Inspection on 12/02/07 for The Beeches

This inspection was carried out on 12th February 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 07/02/06

The Beeches 23/08/05

The Beeches 25/11/04

The Beeches 13/08/04

The Beeches 11/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Beeches Yew Trees Lane Dukinfield Tameside SK16 5BJ Lead Inspector Kath Oldham Unannounced Inspection 12th February 2007 09:10 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 DS0000028452.V308816.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 DS0000028452.V308816.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Address Yew Trees Lane Dukinfield Tameside SK16 5BJ 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) 0161 368 9099 0161 303 0058 Meridian Healthcare Ltd Marie Mcpherson Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32), Physical disability (1), Physical disability of places over 65 years of age (32) The Beeches DS0000028452.V308816.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service user under the age of 63 may be admitted into the establishment. 7th February 2006 Date of last inspection Brief Description of the Service: The Beeches is a purpose built establishment, situated to the rear of Yew Trees, both homes being owned and managed by Tameside Care Limited. The home is registered with the Commission for Social Care Inspection to provide accommodation for 32 older people, some of whom may have a physical disability. All the bedrooms have en-suite facilities and are above the minimum standard size. The doors are lockable and there is a lockable facility in each room. Bedrooms are located over two floors. Each floor has a sitting and dining area with small kitchens. All areas are equipped to a good standard. An additional small lounge is provided on the first floor for those service users who smoke. Kitchen and laundry facilities are provided by the adjacent home (Yew Trees) and a landscaped secure garden (to the rear) is also shared by both homes. A small external sitting area is also available to the front of The Beeches. Car parking is provided at the front of the building. The home is located within a residential area of Dukinfield, close to shops and on a bus route. The home has a statement of purpose, which is on display in the foyer. The service user guide was reported to be given to prospective service users or their families when they visit the home to look round. The fees for staying at the home were reported to be between £356.66 and £366.66 per week. Additional charges are made for toiletries, newspapers, hairdressing, dry cleaning, outings and chiropody services. The home has a social fund where service users are asked if they would like to contribute, this goes towards the cost of entertainers and outings. The Beeches DS0000028452.V308816.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is a report of the key inspection, which included an unannounced visit to the home on 12th February 2007. The purpose of the inspection was to monitor the care and service provided at the home, to check that it was of a good standard and to ensure compliance with the regulations. Time was spent in conversation with the temporary manager, in addition to conversation with the previous manager. Time was also spent talking with service users to get their views and experience of living in a residential care home. People visiting the home were also spoken with. The inspector undertook a tour of the building and looked at a selection of service user and staff records, as well as other documentation, including staff rotas, medication records and some maintenance documentation. A meal was taken with service users. The registered manager has left her employ at The Beeches to take up another manager’s job at a care home owned by the company. A senior member of staff has been appointed to the role of temporary manager whilst awaiting the commencement of the new manager. The new manager has been employed by the company for a couple of years in senior positions and it is understood will take up her position at The Beeches in March 2007. What the service does well: The Beeches provides a warm friendly and welcoming atmosphere where the individuality of service users is promoted. Staff are encouraged and enabled to spend time sitting and chatting with service users. Service users spoken to were, in the main, complimentary about the support they receive at the home. One service user said the staff were “friendly and couldn’t do enough for you”. A relative said their cared for relative had “settled well” and any questions and queries they had, had been answered. Residents’ meetings are periodically arranged to provide an opportunity for service users to contribute their views and opinions on the care they receive and assist in the development of the home. The Beeches DS0000028452.V308816.R01.S.doc Version 5.2 Page 6 Service users spoken with were aware of what they would do in the event of them having concerns or complaints. Service users made positive comments about the staff team, such as “they look after you well”, “nothing is too much trouble” and “they are little gems”. The Beeches is purpose built and all service users have single rooms with ensuite toilet and washing facilities. All bedrooms have numbers and the names of service users on the doors to assist service users to find their way about the home. All other rooms are signed as appropriate, i.e., bathroom, toilet. The home is clean and free from any offensive odours. The home had a stable staff team of care workers, many of whom had worked at the home since it opened in 2002. The inspector received favourable comments regarding the kindness and caring attitude of the staff group. Activities are arranged and these are indicated on a poster for the month on the lounge doors both on the ground and first floor. Service users commented on enjoying the organised activities and some were looking forward to the church service arranged for the day after the inspection. On the afternoon of the inspection service users were playing musical bingo which provided some stimulation either by playing or for others who sang along to the music. Vetting and recruitment procedures for new staff are undertaken properly ensuring that only suitable people are appointed to work in this setting. The home continues to be committed to providing a safe and caring environment for service users. The home is open to suggestions from care workers, relatives and service users on how they feel they can make The Beeches a pleasant and safe place to live. What has improved since the last inspection? The home has undertaken a refurbishment of the decoration and fittings in the months since the last inspection. New carpeting has been fitted in the corridor areas and the walls have been redecorated. Pictures and ornaments have been added to complement the corridors. The Beeches DS0000028452.V308816.R01.S.doc Version 5.2 Page 7 New dining and lounge chairs have also been purchased to enhance the comfort of service users. Replacement curtains have been fitted in the lounges. The manager has spoken with the pharmacist in an effort to improve the pharmacy service provided to the home. The manager said that the pharmacist came to the home and discussed the problems the home was experiencing and they now provide an improved service. 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 DS0000028452.V308816.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 DS0000028452.V308816.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 & 3 (Standard 6 is not applicable) Quality in this outcome area is good. Prospective service users receive a full assessment that assures them their needs will be met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The statement of purpose is available in the foyer for relatives and service users to view. A service user guide was available. The temporary manager said that all service users or their families are given a copy of the service user guide and are asked to read it. It was reported that copies are in service users’ bedrooms. This provides service users with information about the home that can be considered before they make a decision to be accommodated there. The Beeches DS0000028452.V308816.R01.S.doc Version 5.2 Page 10 Four service users said they received enough information about the home before they moved in so they could decide if it was the right place for them and that they had received contracts. Visitors, who were asked, confirmed that they were able to visit The Beeches before their relatives started to live there, in order to assess its suitability. The manager undertakes an assessment of the service user in their own home or on the hospital ward if they are going into care from there. An assessment is recorded by the home. For service users who are being funded by the local authority, social or health care workers undertake an assessment. Examination of a sample of service users’ files found that an assessment was in all but one file. The temporary manger said that the service user had been accommodated at another of the company’s care homes and transferred to The Beeches and that the paperwork must not have been forwarded on to them. The Beeches does not offer intermediate care. The Beeches DS0000028452.V308816.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 good. The home met the health care needs and privacy of the residents. Medication was handled safely. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A selection of service users’ files was looked at. All had a written copy of a care plan. The written care plans are presented as containing sufficient detail to enable staff to offer appropriate care. There was also documentary evidence that care plans were regularly reviewed and that service users were involved in creating and reviewing their care plan. In the files seen there was evidence that the home had sought a ‘social history’ of each service user. This included a ‘getting to know you’ questionnaire. This level of information in connection with each person assisted staff to relate to people as individuals. The Beeches DS0000028452.V308816.R01.S.doc Version 5.2 Page 12 Service users are weighed monthly and an indication is made whether there is any weight gain or loss and what action is taken as a consequence. More frequent weights would be taken if it were identified that there might be a problem. A weight loss had been recorded for one service user within a short timeframe. It was reported that the service user would be weighed again and the doctor would be contacted it there was further weight loss. Examination of the records completed by staff each day and night to detail the care and support service users receive identified, in some instances, minimal information. The records didn’t evidence the care as described by staff as having been provided. Comments such as “appears well” and “CAP”, which is an abbreviation for care as plan were examples of this. The day and night reports are in place to demonstrate the care and support provided. Staff need direction and support in completing the daily reports with enough detail to demonstrate the support and interventions they provide. Examination of service users’ records identified appointments with chiropodists, district nurses and other health care professionals. Service users said they received their medication regularly and that staff took time with specific service users to assist them. It was reported that no service users had pressure sores. All service users, visitors and staff who were spoken to expressed confidence that appropriate medical support was sought in a timely manner. Observations of care practice identified that the support and interventions of staff promoted their privacy and dignity. One relative said “on the whole, we feel that our cared for relative is looked after very well, and they are most kind to her. We are quite satisfied at present.” A further relative said, “Overall, I am very satisfied with the level of care provided for my cared for relative.” Service users who were spoken with said they were happy with the care they received. Five relatives said they are kept informed of important matters affecting their cared for relative. Medication records were looked at. The home uses a pre-dispensed monitored dosage system to administer service users’ medication. Medication was seen to be stored safely. Medication administration records are pre-printed and provided by a local pharmacist. There were no omissions in the recordings observed. The Beeches DS0000028452.V308816.R01.S.doc Version 5.2 Page 13 Labels were attached to the medication administration records when the doctor had prescribed medication after the medication records had been printed. These could removed in error or placed over administered medication. Examination of the controlled drugs record identified this to be completed in line with regulations. Observation of the administration of medication identified that the senior did not wash their hands before or after administering eye drops to a service user. It is also the inspector’s view that conversation and interaction with service users when administering medication provides an opportunity to check with service users how they are feeling and an opportunity for one to one contact and is best practice. The omission of this may have been due to the inspector’s presence. The Beeches DS0000028452.V308816.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. Service users were satisfied with their lifestyles and are able to make their own decisions and choices. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Some service users have an organised routine where they spend the morning reading, then watch television and chat in the afternoon. One service user said they go out periodically with their family or to day centres. Service users were seen reading or doing puzzle books. Service users also commented that they go out on trips organised by the home. Some service users said they were happy with what they do and don’t want very much more than warmth, meals, company and security. Service users said the residents’ meetings are used to decide where they want to go. It was reported that the meetings are held every couple of months and they are told what is happening in the home and can discuss any issues or queries they have with management. The Beeches DS0000028452.V308816.R01.S.doc Version 5.2 Page 15 A member of staff has organised a ‘shop’ where service users can purchase toiletries, cards and such like. Service users said they ask the carer for the things they want her to stock and this is arranged by her. Service users said visitors come regularly and are made to feel welcome by the staff. Visitors are able to go to their cared for service user’s bedroom or sit in the lounge; service users said it was up to you where you see your friends or family. A number of clergy visit the home. One service user said they were looking forward to the local church coming to the home on the day after the inspection. Service users said there is a small quiet lounge where you can also sit if you want private conversations with your visitors and is also used for service users who wish to smoke. There were varied and mixed comments about the food at the home. Some service users said the food was alright, whilst others said they thought it depended on who was cooking. Comments in the complaints record also detail some of the feedback about the meals and the action taken to remedy the difficulties. The meal on the inspection looked ‘sloppy’, service users said it was “alright”. One service user said they liked cottage pie but didn’t like the one cooked at the home and chose a baked potato for their main meal of the day. Rice pudding, containing artificial sweetener, was served to all service users who chose this option. This affected the taste of the pudding. Action needs to be taken to ensure that staff are not making shortcuts when providing meals, which reduces the enjoyment for service users who are not diabetic. The Beeches DS0000028452.V308816.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 good. Service users and relatives have access to the home’s complaint procedure. Service users are protected from abuse or exploitation by the home’s policies and practices. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Service users said they had few, if any, complaints regarding the care they receive at The Beeches and when they did, they would let management know. Residents’ meetings were described as an opportunity to talk things over and forward ideas for change. A complaints book is in place and contained very few recordings. The home had a written complaints procedure, which was displayed in the home, in addition to service users’ bedrooms. All service users spoken to expressed confidence that complaints would be appropriately dealt with. Staff felt confident that any concerns they had could be discussed with the manager and they would be listened to. Staff said they dealt with any comments identified by relatives or service users as they were identified. The Commission for Social Care Inspection has not received a complaint since the last inspection. The Beeches DS0000028452.V308816.R01.S.doc Version 5.2 Page 17 The home has a policy and procedure to respond to allegations of abuse. Staff had received training in issues relating to the protection of vulnerable adults. The Beeches DS0000028452.V308816.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 Quality in this outcome area is good. The Beeches provides a comfortable, clean and homely environment, which meets service users’ needs. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: All the bedrooms have en-suite facilities and are above the minimum standard size. The doors are lockable and there is a lockable facility in each room. Bedrooms are located over two floors. A combined lounge and dining room with a small kitchen is situated on both floors. All areas are equipped to a good standard. The chairs are around the perimeter of the lounges. Not all service users would be able to view the television from where they were sat. One service user said if there was something on the television that they wanted to watch, they would go to their room. The Beeches DS0000028452.V308816.R01.S.doc Version 5.2 Page 19 An additional small lounge is provided on the first floor for those service users who smoke, want to spend quiet time or receive visitors. Meetings are also arranged in this room to promote service users’ privacy. Kitchen and laundry facilities are provided by the adjacent home (Yew Trees) and a landscaped secure garden (to the rear) is also shared by both homes. A small outside sitting area is available to the front of The Beeches; a number of staff and a service user were seen using this area to smoke. The home was clean throughout and free from unpleasant odours. The housekeeper works hard to maintain a good standard of cleanliness within the home. Service users said the house was always clean and tidy. A number of service users’ rooms were seen, these were furnished and equipped to a comfortable standard, some had been personalised by the occupants, with many of the service users being quite self contained in their own rooms. Service users who were asked said that they liked their rooms. Since the last inspection the corridors have had new carpet fitted and the corridor walls have been decorated, and pictures and furnishings displayed. Lounge and dining chairs have been replaced to further promote service users’ comfort. New curtains have been purchased for the lounges. One service user commented that the home was, “proper posh”, and also comfortable. The flooring within the lift is buckled and needs some attention to ensure it is safe for service users. In its current condition it could be a risk. The Beeches DS0000028452.V308816.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. Staff were trained to meet the needs of service users. Sufficient staff are on duty to meet the needs of service users. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A staff rota showing which staff were on duty and in what capacity, was kept at the home. Comments were made that there needed to be additional staff on duty and consistently having four care staff on duty would ensure service users received the care they needed. It was also suggested that three staff on at night would improve the care and support service users received. Two relatives felt, in their opinion, that there were not always sufficient numbers of staff on duty, four thought there were and one indicated that there were usually enough staff on duty. Service users commented that they get ready for bed before the night staff come on duty at 8:00pm. A number of service users at this time retire to their rooms to watch television before going to bed. It was reported that this was service users’ choice. Advice was given to ensure the time staff start and finish work does not give service users the wrong impression that they need to get ready or go to bed. Service users’ care files identified their preferred rising and retiring routines. The Beeches DS0000028452.V308816.R01.S.doc Version 5.2 Page 21 Vacancies exist for cleaning and laundry staff. These were reported to be in hand and new staff have been appointed and await the necessary checks to be received at the home before appointment is confirmed. Since the last inspection two new members of staff have been appointed. Examination of the staff files identified all checks had been undertaken in line with regulations. The staff who spoke with the inspector confirmed they had provided referees and had CRB clearance. The home completes a format to record staff interviews, which promotes equality of opportunity for applicants. Existing staff confirmed that they had undertaken further training to assist them in their role as carers, including moving and handling updates, health and safety, and the safe handling of medicines. There is a system in place to ensure training is kept up to date. Staff have meetings with management when they have the opportunity to influence the running of the home and contribute to its developments. The company continues to support carers to complete the National Vocational Qualification at level 2, which the majority of staff have obtained. The Beeches DS0000028452.V308816.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 good. Systems are in place to protect service users, their visitors and the staff’s health and safety. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A selection of records relating to money held on behalf of service users were looked at. These records presented as being appropriately maintained with receipts in place for items purchased on behalf of service users. Health and safety procedures presented as being effectively implemented. A small selection of records relating to the maintenance of equipment and the fire detection systems was looked at. These presented as being appropriately maintained. The Beeches DS0000028452.V308816.R01.S.doc Version 5.2 Page 23 Staff confirmed they were provided with protective equipment, including disposable gloves and aprons, to minimise the risk of cross-infection. Training for care workers on first aid, administration of medication and moving and handling was in place. Formal supervision with senior management had been taking place, which provides staff with an opportunity to meet with their line manager and discuss practice and development issues. These sessions are recorded. The home maintained up to date records on the checks undertaken to the emergency lighting and means of escape, in line with fire authority regulations. All staff were reported to have taken part in fire drills and practices to make sure staff know what to do in an emergency. Examination of the fire safety records identified routine fire drills and practices having taken place. Those staff spoken to were aware of what to do in an emergency situation. Staff had updated their training in safe handling and moving procedures and health and safety. The home recorded information in respect of falls and accidents by service users. An analysis is also undertaken to see if there are any patterns to the falls or incidents and care plans amended to record any identified risk. This practice goes some way to protect service users. The maintenance of all appliances and equipment is carried out under contract. Those seen were carried out as required by health and safety legislation. A representative of the registered person visits the home monthly in line with the regulations to ensure that they are aware of how the home is operating. The visit includes seeking the views of service users, staff and relatives or visitors; the building is also inspected as part of this visit and checks are made on specific records. Copies of these visits are held at the home. Examination of records found that two service users had died whilst being accommodated at the home. Notifications such as this should be forwarded to the CSCI. This has not been undertaken. The Beeches DS0000028452.V308816.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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 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 2 X 3 X 3 X 3 3 The Beeches DS0000028452.V308816.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 OP37 Regulation 37 Requirement The registered person must ensure that all notifications affecting the health safety and wellbeing (deaths, etc.) of service users are provided to CSCI without delay. Timescale for action 28/02/07 The Beeches DS0000028452.V308816.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 The registered person should provide staff with direction and guidance in what to write in the daily reports to demonstrate the care, support and interventions provided to service users, so it is clear what support they receive. The registered person should ensure that when weight loss is identified in service users, additional practices are put in place before the next scheduled monthly weighing to ensure that the weight loss is not continuing. The registered person should cease using printed labels when medication is prescribed after the medication records are printed and write the medication and dosage on the medication records with a second person also verifying the instructions and signing the record. The registered person should ensure when staff administer eye drops that they wash their hands before and after administration. The registered person should investigate the problems with the flooring in the lift and repair or replace to reduce the risk of slips, trips or falls by service users, staff and visitors when using the lift. 2 OP8 3 OP9 4 5 OP9 OP19 The Beeches DS0000028452.V308816.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 DS0000028452.V308816.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!