Inspection on 28/05/08 for The Beeches

This inspection was carried out on 28th May 2008.

CSCI found this care home to be providing an Good service.

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 03/08/09

The Beeches 29/05/07

The Beeches 31/05/06

The Beeches 05/12/05

The Beeches 12/07/05

The Beeches 25/10/04

The Beeches 22/07/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE The Beeches Green Lane Newtown Stockton-on-Tees TS19 0DW Lead Inspector Michaela Griffin Key Unannounced Inspection 28th May 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Beeches DS0000000053.V364849.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 DS0000000053.V364849.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Address Green Lane Newtown Stockton-on-Tees TS19 0DW 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) 01642 618818 F/P 01642 618818 T L Care Ltd Mrs Valerie Smith Care Home 64 Category(ies) of Dementia - over 65 years of age (32), Old age, registration, with number not falling within any other category (32) of places The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate one named individual who is under the age category of 65 years. 29th May 2007 Date of last inspection Brief Description of the Service: The Beeches is a two storey 64 bedded purpose built care home providing personal care for older people and for individuals suffering from dementia within two specific units. Personal Care for older people is provided on the ground floor whilst care for people suffering from dementia is provided on the first floor. There is a patio and garden area available for use. The home has been operating since January 2002. It is situated within an urban setting with close access to the town centre and public transport. The vast majority of the bedrooms are single rooms all with ensuite facilities. There are two double rooms available within the home also with ensuite facilities. On the date of this inspection the standard fee for personal care at The Beeches was £408 per week. The fee for care on the unit for people who suffer from dementia was £428 per week. The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced Key Inspection as such all of the key standards relating to older people were looked at. This was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use the services, and that it does what the Care Standards regulations say it must. The visit to the home was conducted in one inspection day. During the visit to the home, a number of records were looked at, including records of people who use the service, along with medication records, staff records, training records and maintenance information. Time was spent talking to people who use the service, relatives and staff. A number of surveys had also been completed and returned from people who live at the home, relatives and staff. Time was also spent walking around the home, observing interactions and generally finding out what The Beeches was like for people living there and staff. Discussion also took place with the manager. The Annual Quality Assurance Assessment (AQAA), the services selfassessment of how well they think they are meeting standards. This was received prior to the inspection and some of information has been reflected within the report to support the judgements made. What the service does well: People who live at The Beeches have a warm, homely and comfortable place to live. It is a very relaxed home in which there is choice and flexibility of life. People who were spoken to said their needs were being met at The Beeches. People who live there said, “They are very kind, very patient, which is good”. “I am definitely treated with respect, you are asked if you want a bath and they look after me well. They take me to get my hair done and there is nothing else I would wish for”. Another person said, “Staff are very nice, they are very polite and respectful, I can go to the staff, they are very obliging”. A relative survey stated, “Delighted with the service provided. I cannot praise The Beeches enough and will recommend it to others”. Another survey stated The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 6 in the area of what the service does well, “People look well cared for, neat and tidy, lots of things going on. Garden is fantastic”. Staff said, “This is a well run home, the staff work really well together, they are excellent as a team”. “This is a good home that runs smoothly, it has a good manager who bends over backward to accommodate”. “I really enjoy coming to work, the home is a better place now than it has been”. 66 of staff are trained to NVQ Level 2 and 30 are trained to NVQ level 3. What has improved since the last inspection? 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 DS0000000053.V364849.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 DS0000000053.V364849.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 3 and 6 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People have their needs assessed before being admitted to the home and they were assured those needs would be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: It was confirmed through discussion with the manager that pre admission assessments are carried out prior to anyone being admitted to The Beeches. Three sets of records of people living at the home were looked at, one recent admission, one of a person who had lived at the home for six months and one of a person who had lived at the home for more than twelve months. Each file contained a pre admission assessment and also information from the care manager/social worker. The Beeches does not provide intermediate care. The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 9 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): Standards: 7, 8, 9 and 10 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People, who could say, are happy with the way in which care is delivered by staff. Care records are generally good; some additional development will enhance these further. The system for managing medication is good and only staff who have received the appropriate training have any involvement with medication. The procedures however do not give the required guidance. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The same three files were looked at in more detail to see how comprehensive the individual needs assessments were completed and whether the relevant risk assessments and plans of care had been developed. It was good to see that progress had been made in the level of detail and that they were now more person centred. It was agreed with the manager that some further work was needed, which would make the records even better. A range of risk assessments are being used, these included for example, moving and handling, nutrition and risk of falls. Care is needed in completion The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 10 of risk assessments to ensure that they are fully completed and the information is then cross-referenced, for example weight and skin integrity. There is the need to ensure that where needs have been identified that require support from staff that care plans are developed and then these are evaluated on a monthly basis to show the effectiveness of the care interventions. The evaluations need to be evidenced based and need to contain more information than “no change”. Care plans that had been developed were well written and clearly individualised. Discussion with the manager also identified that the full assessment of need does not need to be evaluated on a monthly basis, that this should happen at a frequency determined by the home or when there are changes to peoples needs. It is also evident from looking at the records that there is a system in place to audit the care plans and to address any shortfalls. There was evidence that accidents and incidents are being recorded. There are clear records that detail the involvement of other people such as GP’s, District Nurses, Optician and Continence Advisors. Relatives also confirmed that they were kept informed of changing health care needs of their loved ones. People who were spoken to said their needs were being met at The Beeches. People who live there said, “They are very kind, very patient, which is good”. “I am definitely treated with respect, you are asked if you want a bath and they look after me well. They take me to get my hair done and there is nothing else I would wish for”. Another person said, “Staff are very nice, they are very polite and respectful, I can go to the staff, they are very obliging”. A relative said, “They really care for my relative, they are always clean, healthy, happy and have put weight back on”. “He/she is happy, well looked after and receives constant attention”. A member of staff said of what was they considered the home did well, “The care is delivered to a high standard”. “I think that the residents seem happy, you know the residents, they residents know you and there is a fun side to it as well” The medication system was discussed with one supervisor and one team leader. There was a very clear ordering procedure and a good range of checks in place to determine that what had been ordered and received was correct. Storage was appropriate and temperature of the medication rooms was being monitored, as was the fridge temperature. It was confirmed that only staff of a certain grade and who have received formal training are involved in the administration of medication and there is also ongoing competency assessments in place. The medication records were well written and well completed with no gaps noted. Care is needed however with short courses such as antibiotics as in one person’s medication looked at, the records indicated that they had received 19 tablets however they had actually only received 17. Items that are kept in the fridge need to be dated when opened The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 11 and an up to date British National Formulary is needed. The policy and procedures for all aspects of medication management within the home needs to be reviewed. They are currently generic, as such do not reflect the way in which medication is managed and administered in The Beeches and do not give staff the guidance and information needed to fully ensure safe practise. The home manager has some additional information at present to support the policies and procedures. The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 12 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): Standards: 12, 13, 14 and 15 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People are encouraged to live their lives as they wish activities are organised that people can choose to join in with. People enjoy visits from families and friends. People are happy with the meals provided. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People who live at the home, relatives and staff said that there was a dedicated person who involved them in a number of activities. These included, film shows, quiz time, beauty time and music. One relative said, “The activity person involves them in games and my relative absolutely loves him, he is really good. Do think they could do with more hours for activities for more stimulation”. Another person said, “They are always having singsongs, there is usually something to do even sitting and chatting”. Notice boards are available on both units and these display information about social events and activities. Staff also confirmed that people spiritual needs are met, currently they have visiting clergy who conduct Holy Communion and there are also church visitors. The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 13 Good links have been made with the local community centre and some of the people who live at the home attend classes there, including computer classes and gardening classes. Links had also been made with a local youth group and people who live at the home have been on outings with them. A number of visitors were seen on the day of inspection. One person said, “The family visit every day and we take him/her out”. Another person said, “I visit every week, the staff are always about, they are very friendly and always greet you, they are nice and they are all approachable”. Another relative said, “I visit at different times, day and night, the right attitude and respect is always shown both to my relative and also to the extended family”. “It provides a flexible life for the residents”. A relatives survey contained the following information, “There is a real warmth and personal touch in the care given, including the way they make visitors feel”. Staff said, “This is their home, they have choice, there are certain routines for certain people, their lives are very much dependant upon them as individuals”. The menu was made available, which was a four-week rotational menu, there was a main meal and a cooked alternative. The teatime meals seemed quite repetitive, for example every Mondays - fish fingers, waffles and beans and sandwiches. People spoken to were very satisfied with the meals provided at The Beeches. They said, “They give me what I want, if the menu isn’t to my liking they will make me something else”. One gentleman said, “The meals and excellent”. A number of relatives spoke of the improvements to their relative’s health since moving into The Beeches and were glad to see that they had put weight on. Staff said, “The meals are excellent, they have a choice, you go round with the menu and they can have other things as well like an omelette”. It was suggested to the manager that they could ask for advise from the dietician about the menu and nutritional content. One of the dining rooms was visited during the inspection; the table were well presented with tablecloths, placemats, napkins, condiments and flowers. The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 14 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): Standards: 16 and 18 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People are confident their complaints would be listened to, taken seriously and acted upon. People are protected from abuse by the home’s policies and procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The AQAA states, “Any complaint is dealt with immediately and investigation is carried out when needed”. The complaints records were looked at during the inspection and it was clear that complaints are being recorded and investigated, outcomes were being recorded. People said, “If I had any concerns I would speak to the staff”. A survey completed by someone living at the home stated if they were unhappy, “Staff will help, they are good, Val is lovely and cares about us all”. Another said, “Just mention ‘IT’ to the boss”. One survey completed by a relative stated when asked in the service has responded appropriately to concerns raised, “Yes, we were very impressed on the odd occasion we mentioned a point of concern, action was taken immediately to put matters right”. Staff know what to do in the event that there is a complaint and they have also received training on safeguarding. The training matrix showed that staff had The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 15 received training in respect of safeguarding and staff also confirmed this when spoken to during the inspection. The Beeches DS0000000053.V364849.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20 and 26 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People who use the service live in a safe and reasonably well-maintained environment that is clean and homely. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Beeches is a purpose built care home, all rooms are single with ensuite facilities. People who live at the home enjoy living in a clean and spacious home, which generally offers a very pleasing environment for people to live. Some improvements are needed in terms of décor and carpets. These had been identified by the manager who has arranged for work to commence in some areas, such as the corridors. Carpets in a number of areas need to be replaced; these included the entrance foyer, the ground floor and first floor dining rooms. Redecoration was needed to a number of areas including the woodwork. There was an unpleasant underlying odour in one of the upstairs lounges. There is a smoking lounge for people who live at the home to use; The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 17 the ventilation to this is currently being looked at with a view to making it more effective. The carpet had a number of cigarette burns on it and a number of chairs needed to be repaired or replaced as they were ripped. Some of the hard flooring needs additional cleaning, due to mildew build-up. It was recommended that the temperature to the large ground floor lounge be monitored, as it was very hot on the day of inspection. People are encouraged to bring their own belongings with them to the home and there was evidence of personalisation of a number of the bedrooms visited. Since the last inspection, the garden had been landscaped. There was new garden furniture along with a gazebo, raised flowerbeds, a herb garden and a water fountain. This provided a very pleasant and accessible area for people to use. New large flat screen TV’s had also been purchased and were in the two large lounges. Further consideration needs to be given to increasing the level of confidentiality around the “nurses station” on the ground floor unit and to ensure that data protection is complied with. Currently it is possible to overhear telephone conversations to GP’s, district nurses and relatives about people who live at the home. The Beeches DS0000000053.V364849.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 27, 28, 29 and 30 were looked at during this inspection. People who use the service experience good quality outcomes in this area. People’s needs were met by the numbers and skill mix of staff who are trained and competent to care for the people who live at the home. People are protected by the home’s recruitment procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Three sets of staff files were looked at, one for a recently employed member of staff, one who had been in post for just over twelve months and one longer serving staff member. All contained the required information such as references, Criminal Records Bureau checks and proof of identity. Discussion with staff also confirmed that good procedures were in place for recruitment and that the necessary checks are undertaken. Staff said they thought there were sufficient numbers of staff on duty to meet the needs of the people who live at The Beeches; the people and their relatives also confirmed this. One person who lives at the home said, “ they are very willing to help, they have time”. One member of staff said, “I believe as a team we have sufficient staff at the moment and the knowledge and skills to met the people’s needs”. “It is working much better now that we have two unit managers”. The manager keeps a training matrix, which details all of the mandatory training for staff and clearly identifies how up to date everyone is with this The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 19 training. A training file was also made available. There is clear evidence of ongoing training for staff. Staff who were spoken to said, “The training rolls over all the time”. Staff also confirmed that they had received training in dementia care. 66 of staff are qualified to NVQ Level 2 in Care and 30 are qualified to NVQ Level 3. The induction that is currently in use in an in-house induction and not the Skills for Care Induction. There was some confusion with this, as the home has an in-house person who delivers some of the training and there is the need for clarity in terms of responsibility for delivering the required nationally recognised induction. One person said, “The girls are marvellous, can’t grumble at all and wouldn’t want to be anywhere else”. The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 20 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): Standards: 31, 33, 35 and 38 were looked at during this inspection. People who use the service experience good quality outcomes in this area. The home was well managed and run in the best interests of the people who use the service. People’s personal monies were safeguarded by the home’s procedures. The health, safety and welfare of people who live at the home and staff are generally promoted and protected, however the policies and procedure need to be reviewed to promote this further. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home continues to be managed by a person who has the experience, knowledge and skill to do so and who is registered with CSCI. The manager had completed the AQAA, which contained a good level of detail. People thought the home was well run and that the manager was approachable. One person who lives at the home said, “The top lady Val is The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 21 lovely I can go to her and she always has a smile for everyone, I couldn’t have got a better place”. A relative survey stated, “Delighted with the service provided. I cannot praise The Beeches enough and will recommend it to others”. Another survey stated in the area of what the service does well, “People look well cared for, neat and tidy, lots of things going on. Garden is fantastic”. Staff said, “This is a well run home, the staff work really well together, they are excellent as a team”. “This is a good home that runs smoothly, it has a good manager who bends over backward to accommodate”. “I really enjoy coming to work, the home is a better place now than it has been”. The quality assurance systems were discussed with the manager. A range of audits were in place including; medication and care plans. Meetings take place within the home, including residents meetings. Relatives have completed surveys and although areas for improvement have been actioned, no actual summary report has been produced. The manager said that they were not entirely happy with the current systems and was looking to do this differently. Provider visits are not taking place as the required frequency although the manager does complete a monthly management report. A small sample of the personal allowances of people who use the service was looked at and the amounts balanced with the information that was recorded. The AQAA detailed that equipment such as fire system and gas are serviced and maintained on a regular basis. A small sample of servicing certificates was looked at, the file was readily available and equipment such as gas safety had been serviced and regular fire drills were taking place. As previously identified, there is a rolling programme of mandatory training for staff. Whilst water temperatures were being tested and recorded on a regular basis, this needs to also include the hot water from the showers. A sample of policies and procedures were looked at and there was discussion with the manager. It was identified that it was not easy to find specific procedures and perhaps would be more helpful if the employment policies were contained within a separate folder making the care related procedure easy to access. It was noted of the procedures looked at that they were generic and not reflective of the service. Additional information is needed to ensure that staff have the relevant information needed to implement the said procedures. The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 23 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 Timescale for action 01/08/08 2. OP19 23 3. OP30 18 The medication policy and procedures must be reflective of the systems in place within the home, which are relevant to the service to ensure that staff have the correct information and guidance for the safe handling of medication This will ensure that good systems are in place and people are protected. A small number of environmental 01/11/08 improvements must take place. This includes the replacement of a number of carpets including the first floor smoking room, the dining rooms and entrance foyer. There is also the need to improve the ventilation to the first floor smoking room. The underlying odour in one of the upstairs lounges must be addressed. This will enhance the environment for people to live in. All new staff must complete the 01/09/08 Skills for Care induction ensuring they have the minimum standard of competency to meet the needs of the residents. DS0000000053.V364849.R01.S.doc Version 5.2 The Beeches Page 24 4. OP33 37 5. OP38 13 6. OP38 13 Provider visits must take place on a monthly basis and a copy of the report available within the home. This will assist in ensuring satisfaction with the service as part of the quality assurance systems. The new policies and procedures must be amended so that they are reflective of the service and give the staff the information and must provide staff, residents and relatives with the information they need to ensure safety, wellbeing and protection. These must be easily accessible to staff. The hot water from the showers must also be tested and recorded to ensure that it meets the required temperature and safe for people to use. 31/07/08 01/09/08 01/06/08 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 OP9 Good Practice Recommendations Care is needed to ensure that medication is administered properly not signed for then not given. • An up to date BNF is needed. • Items kept in the fridge should be dated once opened. The progress that has been made in the individual care needs assessments and care plans should continue, as this will further enhance the care records and information needed for staff to continue to meet the needs of people living at the home. Care is needed with the completion of risk assessment and this information should be cross-referenced. Care plans and not the assessment of need should be The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 25 • 2. OP7 3. 4. 4. 5. OP15 OP19 OP33 OP37 evaluated on a monthly basis. It is recommended that the dietician be consulted about the menu in place to ensure that it is nutritionally balanced. The temperature of the large ground floor lounge should be monitored to ensure that it does not become too hot. The review of the quality assurance system should take place and a more effective system developed. Further consideration should be given to increasing the level of confidentiality around the nurses station on the ground floor to ensure compliance with data protection. This has previously been identified and action has been taken to address this on the first floor. The Beeches DS0000000053.V364849.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 DS0000000053.V364849.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. 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