Inspection on 11/10/07 for The Beeches

This inspection was carried out on 11th October 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 04/10/06

The Beeches 21/11/05

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE The Beeches 16 Lakes Lane Newport Pagnell Bucks MK16 8HP Lead Inspector Joan Browne Unannounced Inspection 11th October 2007 09:30 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 The Beeches DS0000064534.V352886.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 DS0000064534.V352886.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Address 16 Lakes Lane Newport Pagnell Bucks MK16 8HP 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) 01908 210650 01908 217971 thebeeches@brancastercarehomes.co.uk Brancaster Care Homes Ltd Ms Annmarie Sweeney Care Home 32 Category(ies) of Dementia (2), Learning disability over 65 years registration, with number of age (1), Old age, not falling within any other of places category (32) The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home provides care for 32 service users, two (2) of which may require Dementia Care. 4th October 2006 Date of last inspection Brief Description of the Service: The Beeches is a two-storey residential care home providing care for up to 32 older people. The home is comprised of both old and modern buildings and offers twenty-five rooms. Seven bedrooms are shared and eighteen are single occupancy. Eleven rooms have en-suite facilities. The home is divided into three areas. These are the old extension, the house and the new extension. Service users bedrooms are located on the ground and first floors. Access to the first floor is via a stair lift The home is located close to the town centre of Newport Pagnell, which offers a variety of shops, restaurants pubs and other amenities. Service users are able to use taxis and the dial a ride service to access the town centre. Fees range from £450.00-£510.00 per week. Additional charges are made for hairdressing and chiropody. The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection of the service was an unannounced ‘Key Inspection’ and was carried out on 11 October 2007. The inspector spent approximately seven hours in the service and looked at how well the service was doing. The inspection took into account detailed information provided by the service’s manager. Comment cards were sent to some service users, relatives and health and social care professionals. At the time of writing this report response to comment cards were received from nine service users. Their views and those of staff spoken to during the inspection have been reflected in this report. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. Care plans were examined, which was followed by meeting with the individuals to see if the plan matched the assessed care needs. The medication system and accompanying records were examined along with staff rosters, staff recruitment files, training records and health and safety records. A tour of the premises was carried out and some time was spent meeting with service users and staff. From the evidence seen it was considered that the home was providing an adequate service to meet the diverse needs of individuals of various religion, race and culture. The inspector would like to thank everyone who assisted in this inspection in any way. What the service does well: Prospective service users have their needs assessed prior to moving into the home to ensure that the home is able to meet the assessed needs. The lifestyle in the home suits people using the service including their preferences, cultural, religious and recreational needs. People using the service are encouraged to maintain contact with family and friends. Visitors are welcomed at the home. The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 6 People using the service are provided with wholesome and nutritious meals in pleasing surroundings. There is a complaints procedure to ensure that people using the service will be confident that their complaints would be listened to, taken seriously and acted upon. Staffing numbers and skill mix of staff is appropriate to meet the needs of people using the service. What has improved since the last inspection? What they could do better: It is recommended that in the interests of safety the service must ensure that handwritten entries recorded on people using the service medication administration record sheets should be countersigned by a second person to comply with best practice guidelines. It is recommended that in the interests of safety staff who administer medication to people using the service must have their competencies regularly assessed to ensure that they are competent. It is recommended that in the interests of people using the service safety the practice of leaving gloves, pads, aprons and air fresheners on view in bathrooms must be reviewed. Requirements have been made for the following: People using the service must have a detailed care plan reflecting their needs and reviewed monthly or as and when necessary. When medication is administered to people using the service it must be clearly recorded to ensure that people receive the correct levels of medication. To prevent and control the risk of infection to people using the service the waste bins with missing covers must be replaced. The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 7 To prevent and control the risk of infection to people using the service staff must dispose of used gloves in the clinical waste bin provided. To ensure that the home is run in the best interests of people using the service a system must be developed to monitor and improve the quality of care provided at the home to achieve positive outcomes for people using the service. 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 DS0000064534.V352886.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 DS0000064534.V352886.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): 2 People who use 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 home ensures that prospective people to use the service needs are assessed prior to moving into the home and he or she is assured that their diverse needs would be met. EVIDENCE: The home has not had an admission to the service since last year. The home ensures that prospective people to use the service undertake a pre-admission assessment of their care needs before a service is provided. The manager usually undertakes the assessment. Wherever possible prospective service users are expected to visit and look around the home and meet other service users and staff members. Staff spoken to were able to describe the admissions procedure and the importance of making sure that new service users were made to feel welcome. The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 10 The Beeches DS0000064534.V352886.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 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. Weaknesses identified in the lack of detailing of information in care plans would need to be improved to ensure that the health and personal care that people receive is based on their individual needs. Inconsistencies in staff’s medication practice could put people using the service at risk of harm. EVIDENCE: Since the last inspection the home had introduced a new care plan format and staff appeared to be working with the two formats. Information relating to individuals’ daily personal care, daily routine and likes and dislikes were not collated into the new care plan and as a result the plans were not easy to follow and were not complete. There was no evidence that the manager had initiated a regular audit of the standard of record keeping. Care plans were not updated monthly and risk assessments relating to moving and handling and tissue damage were not adequately maintained. Daily entries were made and dated. These detailed the care given but did not say to what extent the care The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 12 plan was being followed or the goals achieved. One service user care plan had not been updated although there were changes to the individual’s health care needs and mobility. A requirement will be made in this report for care plans to be detailed reflecting individuals’ changing needs and reviewed monthly or as and when necessary. A regular programme of care plan audits should be implemented and wherever possible service users should sign the care plan to confirm their involvement and agreement. It is acknowledged that staff had undertaken training in care planning. However, further training should be undertaken to ensure that they are fully conversant with the new care plan format that has been introduced. Arrangements were in place to ensure that service users’ have access to health care facilities such as, chiropody, dental and optical treatment. All service users were registered with a general practitioner who visits the home weekly. The district nurse visits the home when required and staff were able to contact her for advice and support. Professional advice is sought for those service users with continence problems and aids and equipment needed are provided. It was noted that other health care professionals for example, the community dietician and physiotherapist were also supporting the home’s staff. The medication administration and record (MAR) sheets were examined. There were a number of gaps with no explanation of why the medication had not been given. Since the last inspection the manager said that a monitoring system was introduced to minimise the risk of errors but inconsistencies in staff’s practice persist. Handwritten entries recorded on the MAR sheets were not countersigned by a second person to make sure that entries were correct. This practice and the lack of adequate recording have the potential to put service users at risk. During the medication round two staff members were observed pouring the tablets from the pot into their hands and administering them to service users. This is unhygienic and can lead to cross-contamination of medication. Scribbled over entries were noted, which made it look like medication was signed for before being offered to the service user and was then refused. Controlled drugs were safely stored and recorded correctly. It is required that staff must administer medication in full compliance with the regulations and the British Pharmaceutical best practice Guidelines. It is also recommended that the home should retain a list of staff members authorised to give medication, which includes a record of their approved initials. Those service users who responded to the Commission’s comment cards said that they ‘always’ or ‘usually’ received the medical support needed. Those residents who responded to the Commission’s comment cards said that ‘staff respected their privacy and dignity.’ Staff were observed interacting appropriately with service users during the inspection and knocking on their bedroom doors and waiting for a reply before entering. Individuals’ preferred The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 13 choice of name was recorded in care plans seen. Where service users had chosen to share a room portable screening was provided to ensure that their privacy was not compromised when providing personal care. Service users appeared clean and tidy on the day of the inspection with attention to detail. The Beeches DS0000064534.V352886.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 People who use 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 using the service are able to make individual choices about their life style. Wholesome and appealing meals are provided in pleasing surroundings. EVIDENCE: The home does not employ an activity organiser. Staff are expected to facilitate activities for service users during the afternoon. There are also professional therapists such as, an exercise therapist and a pet’s therapist that visit the home to provide physical and mental exercises and animal companionship and comfort to service users. Those respondents who responded to the Commission’s comment cards said that the home ‘sometimes’ or ‘never’ arranged activities that they can take part in. Additional comments noted were as follows: - ‘There should be more, would like to go out.’ The manager said that she recently arranged a theatre trip for service users and only one service user took up the offer. Outings outside the home were arranged and cancelled due to the lack of interests shown or service The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 15 users changing their minds at short notice. It was noted that a Halloween cheese and wine party was being arranged for service users and their relatives. Service users were encouraged by staff to maintain contact with family and friends. Individuals were able to entertain their visitors in their bedrooms if they wished to. Service users confirmed that staff made their visitors feel welcome. Those service users who wished to practice their chosen religion were supported to do so. Two Church of England vicars and an Anglican clergy were visiting the home to offer pastoral support and communion to those individuals who expressed a wish to have their spiritual needs met. The home would encourage service users to look after their finances for as long as they were able to and have the capacity to do so. There were no service users using the services of an advocate at the time of the inspection. The home makes service users aware of their entitlement to move in with some personal possessions if they wished to. Some bedrooms seen were personalised with items of furniture such as chairs and dressing tables. The home provides three meals daily and hot and cold drinks and snacks throughout the day and night. The midday meal was observed. Lunch consisted of roast chicken, mashed potatoes, Brussels sprouts and carrots. There was also an alternative choice of an omelette if individuals did not wish to have the main choice. There was a selection of fruit juices or water. Choices on offer for dessert were vanilla sponge and custard or ice cream. Lunch was sampled and it was tasty and well presented. Service users spoken to said that ‘lunch was always tasty and well presented.’ They also said that an alternative would be provided if they did not wish for what was on the menu. Lunchtime was a relaxed activity and service users requiring assistance were provided with assistance in a sensitive and discreet manner. The Beeches DS0000064534.V352886.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 People who use 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 home has a complaints and a safeguarding of vulnerable adult procedure in place, which should ensure that people using the service are able to express their concerns and have access to a robust and effective complaints procedure and are protected from abuse. EVIDENCE: The home’s annual quality assurance assessment (AQAA) reflected that within the last twelve months the home had received five complaints and 95 of the complaints were resolved within twenty-eight days. The home maintains a record of all complaints with outcomes of the investigation. It is pleasing to report that no complainant had contacted the Commission with information concerning a complaint made to the service since the last inspection. Of the nine residents who responded to the Commission’s comment cards. Eight said they were aware of how to make a complaint and one individual said that they were not aware. This information was passed on to the registered manager to be addressed, which should ensure that all residents are fully conversant on the home’s complaints procedure. Those residents spoken to during the inspection said that if they had a concern it would be discussed with the manager in the first instance and were confident that it would be dealt with appropriately. The home has acknowledged in its completed AQAA that further improvement was needed in the recording of complaints. In the past it had The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 17 not recorded minor complaints from service users for example, a button missing from a cardigan. However, it intends to record all complaints in the future. The home conforms to its organisation’s safeguarding of vulnerable adult (SOVA) and whistle blowing policies. The home’s annual quality assurance assessment (AQAA) reflected that ‘ staff were trained in looking for signs of abuse. If abuse is suspected details are recorded and the incident is reported to the local safeguarding of vulnerable adult team to be investigated. All staff undergo an enhanced criminal record bureau (CRB) check before commencing employment. The Commission has not been contacted with information concerning any allegation of abuse made to the service since the last inspection. The Beeches DS0000064534.V352886.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 & 26 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit to the service. People who use the service live in an environment that is generally clean, tidy and free from odours. However, poor infection control practice by staff could compromise on individuals’ health and safety. EVIDENCE: The Beeches is situated in Newport Pagnell close to shops and other amenities. It is divided into three areas known as the old extension, the house and the new extension. There is an ongoing programme of maintenance and renewal of the fabric and decoration of the premises to enhance the appearance of the building. The manager stated that she recently replaced curtains and armchairs in some bedrooms and three divan beds had been purchased. The grounds were tidy, satisfactorily maintained and accessible to residents. The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 19 The building complies with the requirements of the local fire service and environmental health department and the manager said that there were no outstanding fire and environmental requirements. Individuals spoken to said that they liked their bedrooms and the facilities in the home. Those who responded to the Commission’s comment cards said that the home was ‘always’ or ‘usually’ fresh and clean. The rooms of some residents were viewed and they were clean and free from odours. Individuals had personalised their bedrooms, with family pictures, mementoes and personal furniture to reflect their characters. In one bedroom viewed it was noted that staff had laid out on the individual’s bed in the early afternoon towels, flannel, pad, and gloves in preparation for assisting the individual with washing later that evening. This practice could be perceived as institutionalised and should be reviewed. Aids and equipment to assist with mobility were provided. It was noted that the home had purchased two new hoists to assist with moving and handling. In two bathrooms and toilets viewed it was noted that covers on waste bins were missing and needed to be replaced to prevent the potential risk of infection. It was observed that a pair of used latex gloves was disposed of in a general waste bin. Staff must comply with the infection control policy and dispose of used gloves in the clinical waste bins provided to prevent and control the risk of infection. The laundry room was sited away from where food is stored prepared and cooked. It was satisfactorily maintained and equipped with two washing machines and driers. The washing machines had been modified to a chemical system to control the risk of infection and to ensure that infected and foul linen is thoroughly washed. The paintwork on the walls in the laundry room was peeling. The manager said that refurbishment work was due to be carried out in this area. The Beeches DS0000064534.V352886.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 People who use 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 home ensures that People using the service diverse needs are met by staff in sufficient numbers who are trained and appropriately recruited, which should support the smooth running of the service. EVIDENCE: Information submitted in the home’s completed annual quality assurance assessment (AQAA) indicated that the home employs thirty-three care staff, four housekeeping staff and a chef. The staff team is multi-cultural which should meet the diverse needs of people using the service. The manager said that five staff were rostered to work in the morning. This number is reduced to three in the afternoon between 14.00 pm- 16.30 pm. After 16.30 pm the number is increased to five. Three staff cover the night shift. The manager is supernumerary to the rota and there is always a senior member of staff on call during the night to give advice and support if there is an emergency. The home does not employ agency staff and has its own pool of bank staff; this ensures continuity of care for individuals. Service users who responded to the Commission’s comment cards said that staff were ‘always’ or usually available when needed. Those spoken to during the inspection said that ‘staff were kind and nice.’ The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 21 The home has achieved the minimum ratio of 50 of the staff team holding an NVQ qualification. Thirteen staff had achieved the national vocational qualification (NVQ) in direct care in level 2 or 3 and seven were working towards achieving it. The recruitment file for the most recently appointed staff member was examined. The file contained a completed application form, an enhanced criminal record bureau (CRB) clearance and two written references. However, the reference from the individual’s last employer did not have an official stamp to confirm its authenticity. It is recommended that in instances when references are obtained without an official stamp a note should be recorded on the reference confirming that the authenticity of the reference had been verified. Information relating to mandatory training and other specialist training submitted to the Commission after the inspection reflected that mandatory training such as, moving and handling, food hygiene, first aid, fire awareness, dementia, infection control and the safeguarding of vulnerable adult were updated. Staff were able to access training from the local college. The manager said that ‘the staff team had a positive attitude towards training and were motivated.’ The Beeches DS0000064534.V352886.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 & 38 People who use 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 home aims to provide a consistent service to people using the service. However, the lack of detailed information recorded in care plans on how individuals’ care needs should be met and no formal system in place for monitoring staff’s practice and health and safety to enable quality monitoring could hinder service delivery and outcomes for people using the service. EVIDENCE: The manager has fifteen years experience in the care sector and has the advanced certificate in care management and a degree in operational management. She said that she regularly undertakes training to update her The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 23 knowledge and skills. She is supported by team leaders and has delegated some responsibilities to them. Staff meetings take place every two to three months and copies of minutes of meeting held were on file. The manager said that staff receive one to one and group supervision meetings and an appraisal system was being introduced. There was evidence seen which indicated that the home had targeted the views of service users and their representatives on the service delivery. The home’s quality assurance needs to be further developed to ensure that care documentation is appropriately maintained and care plans contain detailed information on how individuals’ care needs should be met. Care practices would need to be monitored to ensure that staff are accountable and are providing a consistent service to ensure that individuals’ health and safety are promoted and positive outcomes for people using the service can be achieved. It was noted that one of the organisation’s directors visits the home monthly to carry out regulation 26 visits. The home’s manager said that the home does not look after residents’ finances. It was noted that gloves, plastic aprons, pads and spray air fresheners were on view in toilets and bathrooms. This practice should be reviewed to ensure that service users’ dignity is not compromised and their safety is promoted. For example, the air freshener could be mistaken as a body spray and gloves ingested. Yellow plastic bags for the clinical waste bins were stored on the floor. In the interests of safety they should be stored in the cupboards provided. Toiletries such as, shampoo and bubble bath were observed in a bathroom, which made it look like they were being shared. Staff are reminded to return toiletries to individuals’ toiletries after use. This would ensure that safe hygiene practice is promoted. Examination of a sample of the fire records indicated that they were up to date and in order. Information reflected in the home’s completed annual quality assurance assessment (AQAA) indicated that routine servicing and maintenance of equipment was not always undertaken at the appropriate intervals. The Beeches DS0000064534.V352886.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 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 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 2 X 3 X X 2 The Beeches DS0000064534.V352886.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. Standard OP7 Regulation 15 Requirement People using the service must have a detailed care plan reflecting their needs and reviewed monthly or as and when necessary. When medication is administered to people using the service it must be clearly recorded to ensure that people receive the correct levels of medication. To prevent and control the risk of infection to people using the service the waste bins with missing covers must be replaced. To prevent and control the risk of infection to people using the service staff must dispose of used gloves in the clinical waste bin provided. To ensure that the home is run in the best interests of people using the service a system must be developed to monitor and improve the quality of care provided at the home to achieve positive outcomes for people using the service. Timescale for action 30/11/07 2. OP9 13(2) 30/11/07 3 OP26 13(3) 30/11/07 4 OP26 13(3) 30/11/07 5 OP33 24 31/12/07 The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Care plans for people using the service should be audited regularly to ensure that they are up to date and reflect changes to individuals’ care needs. Staff should undertake further training in care planning to ensure that they are competent and skilled in using the new care plan format that has been introduced in the home Handwritten entries recorded on people using the service medication administration record sheets should be countersigned by a second person to comply with best practice guidelines. Staff who administer medication to people using the service should have their competencies regularly assessed to ensure that they are competent in the safe handling and administration of medication. To comply with the British Pharmaceutical Guidelines the home should retain a list of staff members’ names along with their initials authorised to administer medication. In the interests of people using the service safety the practice of leaving gloves, pads, aprons and air fresheners on view in bathrooms should be reviewed. 2 OP7 3 OP9 4 OP9 5 6 OP9 OP38 The Beeches DS0000064534.V352886.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 DS0000064534.V352886.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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