Inspection on 16/10/06 for The Beeches

This inspection was carried out on 16th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Beeches 17/01/06

The Beeches 04/08/05

The Beeches 30/12/04

The Beeches 22/07/04

The Beeches 13/11/03

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE The Beeches St Georges Road Hayle Cornwall TR27 4AH Lead Inspector Ian Wright and Diana Penrose Key Unannounced Inspection 9:00 16 and 17th October 2006 th 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 DS0000008967.V311887.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 DS0000008967.V311887.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Address St Georges Road Hayle Cornwall TR27 4AH 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) 01736 752725 01736 754324 Mr Peter Ian Pool Mrs Lesley Jennifer Pool Mrs Marian Rich Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28), Physical disability (5), Terminally ill (5) of places The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Accommodation can be provided to service users aged 50 years and above who have a physical disability or terminal illness. 17th January 2006 Date of last inspection Brief Description of the Service: The Beeches is registered to provide accommodation and care, with nursing, for up to 28 older persons. The registered providers are Mr P I Pool and Mrs L J Pool. The registered manager is Mrs Marian Rich. The home is in a pleasant area of Hayle. There are 22 single rooms and three shared rooms. All the bedrooms have en suite washbasins and toilets. In regard to access for people with mobility problems, there is a small step at the main front door, but a portable ramp is available for wheelchair users. The ground floor is level and there is a passenger lift to the first floor. Communal space comprises a large dining room, a lounge and a conservatory. There are attractive and spacious gardens providing areas accessible to service users. A copy of the inspection report is available from management and did not appear to be on display at the time of inspection. The range of fees at the time of the inspection is £525 to £625 per week. There are additional charges e.g. for hairdressing, chiropody, and newspapers etc. The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place in fourteen hours over two days. A second inspector Mrs Diana Penrose, who is a registered nurse, accompanied Ian Wright, the lead inspector. All of the key standards were inspected. The methodology used for this inspection was: • To case track four service users. This included, where possible, meeting and discussing with the service users their experiences, and inspecting their records. • Discussing with staff their experiences working in the home. • Discussion with other service users and their representatives. • Observing care practices. • Discussing care practices with management. • Inspecting records and the care environment. Other evidence gathered since the previous inspection, such as notifications received from the home (e.g. regarding any incidents which occurred), was used to help form the judgements made in the report. What the service does well: What has improved since the last inspection? The registered providers have addressed the majority of requirements since the last inspection. For example there is now a nurse call point in the downstairs bathroom, screening has improved in one of the bedrooms and all bathroom / toilets have a lock on the door. The death and dying policy has been updated, and the home is part of a pilot scheme to provide a high standard of palliative care. There had been some slippage in ensuring the fire alarms were tested and this has now been addressed. The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 6 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 Beeches DS0000008967.V311887.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 DS0000008967.V311887.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. The registered provider’s statement of purpose and service user guide are satisfactory, so service users and their representatives receive suitable information about services offered. Service users receive a suitable contract on admission, so they have information regarding their rights and responsibilities. The pre admission assessment procedure is good, and enables the registered persons to ascertain they can meet the needs of service users, before admission is arranged. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with service users, staff and the registered persons. Copies of the registered provider’s statement of purpose and service user guide were inspected and are satisfactory. The registered manager said this information is issued to service users prior to admission to the home. A copy of either a social services contract (if the person is state funded) or the registered provider’s contact (if the person is privately funded) was contained in service user files. The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 9 The registered manager assesses service users before admission is arranged. Staff said service users or their relatives could visit the home before formal admission is arranged. Some service users said they remembered a member of staff coming to assess them before they moved in. Copies of assessments were available for inspection in service user files. The home does not provide an intermediate care service. The Beeches DS0000008967.V311887.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individual care plans are written for each service user although more detail regarding care instruction would be beneficial. Service users have access to health care services, as necessary, to ensure their assessed needs are met. There are systems and policies in place for dealing with service users medicines that assure service users safety, however some additional safeguards will ensure a safer system. Systems are in place to ensure that service users are respected and their privacy is upheld at all times. Service users are treated with care, sensitivity and respect at the time of their death, and staff take into account individual wishes and religious beliefs. EVIDENCE: Evidence was provided in the form of documentation, records, observation, case tracking and interviews with service users, relatives and staff. Each service user has a written care plan that includes all aspects of their care needs including nursing needs. There is another care plan for the care staff that details personal care needs. More detail would better inform and direct staff in the specific care to be provided. This would be especially beneficial for new employees. The registered manager stated that care plans are compiled The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 11 with the service user or representative, if possible, and reviewed monthly. Risk assessments include Waterlow scoring, nutrition, moving and handling and falls. Daily records are maintained by the nurses and care staff. Service users said their health needs are met and they have access to a GP and health professionals when required. Care practice was observed to be appropriate during the inspection and carried out in a calm, efficient manner. Appropriate pressure relieving equipment is supplied and hospital style beds are provided where needed. There is suitable equipment in the home for moving and handling and staff receive training in house. Some nurses specialise in specific subjects and link with external agencies to remain up to date, for example continence, tissue viability and Parkinson’s Disease. Community nurse specialists provide advice when necessary. A monitored dosage system for medication is used in the home. No service users administer their own medicines at present. There is a medicines policy that must be reviewed and updated to comply with regulations; it must include all aspects of the homes medication system. It needs to include the use of insulin, oxygen and medicinal creams, training for staff etc. The disposal system used must be included and the policy should state that errors are reported to CSCI. The British National Formulary is available for reference and some patient information leaflets are kept. The registered manager agreed to obtain the patient information leaflets for all medicines in use. Storage of medicines is safe and secure. Records are generally satisfactory however any transcribing onto the medication administration charts must be witnessed and signed by the two people involved; the registered manager and deputy manager agreed to address this with the nursing staff. Medicines are disposed of appropriately through a waste disposal company; the pharmacist collects the controlled drugs. A registered nurse administers all medicines and the lunchtime medicines were administered in a professional manner. Some care staff have received training in medicines, the manager said she would ensure that basic medicine awareness training is provided for all care staff and included in the induction programme. Service users’ privacy was upheld during the inspection. Service users said they are treated with respect and their privacy is upheld at all times. Shared rooms are provided with appropriate screens. The death and dying policy has been updated. The registered manager said that service users are treated with respect at the time of their death. Relatives can stay if they wish and time is spent with them. External health professionals are involved for example the Macmillan service. The home is piloting the ‘Liverpool End of Life Care Pathway’ and ‘Gold Standard Framework for Cornwall’. Staff training is taking place and appropriate systems are being put in place. The home discusses the service users’ wishes for the time of their The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 12 death and these are recorded. Some staff have attended training in palliative care and nursing staff receive cardio pulmonary resuscitation training. The registered provider has a satisfactory policy regarding anti discrimination. There are currently no service users from ethnic minorities, although staff stated the home would be more than happy to accommodate service users from other cultures. The local population is predominantly Cornish, and from ‘White-UK’ background. Issues regarding sexuality, gender and disability seem to be suitably addressed. The Beeches DS0000008967.V311887.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities and aims to offer a lifestyle that meets individual service users needs. Visiting arrangements are open so service users can maintain contract with friends and relatives. Suitable arrangements are in place regarding the management of service users’ monies, to enable service users to bring their own possessions into the home and to provide information regarding advocacy. This ensures service users are assisted to maintain their autonomy and receive information regarding agencies to help them make major decisions. Meals provided are to a good standard although information regarding choice of meals could be improved. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with service users, staff and the registered persons. Service users said they could get up and go to bed when they wished. Routines seem individualised and staff said effort was made to ensure The Beeches is made as much service users’ home as possible. Two staff organise activities in the home. Posters are displayed to inform service users of what is on offer. Activities include entertainers, crafts, bingo, games and singers. A trolley shop is soon to be introduced. Several events have been arranged for Christmas and The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 14 recorded in a diary. Holy Communion takes place in the home each week. Several people talked about a trip out and how enjoyable it was. Service users’ social interests and hobbies are recorded and there is a care plan for social needs. Recording of activities attended could be improved and the registered manager agreed this would be arranged. There was a steady stream of visitors on the days of the inspection. Relatives and friends of service users spoke very positively regarding care service users receive. Visitors said they felt welcome by staff. Service users can receive their visitors either in their bedrooms or in one of the communal rooms. Suitable arrangements are in place to manage service user finances as outlined later in the management section of this report. Service users said they could bring their own possessions into the home. Information regarding contacting advocacy services is contained in the service user guide. One of the inspectors had lunch with service users. The meal was to a good standard (Chicken and vegetables, followed by fruit flan). Drinks were provided. Support provided by staff was to a good standard. Menus are suitably recorded. Although there is not a choice of meal, the registered persons said the cook and staff are aware of individual preferences, and an alternative can be provided. One service user who is vegetarian however said they were not provided with much choice in terms of a vegetarian option. The registered persons said they would be surprised if this was the case and but would look into the concern. It is suggested the menu and days meal is displayed (e.g. on the white board in the dining room). Staff should also inform service users of what food will be offered either the day before or at breakfast time so service users can make a more informed choice of meals available. Service users said there was always enough food available, and thought meals were to a good standard. The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. The registered persons have suitable procedures regarding complaints and adult protection. Subsequently service users can be assured there are appropriate procedures to deal with any concerns or bad practice. However improvement to ensure staff have a Criminal Record Bureau / Protection of Vulnerable Adults (CRB/POVA) check needs to take place EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with service users, staff and the registered persons. The registered persons have suitable complaints and adult protection procedures. The registered persons keep a record of complaints. Service users said they were very happy with the service provided and had no complaints. Staff and service users said they had not experienced or witnessed any poor practices. However one member of staff did not appear to have received a CRB/ POVA check although they had worked in the home for some time. This needs to be rectified. There does not appear to be any system for staff receiving a POVA First check (as required by regulation) before they commence employment. This needs to be rectified. No complaints have been received by the Commission for Social Care Inspection and there have not been any adult protection referrals. The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Quality in this area is good. The judgement has been made using available evidence including a visit to the service. The Beeches provides a pleasant, homely, clean and well-maintained environment for service users to live and feel at home in. EVIDENCE: Evidence was provided in the form of inspecting the building, records, observation, and interviews with service users, staff and the registered persons. The inspector was able to view many bedrooms in the process of talking to service users. These appeared to be generally pleasant, well furnished and decorated according to individual tastes. Bedrooms at least have an en suite toilet, and some have an en suite bath-although baths have only limited access for those with mobility problems. All bedrooms offer satisfactory space. Screening in the bedroom, situated off the dining room, has been improved since the last inspection. The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 17 Currently only some of the bedrooms are lockable. Individual risk assessments have been written stating individual service users would be unsafe if there was a lock on their bedroom doors. However, on admission, individual service users can request a door lock if it is safe for the person to have one. Service users are able to bring their own possessions and furniture into their bedrooms when they come to live in the home. There is a lounge and a dining room. The dining room is also used as a sitting area. There are two staircases and a lift to enable service users to get to the first floor. Toilet and bathroom facilities are to a suitable standard. For example there is a new ‘Parker’ bath with a hydrotherapy facility. Other assisted bath facilities are also available. All facilities are lockable and have access to a call bell facility. The home was warm with satisfactory light on the day of the inspection. Kitchen and laundry facilities are to a good standard. Two sluices are available. The home was clean, hygienic and there were no unpleasant odours on the day of the inspection. Service users and staff said they were very happy with the facilities. The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this area is adequate. The judgement has been made using available evidence including a visit to the service. Staffing levels appear to be suitable so service users can be assured there is enough staff to meet their needs. Recruitment records are adequate, although two references need to be obtained when staff are recruited. Criminal Records Bureau / Protection of Vulnerable Adults check procedures need improving so service users can be assured staff have suitable checks. Some improvement to induction for nursing staff, and training for all staff as required by regulation, is required. This will improve the ability of staff to meet the needs of service users. The registered persons have a good approach to ensuring staff have a national vocational qualification in care. Equal opportunities issues regarding recruitment and work practices seem satisfactory. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with service users, staff and the registered persons. Suitable records regarding staff hours worked / to be worked are kept. Rotas showed there are 2 nurses on duty from 7:45-16:00, and one nurse on duty for the remainder of the 24-hour period. There are suitable numbers of care staff on duty for example there are five care workers on duty during the mornings until 14:00, and five from 16:00 to 20:00. There are four care workers on duty from 14:00 to 16:00. Two waking care assistants are on duty from 20:00 to 07:00 working alongside a registered nurse. Two cooks and two domestic staff are also employed. The inspector felt there were suitable The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 19 numbers of staff on duty throughout the inspection. Currently the home is fully staffed. The home has an appropriate recruitment policy and procedure. The registered provider’s approach to equal opportunities and anti discrimination is satisfactory. Staff records are generally satisfactory although two references had not been obtained for several care staff. Two references must be obtained for all staff subsequently employed. One member of staff, did not have a Criminal Records Bureau / Protection of Vulnerable Adults (CRB /POVA) check, although this person is not employed in a caring capacity. The person had received the checks previously via a previous employer, but the checks are not transferable. New checks must be obtained. Staff do not appear to have a POVA First check before they commence employment as is required by regulation. This needs to be actioned for all new staff. The turnover of nursing and care staff is low. Care staff appear to receive a suitable induction. There is an induction booklet for the induction of care staff, although there were some gaps regarding the completion of this for a number of staff. Medication training needs to be included as part of care staff induction. There does not appear to be a formal induction programme for nursing staff. Suitable induction needs to be arranged for nursing staff. The registered manager acknowledged this is a breach of regulations and said she would rectify this. The registered persons have a suitable approach to providing National Vocational Qualifications for care staff. The registered provider said currently 57 of staff have an NVQ 2 or 3. Staff training records were inspected. The registered persons have an ‘Investors in People’ award which has just been renewed for the next three years. There is a suitable staff-training programme; however there appears to be some gaps in training required by regulation. The majority of staff have received fire training and moving and handling training. However there is a need for some staff to receive this training. This training is completed in house and the registered persons said they felt the training courses provided were suitable. Formal infection control training needs to be arranged for most care and nursing staff. The registered manager said she had difficulty finding a suitable training provider, but the inspectors suggested she contact the Health Protection Agency. Some staff have however received suitable training and infection control precautions seem to be good. Approximately a third of staff have first aid certificates. The registered persons said they were sure there is always an approved first aider on duty. However the registered persons must ensure this is always the case, and they are advised to ensure at least all nursing staff, and possibly senior carers, have a current appointed persons first aid certificate. Eight staff have a current food hygiene certificate. The registered manager said only these care staff prepare The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 20 food. The cook however needs to have a food-handling certificate although this is planned. The registered persons must ensure that any member of staff who prepares food (e.g. a sandwich) has an food handling qualification in line with the Food Safety (General Food Hygiene) Regulations 1995. The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a suitable system in the home for dealing with service users’ money. However the registered persons need to update the service user money policy to reflect current practices and provide further safeguards. Efforts to ascertain satisfaction of staff, service users and their representatives are satisfactory. Subsequently service users can be assured there is a suitable means to ascertain their views of the service and bring improvement where this is necessary. Health and safety precautions need some improvement so service users can be assured all efforts are made to ensure the environment is safe. EVIDENCE: Evidence was provided in the form of documentation, records, observation, and interviews with service users, staff and the registered persons. The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 22 The registered persons appear to have suitable skills, experience and knowledge to manage the home. The registered persons have a suitable quality assurance policy. The registered manager has completed a survey of service users and their representatives, which has concluded positive outcomes for service users. The majority of respondents were very satisfied with care provided. There are separate meetings for nursing staff, care staff and for service users to enable people to make comments and suggestions for improving practice. There is a suitable system in place for the handling of service users’ money. Five service users deal with their own money and relatives deal with some of the other service users’ money. There is a policy for dealing with service users’ money. The policy needs to be updated to detail the actual system in place and the procedure to be followed when the registered manager is not in the home. Records are maintained of all transactions and receipts are kept. The monies are held in the safe; the total is checked periodically by two people and signed on the records. Money raised from fundraising goes into a comfort fund for the service users. The registered provider has a health and safety policy. Records kept of checks required by regulation are generally satisfactory. For example there are suitable records for the testing of fire equipment, gas appliances, moving and handling equipment and portable electrical appliances. However the electrical hardwire circuit was last tested in 1999, and needs to be retested every five years. Accident records are suitably maintained. A requirement to set up a health and safety risk assessment system was made on the inspection 17th January 2006. This however has not been actioned. This needs to be set up as required under the Management of Health and Safety at Work Regulations 1999. This must include a risk assessment to prevent Legionella. Appropriate control measures must subsequently be implemented. Information regarding these issues can be obtained from the Health and Safety Executive. There are some gaps in health and safety training as highlighted in the ‘Staffing’ section of the report. The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 23 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 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP9 Regulation 13 Requirement Carry out the following improvements to the medication system: • The homes medicines policy must be reviewed and updated as outlined in the report. • All transcribing onto the MAR charts must be witnessed with two signatures recorded. • Basic medication awareness training should be provided for all care staff and included in the induction programme. • Patient information leaflets should be maintained for all medicines in use and be available to service users. The registered persons must ensure two references are obtained for new staff employed. The registered persons must obtain for all staff: • A Protection of Vulnerable Adults check (POVA First) check before they DS0000008967.V311887.R01.S.doc Timescale for action 01/12/06 2. OP29 19 01/12/06 3. OP29 OP18 12, 13, 19. 01/12/06 The Beeches Version 5.2 Page 25 4. OP30 18 5. OP38 13, 23 commence employment. A full Criminal Records Bureau / Protection of Vulnerable Records check. Staff must remain appropriately supervised until this is received. The registered persons must ensure staff receive training appropriate to the work they perform. This must include training required by regulation for example first aid, fire training, infection control, food handling, and manual handling. Health and safety precautions must be improved: • A health and safety risk assessment system must be set up, and control measures put in place for any risks identified. • A risk assessment to prevent Legionella must be developed. Appropriate control measures must subsequently be implemented. • Previous deadline of 01/05/06 not met. Second notification 01/03/07 01/12/06 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 Refer to Standard OP7 OP12 Good Practice Recommendations Care plans should be more detailed to fully inform and direct staff in the care to be provided Activities attended by service users should be recorded DS0000008967.V311887.R01.S.doc Version 5.2 Page 26 The Beeches 3 OP15 Provide better information regarding meals available to service users, so service users can make a choice regarding food available. A vegetarian option should always be available. The Beeches DS0000008967.V311887.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection St Austell Office John Keay House Tregonissey Road St Austell Cornwall PL25 4AD National Enquiry Line: 0845 015 0120 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 DS0000008967.V311887.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. 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