Inspection on 25/04/07 for The Beeches

This inspection was carried out on 25th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 13/09/07

The Beeches 04/01/07

The Beeches 10/02/06

The Beeches 03/08/05

The Beeches 29/03/05

Similar services:

Abbey The

Snydale Care Home

Whiteley House

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Beeches 59 Ferrybridge Road Castleford West Yorks WF10 4JW Lead Inspector Stephen French Key Unannounced Inspection 25th April 2007 08:30 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 DS0000060847.V333425.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 DS0000060847.V333425.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Address 59 Ferrybridge Road Castleford West Yorks WF10 4JW 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) 01977 517685 01977 517685 Care Care Care Ltd Mrs Karen Elaine Smith Care Home 23 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (23), Old age, of places not falling within any other category (23), Physical disability over 65 years of age (23) The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2007 Brief Description of the Service: The Beeches is a care home providing accommodation and personal and nursing care for up to 23 older persons who may have additional physical disabilities or enduring mental health problems. The home is privately owned through a limited company. The accommodation is on two floors with a passenger lift between the floors. Not all the rooms are single and few have en-suite facilities. The home is sited on a main road close to the centre of Castleford. The accommodation has a garden to the front and a car park to the side and rear of the building. The manager informed the Commission for Social Care Inspection on the 25/4/07 that fees at the home range from £380 to £519 per week depending on the individual resident’s assessed level of care need. Information about the home is available within the Statement of Purpose and the Service User Guide,which also inform people who live in the home about the role of the Commission for Social Care Inspection, both of which are available, on request, from the home. The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home carried out on the 25/4/07. The inspector arrived at the home at 08.30 am and left 03:00pm. During this visit the inspector spoke to some of the people living in the home, some of the staff and the home’s management. The inspector read care records, audited a sample of medication, reviewed staff recruitment and training records and carried out a brief tour of the building. Prior to the inspection 16 questionnaires were sent to the home to obtain peoples views about living at the home. Nine completed questionnaires were returned. Comments included “The home provides social activities but I would like more” “The staff are kind and caring” Overall the people living in the home are happy with the services provided. Some of the people in the home are very frail and would not be able to complete a questionnaire. There were Sixteen people resident in the home on the day of this visit. Relative surveys were also sent out and eleven were returned. Comments included, “ The food is excellent”,” Medical care and management are good”, “Staff are willing and friendly” , “I feel they excel in all aspects of care” and “ The home exceeds my expectations and would recommend it to anyone” Other information used in the inspection process included notifications from the provider to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the provider and a pre inspection questionnaire completed by the manager. What the service does well: The home provides a homely friendly environment in which people can live. Their needs are assessed prior to them moving into the home to ensure the home and the staff can meet those needs The staff are competent in their role and show a great empathy towards the people who live at the home. The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 6 People who live at the home said that they were happy with the care provided and that the food was very nice they also said the staff were very kind and always around to help. What has improved since the last inspection? What they could do better: Comprehensive care plans need to be developed, setting out how people’s needs in respect of health & welfare will be met. The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 7 All care plans must be reviewed to ensure they detail current needs and choices to ensure peoples needs are met. Stock balances of medication must tally with records held within the home All medication administered must be signed for. Suitable social activities should be arranged on a daily basis and people made aware of what activities are on that day to enable them to have a choice in joining in. Redecoration of the corridors and bedroom doors should be undertaken to improve the environment for people living there. The toiletries in the bathroom should be locked away or kept in people’s own rooms to prevent cross infection and communal use or from accidental swollowing. The manager should keep under review the staffing situation within the home in order to make sure that the needs of people living in the home are met. This should include staff availability to meet with peoples social and leisure needs The staff application form should be adapted to ensure the applicants full career history can be checked. People should be made aware of the outcome of surveys and the manager should produce an action plan to address any shortfalls. The manager must ensure that safeguarding referals are made were appropriate to protect the people who live in the home. 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 DS0000060847.V333425.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 DS0000060847.V333425.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): 3,6 People’s needs are assessed to ensure the home and its staff can meet those needs. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service EVIDENCE: The manager said that prior to a person being admitted to the home she receives a community care assessment, which has been completed by the person’s social worker. This assessment outlines the care the person requires. Following receipt of this assessment the manager said that she visits the person, either in their own home or hospital and completes her own assessment. Following this assessment the manager then decides if the home can meet those needs. The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 10 All nine of the questionnaires received by the Commission from people living in the home confirmed that they were given enough information before moving into the home to make a decision as to whether this was the home in which they wished to live. Three completed pre admission assessments were seen for people recently admitted to the home, confirming that the home is following their admission policies and procedures. The manager said that the home does not offer Intermediate care. The Beeches DS0000060847.V333425.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 are treated with respect, but their health would be better ensured if clear care planning systems were in place and if medication records evidenced that people receive their medication as prescribed. People who use the service experience poor outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service EVIDENCE: People spoken with at the time of the visit said that they were satisfied with the care and support provided by the staff. This was also reflected in the comment cards received by the Commission. The manager said that each person has a care plan. Four care files were examined and these contained assessments for such things as moving and handling, skin integrity and nutritional support, most of these had not been reviewed at regular intervals to ensure risks are identified and addressed. The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 12 Following a requirement made at the last visit information about peoples preferences regarding social activities has been recorded. Care plans seen were basic and did not give sufficient detail to direct staff in meeting the health and social care needs of the people living in the home. Although risk assessments for such things as tissue damage were completed, care plans did not direct the care staff in the care they are to deliver to prevent further deterioration in the persons skin. They did not identify specialist equipment, such as pressure relieving mattresses, used which could mean people will not get the care or equipement they need. One care file identified a person as having challenging behaviour but there was not a plan in place to inform the staff on how they could defuse this situation should it arise. A person who had been admitted to the home ten days previously did not have any risk assessments or care plans in place even though the pre admission assessment had identified areas in which the person required help. The manager was informed of this and the relevant documentation was completed straight away to ensure their needs were being met. The care needs of people living at the home seem to be being met,however the care documentation does not reflect the current and changing needs of the people and this must be addressed. There was evidence in some of the care plans examined that service users wishes regarding rising and retiring times have been taken into consideration. One person said that the care staff were good and always willing to help. Interaction between care staff and people at the home was observed to be appropriate. Qualified nursing staff are responsible for the administration of medication. people who wish to self medicate may do so following completion of a risk assessment. Whilst people were receiving the medication prescribed, at the prescribed times the medication records do noot tally with the medication in stock. This was discussed with the manager and apears to be due to previous stock balances not being carried forward. Eight peoples medications were audited against the medication administration records held by the home. Two stock balances did not tally with the records held. Four service users medication audited had not been signed as given but on further examination it was found that the service user had received the medication. These practices could place the people living in the home at risk and must be addressed to ensure the safe administration of medication. The Beeches DS0000060847.V333425.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 The range and frequency of social activities within the home needs to improve to ensure people have a greater choice of activities to meet the expectations of the people living there. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service EVIDENCE: The home does not employ a social activities co-ordinator. The responsibility for arranging social activities lies with the care staff and is dependant on them having the time to arrange and supervise these. In the office there was a board which displayed the activities for the week, however this was only filled in for two days and was not accessible to people living in the home. When questioned about how the people who live in the home know what activities are on offer the manager said that this was something she was The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 14 looking into. It was advised that a weekly program of activities is either displayed in the reception area or put in people’s rooms. Questionnaire’s received by the commission from people who live at the home stated that there were usually activities within the home in which they can take part in. One questionnaire received said that the person would like more social activities to take place. On the day of the visit there were no meaningful activities taking place and people were observed to be sitting in the lounge watching television. When questioned the manager said that the social activity for the day was a visit from the hairdresser. As not all of the people would be visiting the hairdresser the inspector informed her that this is not a recreational activity. There were only another two occasions were activities had been arranged this was Wednesday, Bingo and Friday, an organ recital given by a member of staff. The manager said that she and another member of staff had completed a training day on social activities and was looking to improve the choice of things on offer. She also said that the current nursing office was going to be relocated and the office converted into a activities room and planning is happening in relation to this. One person stated that social activities within the home were not very good, but another said she was happy with the variety of things on offer. The manager said that relatives and friends of the people living in the home are encouraged to visit as often as they like and are able to stay and have a meal. Within the care files examined, and people spoken to it was confirmed that people are able to exercise choice and control in most things they do this includes the time they rise and retire and where and how they spend their day. The home operates a four-week menu choice, which includes a full English breakfast and two options of meals for lunch. The meals seen were well presented and comment cards received all complimented the home on the quality and variety of food on offer. The Inspector observed some of the people having lunch and noted that a carer, who was assisting a person with their meal, was stood up. This practice may give the impression to the person being assisted that the staff are in a hurry therefore staff should be encouraged to sit next to the person when assisting with feeding. The Beeches DS0000060847.V333425.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People are confident that complaints are listened to and investigated, and staff are trained in safeguarding people,however apprpriate referals have not always been made. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service EVIDENCE: The home has a complaints policy, which is displayed in the reception area and the manager said that people are given a copy when they move into the home. All of the comments cards received by the commission for Social Care Inspection confirmed that people were aware of the policy. Complaints received by the home are investigated by the manager and the complainant is made aware of the outcome of any investigation, which has taken place. There have been no complaints to the home since the last visit in January 2007. The manager said that all new staff receive training in the protection of vulnerable adults as part of their induction training. Since the last visit the home has obtained training material from Wakefield District Council Adult The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 16 protection team and all staff are currently working through this training package. Three staff questioned on this subject were able to describe to the inspector the actions they would take if they suspected any form of abuse taking place. In the past the manager and propriator failed to alert the appropriate authorities when an incident of suspected abuse had taken place. This was discussed with the manager who said she had undertaken further training in safeguarding individuals and was aware of the importance of reporting all concerns. The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 17 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): 19,21,23,24,25,26 People live in a safe, satisfactorily maintained home where some minor redecoration is required to further improve their surroundings. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service EVIDENCE: As part of this visit a tour of the home was conducted. This included a number of bedrooms, communal areas, bathrooms and the laundry. People’s bedrooms were personalised with their own things such as ornaments and pictures. Some minor redecoration and replacement of carpets and furniture is required in a number of bedrooms and doors are in need of repainting due to wheel chair damage, to improve the quality of the home for people living there. The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 18 There are two lounge areas and a dining room, where people are able to sit. Some of the furniture in the main lounge is in need of renewing, as it is looking tired and worn. There are a number of communal bathrooms and toilets within close proximity to service users bedrooms and communal areas. During a tour of these it was noted that a bathroom contained a number of personal items such as soap, talc, shampoo and dental cleaner. These were not named and it had to be assumed that they are being used communally which raises the risk of cross infection and gives a feeling of institutional care rather than people having personal items of their own choice. There is a laundry, which is responsible for washing service users’ personal clothing. The standard of cleanliness throughout the home was satisfactory and there were no unpleasant odours detected. The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 19 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 There are currently sufficient numbers of staff to meet the service users needs, however the manager should monitor how quickly staff respond to peoples needs and staffing levels should be increased if peoples needs are not being met promptly. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service EVIDENCE: The staff duty rota was examined for March and April 2007 for 23 people. Staffing consisted of 1 trained nurse and 3 care staff on a morning and 1 trained nurse and two care staff on an afternoon. There was 1 trained nurse and 1 care staff on duty during the night. Staff spoken to said that they felt there were enough staff on duty throughout the day but not at night. There are several people who require the assistance of two staff to meet their personal care needs, which means that if two staff are attending to a person during the night then no other staff is available to oversee the needs of the other people. The manager was informed of this and she said that she often covers night shifts and does not think this is a problem. The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 20 Comment cards received from people who live at the home and relatives felt that there were adequate numbers of staff on duty to meet their needs. A sample of six staff recruitment records was audited and these were found to hold the correct information. It was noted that the new application forms, which have been developed recently, do not encourage the employee to give information on their past career history, this makes it difficult for the manager to be able to check any gaps in employment when selecting staff to work at the home. The manager said that new staff complete an induction programme, which covers, amongst other things, moving and handling, fire training and health and safety. Carers spoken to, who have been employed at the home for some months informed the inspector that they had completed induction training and had worked alongside a senior member of staff for the first week of employment until they felt confident. This means that people should be cared for by staff who are trained to meet their needs. One member of staffs induction record examined had not been completed fully even thought the manager said she had completed all the units. It was advised that this should be signed by the member of staff and the manager as confirmation that this training had been given.The manager said she would ensure this was completed. Carers spoken to stated they felt supported by the qualified nursing staff and the manager, however they felt that sometimes issues brought to the attention of the manager were not always addressed. The Beeches DS0000060847.V333425.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 The management of the home would be improved if issues brought to her attention were addressed in a timely manner and people were made aware of the outcomes of quality questionnaires. People who use the service experience adequate quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service EVIDENCE: The home is managed by a qualified nurse, who is supported in her role by a deputy manager. She is aware of the aims and objectives of the home and is due to commence her registered managers award training in May 2007. Staff spoken with said she was approachable but at times issues brought to her The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 22 attention were not always addressed in a timely manner. They also said that staff meetings do not always take place at regular intervals and when they do the agenda is usually set by the manager therefore issues which staff want to bring up, such as staffing levels and care practices are not discussed. There was discussion with the manager about the importance of staff issues being discussede to ensure people get the care they need. Comment cards received from relatives of people living in the home said that the management of the home was good. The manager said she completes monthly quality audit to ensure the care and service offered by the home meet the expectations of the people living in the home. Completed audits were seen for medication, falls and pressure sores however the medication audit completed in March 2007 did not highlight the problems identified during this visit. Questionnaires are sent out to people who live in the home and their relatives to gain their views on the home and the care that they receive. There was discussion with the manager about ensuring that an action plan is put into place following the results of the questionnaires to ensure that short falls are addressed and also that people who have completed the survey are informed of the outcome. The results of the previous survey were seen and there were some possitive and negative comments made. It is an expectation that all staff receive bi monthly supervisory meetings with a senior member of staff where they could discuss, amongst other things, training issues and the aims and objectives of the home. Documentation examined confirmed that these were taking place. Training records examined confirmed that staff had received training in moving and handling, fire and health and safety. It was advised that all other training undertaken by staff should also be recorded so the manager can identify training that needs to be updated and plan for this. People are able to keep small amounts of personal monies within the homes safe. This enables them to be able to purchase small items such as sweets, newspapers and pay for hairdressing. Prior to the visit the manager confirmed to the commission that maintenance of essential services to the home for maintaining the health and safety of the people living in the home and staff such as, fire safety, environmental health, lifts and hoists, checks on gas, electricity and water, were all up to date. The Beeches DS0000060847.V333425.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X 3 2 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 3 The Beeches DS0000060847.V333425.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 OP7 Regulation 15(1)(2) Requirement Comprehensive care plans need to be developed, setting out how people’s needs in respect of health & welfare will be met. All care plans must be reviewed to ensure they detail current needs and choices. Previous requirements made regarding care plans with a timescale for action of 28th February 2007, were not fully met. 2 OP9 13(2) The registered provider shall 31/05/07 make arrangements for the safe recording and handling of medications. Stock balances of medication must tally with records held within the home All medication administered must be signed for. Timescale for action 31/07/07 The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 25 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 OP12 Good Practice Recommendations People should be consulted about the range of activites and suitable social activities should be arranged on a daily basis and people made aware of what activities are on that day to enable them to have a choice in joining in. Redecoration of the corridors and bedroom doors should be undertaken. The toiletries in the bathroom should be locked away or kept in people’s own rooms. Bedroom furniture should be renewed The manager should monitor and review the staffing within the home in order to make sure that peoples needs are met promptly. This should include staff availability at night to meet with peoples choice of social and leisure needs. The application form should be adapted to ensure the applicants full career history can be checked. People should be made aware of the outcome of surveys and action plans put into place to address any shortfalls. Audits should be reviewed to ensure they reflect the findings accurately. Staff meetings should include issues which staff wish to discuss. 2. 3. 4. 5. OP19 OP21 OP24 OP27 6. 7. OP29 OP33 The Beeches DS0000060847.V333425.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 DS0000060847.V333425.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!