Inspection on 29/03/05 for The Beeches

Care Home For Older PeopleThe Beeches59 Ferrybridge Road Castleford West Yorks WF10 4JWAnnounced Inspection29th March 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment The Beeches Address 59 Ferrybridge Road, Castleford, West Yorks, WF10 4JW Email address Name of registered provider(s)/company (if applicable) Care Care Care Ltd Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 23 Tel No: 01977 517685 Fax No:Category(ies) of registration, with (number of places) Mental Disorder, excluding learning disability or dementia - over 65 years of age (23), Old age, not falling within any other category (23), Physical disability over 65 years of age (23) Registration number J510002114 Date first registered Date of latest registration certificate 27th September 2004 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 27th September 2004 YES NO N/A If Yes refer to Part CThe BeechesPage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector Name of inspector Name of specialist (e.g. Interpreter/Signer) (if applicable) 1 2 3 429th March 2005 08.30 am John Gregory -ID Code101299Name of establishment representative at the time of inspectionAllison Green deputy manager Anabella McClumpha (Acting manager) Shaun Ramsey (owner)The BeechesPage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementThe BeechesPage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of The Beeches. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.The BeechesPage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The Beeches is a care home providing accommodation and personal care for up to 23 Older persons who may have additional physical disabilities or enduring mental health problems. The enterprise is privately owned through a limited company. The accommodation is on two floors that has a passenger lift between the floors. Not all the rooms are single and few have en-suite facilities. It 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 BeechesPage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The inspection was announced and took place over the course of one day in March 2005. The inspection found that attention was needed to meet the National minimum standards in most areas of the homes operation. This work is achievable with the concerted effort of the management team. Several of the service users and their relatives were interviewed as part of the inspection process. They all expressed satisfaction at some aspects of the care on offer but were concerned in other areas that are outlined in the report. Choice of Home (Standards 1-6) Four of these 6 standards were assessed. Two standards were met in part. Two standards were not met. The service provider should carefully consider the category of service user whose needs he is best placed to meet. Assessments of service users must improve and the outcome confirmed for them in writing. Health and Personal Care (Standards 7-11) Four of these 5 standards were assessed. One standard was met in full. Two standards were met in part. One standard was not met. The service provider has good contacts with medical services. The care planning system must improve and involve service users and their carers. The detail of the administration of medication must improve. Daily Life and Social Activities (Standards 12-15) Two of these 4 standards were assessed. One standard was met in full. One standard was met in part. The homes visiting arrangements are good. The choices of food available for service users at mealtimes should be improved. Complaints and Protection (Standards 16-18) Two of these 3 standards were assessed. Neither standard was met. The service provider must improve the process of complaints resolution. The detail of process and the training of staff in issues concerned with the protection of vulnerable adults must improve. Environment (Standards 19-26) Six of these 8 standards were assessed. Three standards were met in full. Three standards were met in part. The accommodation is well maintained. The service provider should consider whether the accommodation is appropriate for persons with physical disability.The BeechesPage 6 Staffing (Standards 27-30) All of these 4 standards were assessed. One standard was met in full. Two standards were met in part. One standard was not met. The home is staffed at a level agreed by the previous regulator. The level of staff qualification should improve. The recruitment process must improve. Management and Administration (Standards 31-38) Five of these 8 standards were assessed. One standard was met. Three standards were met in part. One standard was not met. The manager should apply for registration. Attention needs paying to update the policies procedures and records. Matters concerned with health and safety and fire safety should be improved. The inspector would like to thank the managers, staff, service users and their relatives for their time cooperation and hospitality during the course of this inspection.The BeechesPage 7 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)The BeechesPage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action The service provider must not provide accommodation to a service user at the care home unless, so far as it is reasonably practical to do so the needs of the person have been assessed by a suitably qualified person. OP4OP3 And the service provider has confirmed in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users needs in respect of his health and welfare. The service provider shall produce an action plan of how the homes registration categories are to be reconciled with a relevant service user group. This action plan must be submitted to the CSCI for consideration by 15/05/05. The service provider must after consultation with the service user or their representative prepare a written plan as to how the service users needs in respect of health and welfare are to be met. -make the plan available to the service user -after consultation with the service user of their representative revise the service users plan The Beeches Page 9114 (1) a,d15/05/05215 (1) (2)OP701/05/04 The service provider must redraft the medication policy to meet all the areas covered in the Royal Pharmaceutical Society guidance for care homes. 3 13(2) OP9 The service provider must return all unused medicines to the pharmacy at the end of the MAR period. The medication records must be maintained accurately. The service provider must ensure that any complaint made under the complaints procedure is fully investigated. Inform the complainant within 28 days of any action that is to be taken The service provider must redraft the complaints procedure to reflect the legal requirement, and should meet national minimum standards, and must appropriately let service users know of the revision Individual risk assessments, confirmed through care reviewing process must occur, and be reviewed, in relation to: · 5 13 OP18 · the use of the restraining devices on stairs locking devices on service users doors which restrict service user choiceImmediate and ongoing422 (3) (4)OP1601/05/051.6.05Any restrictions must be detailed in the statement of purpose of the home. The service provider must obtain the following information in respect of all persons working in the care home. 6 19 Schedule 2 OP29 Proof of identity including a recent photograph Two written references An enhanced criminal conviction check 01/05/05The BeechesPage 10 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 OP2 All service users should be issued with an up to date statement of terms and conditions. · 2 OP7 · · · · · · 4 OP15 · 5 OP16 The service provider should ensure that all care plans are uniquely designed for each service user. The care plans should be reviewed monthly by the care staff. The service users or their representative should be actively involved in the care planning process. The service provider should systematically record the service users health care. The service provider should actively address, and record, the service users needs for specific incontinence equipment. The service provider should undertake a nutritional assessment on all service users The service provider should ensure that the Menu reflects the food on offer. The service provider should offer a choice of main meal and tea.3OP8All staff should receive training in the principles and detail of the complaints procedure.The BeechesPage 11 ·The service provider should redraft the procedure for the protection of vulnerable adults with reference to `No secrets and the local joint agency procedure. The service provider should redraft the procedure for whistle blowing in the light of the legislative base and good practice guidance The service provider should undertake risk assessments on the use of bed sides in the light of the homes own restraint policy The service provider should ensure that all staff receive training in Whistleblowing. The service provider should ensure that all staff receive training in the management of aggression.·6OP18· · ·7 8OP25 OP28The service provider should review the heating in all areas used by service users and ensure it is adjusted to meet individual preferences, and risk assessments should inform the use of window restrictors. 50 of staff should acheive the NVQ level 2 qualification in 2005. · The service provider should ensure that the manager completes an application form for registration. The managers hours should be made supernumery to the care rota and lodge the application to register9OP31·10OP36The service provider should ensure that all staff receive supervision at least six times per year. · · · The service provider should undertake a fire risk assessment for the whole building The service provider should undertake a work place risk assessment. The service provider should undertake tests of the emergency lighting weekly.11OP38* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.The BeechesPage 12 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) NO YES YES YES YES YES NO NO YES NO YES NO YES YES NO YES NO YES NO YES 4 2 0 NO NO YES YES 15 6 29/03/05 08.30 7.5The BeechesPage 13 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.The BeechesPage 14 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 320 To (£) 340Any charges for extrasYESHAIRDRESSING If yes, please state what the extras are: 2 Key findings/Evidence Standard met? The new service provider has redrafted the statement of purpose and service users guide which contains the broad areas recommended in the national minimum standards. However the detail needs development in terms of the service user group(s) to whom the service provider intends to offer care. This issue is developed in standard 4 and is the subject of a recommendation. The information should also give details of the limits placed on service user choice. This matter is further discussed in standard 18 and is subject of recommendation.The BeechesPage 15 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 2 Key findings/Evidence Standard met? All the service users files contained a contract issued by the sponsoring authority and some of the files contained a copy of the service providers statement of purpose. However not all the service users have been issued with a statement of terms and conditions and a recommendation is made in this matter. Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 1 Key findings/Evidence Standard met? All of the case files examined contained details of an assessment being completed on the service users. On two of these cases the assessments took place on the day of admission. On none of the case files was there evidence of the service users of their relatives receiving information in writing that the service provider was able to meet their needs. Requirements are made in these matters. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 1 Key findings/Evidence Standard met? The service provider is registered to admit three categories of service user. Older persons, older persons with mental health disorders, and older persons with a physical disability. In terms of staff training and background and established networks in the community the service provider is not able to demonstrate the ability to meet the needs of those older people with mental health disorders. The accommodation in terms of its personal bedroom space does not have the ability to meet current standards for those with a physical disability. Further the service provider is admitting individuals with a primary need of dementia which the registration does not allow. It is required that the service provider produce and action plan which identifies either which service user group it is intended that the home meet, or clarifies how the services currently provided are going to be extended to meet the needs of those service users whose needs the home is registered to meet. And submit this for consideration by the CSCI. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? The standard was not assessed on this inspection.The BeechesPage 16 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Intermediate care is not provided at the home.Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 1 Key findings/Evidence Standard met? The case files of five service users were examined. It was found that the care planning system was based on a proforma system that did not fully address the exact needs of individual service users. A recommendation is made in this matter. The care plans were not consistently reviewed every month by care staff as recommended in the national minimum standards, a recommendation is made in this matter. There was no evidence on the files that service users nor their carers were involved in the care planning process nor the review process, carers interviewed identified that they were not involved in the process. A requirement is made in this matter.The BeechesPage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) X 12 Key findings/Evidence Standard met? There was evidence at various places in the service users files of the service users involvement with the primary health care team and specialist consultation. This information would be clearer if it were included in one place in the file. A good practice recommendation is made in this matter. Service users who develop pressure sores are able to be subject of specialist intervention. Some service users were concerned over the quality of incontinence aids available for their care through the incontinence service. It is recommended that the service users actively address their service users needs for relevant incontinence equipment. Service users were not the subject of nutritional assessment and a recommendation is made in this matter. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? The policy and procedure on the administration of medication used by the service provider is perfunctory and does not contain all the detail recommended by the Royal pharmaceutical Society guidance for care homes. A recommendation is made that the documentation be updated to meet that standard. The medication, including controlled medication, is well stored in secure cabinets kept in the treatment room. The administration of medication is based on the blister pack system. The medication records were sample audited and the medication held in the blister pack system was seen to be accurate. The medication dispensed from bottles and boxes exceed the amounts recorded on the MAR sheets. It is recommended that all the unused medication is returned to the pharmacy at the end of the prescribing period.The BeechesPage 18 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Service users were seen to be well dressed and groomed, and in their own clothing. Service users and carers were able to confirm that service users use their own rooms for private purposes. All double rooms containing screens. Personal care is undertaken in private. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? The standard was not assessed on this inspection.Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? The standard was not assessed on this inspection. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? Service users and carers confirmed that visiting is encouraged at any reasonable time and facilities are available for meetings in private. The Beeches Page 19 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? The standard was not assessed on this inspection. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 2 Key findings/Evidence Standard met? The service providers menu was examined and was seen to identify a choice of main dish on the main meal of the day. However, this choice was not confirmed either in the record of food served or on interview with service users. A recommendation is made that a choice of main meal be made available for service users. Although the tea time meal identified a choice of light meal in the evening service users spoken with said they were tired of receiving sandwiches at this meal. A recommendation is made that additional choices are made available at this meal. The service users confirmed that they had choice where the meal was served, in the dining room, in their rooms or in the lounges.The BeechesPage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 2 X X X X 1 100 1 Key findings/Evidence Standard met? The service provider complaints procedure did not contain details of the 28 days time scale for the response to a complainant and was not accurate in terms of all the stages open to complainants should they not be satisfied with the homes response. A recommendation is made that the complaints procedure be redrafted. Two written complaints were seen in the home. In neither case was there evidence of an investigation having taken place. There was no information as to whether either of the complaints was substantiated. Neither was there information on remedial action or of access to other forms of redress. A requirement is made that the service provider meets the letter and spirit of the legislation in this matter. Staffs interviewed were not clear of the processes involved in the complaints procedure and a recommendation is made that they receive training in this matter.The BeechesPage 21 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? The standard was not assessed on this inspection. Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists NO 01 Key findings/Evidence Standard met? The service providers policy on the protection of abuse to adults was outdated and does not contain the necessary links to the local joint agency procedure. It is recommended that the procedure is redrafted in line with the DOH guidance `no Secrets and in conjunction with the local joint agency procedure. The whistle blowing procedure did not contain the legal base of the process and did not provide the necessary links to the registered provider. A recommendation is made that the procedure is redrafted using the legislative base and good practice guidance. The policy on the use of restraint was good. However it was noted that the risk assessments for the use of bed sides did not follow the guidance of the document and existed only in the form of a document signed by relatives giving `carte blanche to nursing staff. A recommendation is made in this matter. It was further noted that the homes staircase had indiscriminate restraining devices at the top and bottom. The purpose of these was not seen on any service users file or in the homes statement of purpose as restrictions on choice for service users. A requirement is made that the use of these devices be reviewed and either removed or justified by individual risk assessment confirmed through care reviewing processes. Similarly the current method of providing locks to service users doors that only operates as a lock from the outside and which service users do not have a choice to lock from the inside be reviewed on the basis of individual risk assessment and confirmed through care reviewing processes. On interview staff were unclear on how procedures for the protection of vulnerable adults and whistle blowing would work. A recommendation for their training is made in this matter. On interview some staff were concerned about the necessity to deal with aggression in the home. A recommendation is made that training is provided in this area. The CSCI is concerned at the lack of structure, training of staff and unjustified use of restraint in this area of the protection of vulnerable adults.The BeechesPage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The accommodation is a large adapted property on a main road close to the centre of Castleford. It is well maintained light and airy and furnished and decorated in a domestic fashion. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? The accommodation was not re measured on this inspection. Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? The standard was not assessed on this inspection.The BeechesPage 23 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? The accommodation was equipped with a variety of fixed and portable aids to meet the needs of the service users groupThe BeechesPage 24 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 17 2 4 0 17 00 8 4 02 Key findings/Evidence Standard met? The accommodation meets the standard of the previous local authority regulator. The service providers registration provides for the admission of older persons with physical disability. The rooms are generally not of a size that could accommodate an individual of other than minor disability levels. Rooms were seen to be overcrowded with mobility aids and commodes that restrict the options on internal mobility for service users. At least one service user was concerned over the restriction imposed by this issue. The matter is addressed in standard 4 and the subject of a requirement.The BeechesPage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 2 Key findings/Evidence Standard met? See standard 23 Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 2 Key findings/Evidence Standard met? The accommodation was well lit through a central heating system based on covered radiators. Almost all the service users complained about the heat in the home on the day of the inspection and their inability to open windows sufficiently to increase the ventilation. It is recommended that the central heating in service users rooms is assessed and adjusted to meet the service users preference and that the window restrictors are risk assessed against individuals needs.. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The accommodation was clean tidy and free of any offensive odours. The laundry is in two separate rooms in the cellar one containing washers the other containing drying equipment both forms of equipment being of a commercial nature. Both rooms have walls and floors of an impervious nature.The BeechesPage 26 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 392 X X 1686 15 63 Key findings/Evidence Standard met? The current staffing level provides for a trained nurse to be on duty on all shifts. There are four care staff on duty on the morning shift. Two care staff on the afternoon shirt and one care staff on the night shift. The home has recently been through problems of staff retention and recruitment which has lead to the manager being fully involved in the rota. The deputy manager acts as the homes administrator. The owner and managers feel that the worst of the staffing issues may now be over. The matter will be closely examined at the next inspection.The BeechesPage 27 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 5 35 2 Key findings/Evidence Standard met? It is recommended that 50 of care staff achieve the NVQ level 2 qualification by 2005 Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 1 Key findings/Evidence Standard met? The staffing files of six staff were examined in detail. It was identified in the cases of three staff that the CRB check post dated the starting date by several months. There was no evidence that the staff had been permanently supervised in that period. In the case of the most recent appointment the staff had started work without the service provider having evidence of identity, two references or a CRB check and action that is unsafe. Requirements are made in these matters. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 Key findings/Evidence Standard met? Recommendations are made in standards 4 and 18 for training to be related to the purpose of the home and in the protection of vulnerable adults to supplement the basically health and safety training that the current staff undertake.The BeechesPage 28 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 1 Key findings/Evidence Standard met? The current manager of the home has been in post for some three months. She is a trained nurse with a background in both care home management and hospital based nursing. Currently due to staff shortages most of her time is spent on clinical work. In the light of the number of recommendations made concerning the infrastructure of the care in the home a recommendation is made that she be made supernumerary to the rota. The manager said that she has had the application to become manager for some three weeks without it being returned. The service provider should ensure that the manager completes the registration document and returns it as soon as possible to the CSCI, and applies for the required CRB through CSCI.. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? The standard was not assessed on this inspection. Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? The standard was not assessed on this inspection. The Beeches Page 29 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? The standard was not assessed on this inspection. Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X3 Key findings/Evidence Standard met? The accounts of service users personal allowance were sample audited and found to be accurate. Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 2 Key findings/Evidence Standard met? The staff spoken with confirmed that they were subject to regular appraisal. There was evidence of structured written supervision having been provided some time ago. Staff were able to confirm the record that they do not receive structured written supervision at least six times per year. A recommendation is made in this matter. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? The records were only sampled on this inspection recommendations are made on issues in previous standards in the report.The BeechesPage 30 Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? The Records on fire safety were examined and it is recommended that a work place risk assessment on fire safety be undertaken. Tests of the emergency lighting system should take place weekly and a recommendation is made in this matter. The health and safety records were examined and it is recommended that the service provider undertake a work place risk assessment. COSSH records were in order.The BeechesPage 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorJohn GregorySignature Signature SignatureRegulation Manager Ruth Rainey Date 20 June 2005Public reports It should be noted that all CSCI inspection reports are public documents. The Beeches Page 32 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 29 March 2005 of The Beeches and any factual inaccuracies: Please limit your comments to one side of A4 if possibleThe BeechesPage 33 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Status of the Providers Action Plan at time of publication of the final inspection report:Action plan was requiredYESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther:The BeechesPage 34 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of The Beeches confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of The Beeches am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.The BeechesPage 35 The Beeches / 29th March 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000060847.V207965.R01© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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!