive quality assurance system needs to be implemented for people to be fully confident the service is being run to meet their needs. Satisfactory systems are in place for managing small amounts of money on behalf of people who live in the home. The health, safety and welfare of people living in the home is promoted and protected by arrangements for appliances and equipment to be regularly checked and serviced and staff being trained in health and safety. The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 23 EVIDENCE: Since our last visit the service has recruited an experienced acting manager. The records show she undertakes periodic training to update her own knowledge and skills. She told us she is in the process of completing an application to become the registered manager for this service. There are no records of visits made to the service by the owners. Regular unannounced visits should be made to monitor and report on the service’s performance in meeting its aims and objectives. Written copies of the report should be kept available at the home. There is some evidence that the service is monitoring its own performance. Care plans have been reviewed with individuals and/or their relatives/representatives to ensure needs are being appropriately met, more frequent ‘residents’ meetings are being held enabling people to express their views about the service. Regular checks are carried out on the environment, for example the hot water temperatures to ensure people are kept safe from harm. The manager told us she will be providing satisfaction questionnaires to seek the views of people living in the home and their relatives. This tells us the service is working towards developing a comprehensive quality assurance system to measure its own performance. An annual development plan should be produced based on the comments received by the service, as well as its own evaluation of practice, for people to be fully confident their views are listened to and acted upon. As stated earlier in this report the service has suitable arrangements for the safekeeping and handling of small amounts of people’s personal allowance. Records and receipts are kept of all transactions. Staff we spoke to told us they able to seek advice and guidance from the manager or deputy at anytime. Individual supervision sessions take place once every two months, for which records are kept, and arrangements are made for staff meetings to be held periodically throughout the year. Records are kept of all accidents that occur in the home. These are regularly monitored by the manager and, where possible, strategies are put in place to reduce the risk of similar incidents occurring. Staff records show health and safety training has been undertaken that includes first aid, fire safety, moving and handling and infection control. Appliances and equipment are regularly checked and certificates kept of all services. The West Midlands Fire Service visited the premises in February and reported fire safety arrangements were satisfactory. The Beeches DS0000066611.V376242.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 3 X 2 X 3 X 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 3 The Beeches DS0000066611.V376242.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. Standard Regulation Requirement Timescale for action 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. Refer to Standard OP3 OP7 OP9 Good Practice Recommendations The assessment process should be consistently applied to ensure all people’s care needs are identified. People’s care plans should be produced in a format that is easily accessible and understood. The management and administration of medication procedures should include information on dealing with errors to ensure people’s health is fully safeguarded. Consideration should be given to identifying the most suitable location for keeping medication when not in use. Entries on the medication administration records should be made by the staff member applying creams or ointments. The bathroom identified in this report should be refurbished so it can be used by the people living in the home. DS0000066611.V376242.R01.S.doc Version 5.2 Page 26 4. OP19 The Beeches 5. OP27 6 OP33 The work being carried out on the re-decoration and refurbishment of the premises should be completed providing people with a comfortable and safe place to live. Staffing levels and deployment of staff should be kept under constant review to ensure people’s needs and interests are being met and appropriate catering arrangements are in place. Regular visits to monitor the service’s performance should be carried out by the provider and a written report produced of each visit. A quality assurance system should be fully implemented and an annual development plan produced for people to be fully confident the service is being run in their best interests. The Beeches DS0000066611.V376242.R01.S.doc Version 5.2 Page 27 Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.westmidlands@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. The Beeches DS0000066611.V376242.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. 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!