Inspection on 04/01/07 for The Beeches

This inspection was carried out on 4th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Beeches 13/09/07

The Beeches 25/04/07

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Beeches 59 Ferrybridge Road Castleford West Yorks WF10 4JW Lead Inspector Gillian Walsh Key Unannounced Inspection 4th January 2007 10:00 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.V326354.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.V326354.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.V326354.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2006 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 enterprise 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 in January 2007 that fees at the home range from £359 to £492 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 both of which are available, on request, from the home. The Beeches DS0000060847.V326354.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this full inspection, one inspector from the Commission for Social Care inspection (CSCI) undertook an unannounced visit to the home. The visit started at 9.45am and finished at 7pm on 4 January 2007. The inspector’s time was spent speaking with residents and staff, reviewing documentation and taking a tour of the home. Alongside this, the service provider was asked to complete a pre-inspection questionnaire which was returned prior to the visit. Questionnaires were sent to residents, their relatives, visiting professionals and GPs. 10 residents’ questionnaires were sent out with 9 received back. One of these included comments which have been incorporated into the report; others did not contain comments but indicated overall satisfaction. Of the 9 relatives’ questionnaires sent out, 4 were returned. One person said that their relative is “very happy at the Beeches”. Two people said they were unaware of the home’s complaints procedure and one person felt there was not always enough staff on duty. Other than this, people appeared generally satisfied. Of the 4 General Practitioner questionnaires sent, 3 were returned; no comments were made but indicated satisfaction with the service. In writing this report, information and evidence was not only obtained by way of visiting the home but also from notifications and information obtained by CSCI and from the last CSCI inspection report. In gathering evidence, CSCI undertook an examination of all documents relating to four individuals’ care, reviewed documentation, sought feedback from residents and their families, staff, the home’s manager and other relevant stakeholders, and undertook relevant observations and discussions appropriate to needs of the residents, taking into account their needs and communication abilities. Due to potential risks to residents, immediate requirements were issued to the home during the inspection regarding the lack of window restraints on first floor windows and systems in relation to medications. The inspector would like to thank residents and their relatives and staff for their time and assistance during this inspection. The Beeches DS0000060847.V326354.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Several areas of development are needed to ensure that the home provides a comfortable, safe and pleasant environment where residents can enjoy their lives as much as possible. Improvements are needed in the following areas: • Assessments & care planning to comprehensively address health, welfare & leisure needs • Procedures in relation to medication • Updated complaints information made available as required • Maintaining residents’ confidentiality • Ensuring residents’ needs are met by appropriately deployed staff • Maintenance and issues about infection control • Provision of activities • Identified risks relating to windows, inappropriate storage in bathrooms & wedging open of fire doors in the basement to be addressed • Staff recruitment references & clearance to the required standard • Staff training regarding o Safe moving and handling of residents o Inter-agency safeguarding procedures The Beeches DS0000060847.V326354.R01.S.doc Version 5.2 Page 7 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.V326354.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.V326354.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. Standard 6 is not applicable as the home does not provide intermediate care. Quality in this outcome area is good. No resident is admitted to the home without having their needs assessed by a person qualified to do so. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three of the four care plan files seen included a pre admission assessment which had been completed by the manager prior to accepting the potential resident for placement at the home. One of the files seen was for a person who had previously lived a long way away which made it very difficult for staff from the home to do their own assessment. In this case, staff had gained information from the previous home and had obtained a copy of the social worker’s assessment. The Beeches DS0000060847.V326354.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is poor. Resident’s’ health, personal and social care needs are not all fully set out in individual plans of care and not all of residents’ healthcare needs are met. Procedures relating to medication are unsafe. Systems within the home do not always protect residents’ dignity and right to privacy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As part of this inspection visit, four care plan files were examined. All of the files included a number of assessments including tissue viability, pain assessment, nutritional assessment and moving and handling assessments. Whilst all of these assessments had been completed, several had not been The Beeches DS0000060847.V326354.R01.S.doc Version 5.2 Page 11 reviewed and did not reflect the residents’ current needs; this was of particular concern where individuals’ physical states had changed substantially. All of the moving and handling assessments seen had been photocopied which resulted in the document’s headings being badly reproduced and almost illegible. In addition, the document did not contain enough detail of the equipment needed to ensure staff used a safe technique. For example, where the assessments said that a hoist should be used, there was no information about which sling should be used which could result in residents being put at risk. Additionally, where the residents’ weight needed to be ascertained for pressure sore and nutritional assessments, this had not been done. One of the files seen contained a number of assessments which had not been reviewed to reflect significant changes in the resident’s condition and were, therefore, both inappropriate and inaccurate. All of the files seen contained some care plans although the majority of these were very scant in detail and did not cover all areas of daily living. An example of this was that in one resident’s file, only three care plans had been developed. These were for the risk of falling, the risk of pressure sores and effects of medication. Care plans had not been developed in relation to choices, abilities and needs in relation to areas such as personal hygiene, nutrition and spiritual, leisure and social needs. Another file contained a care plan which said that the resident was at risk of developing a particular condition and said that this needed to be reviewed on a weekly basis. Again, the care plan lacked detail and did not include actions that staff could take to help prevent the risk of this condition developing and documentation was not available to demonstrate that the weekly review had taken place. Concern was expressed to the manager about the lack of detail in assessments and care plans. This was particularly evident in the care plans for a resident whose needs had changed considerably but the care plan had not been reviewed to reflect any of these changes of needs and abilities. It was also of concern that information from a hospital regarding the aftercare of pressure areas needed for a person recently discharged had not been included in the care plan and no written evidence was available to show that this care was being delivered. When asked about this, the manager said that staff at the home did not like the preparation that the hospital staff had advised using and were using a different treatment. No evidence to substantiate that an alternative treatment was being given was available and no referral had been made to the district nurse. It was also of concern that documentation was not available to show that staff had considered pain management for this person. Discussion took place with the manager and deputy manager about the use of a “bath and bowel book”. This book is being used to record when all residents are bathed and when they have had their bowels opened. The manager was The Beeches DS0000060847.V326354.R01.S.doc Version 5.2 Page 12 informed that such private information should be recorded in individual care records and not held collectively in a book. Evidence was available within documentation that residents’ healthcare needs are generally referred to the appropriate healthcare professional such as GP or district nurse. On the day of the visit a district nurse was attending to the nursing needs of one resident and was observed to hand over information about her visit to the home’s own staff. Three responses to questionnaires sent out to GPs by the Commission were received back. All gave a positive response but did not contain any specific comments. Some care plans were in place with regard to pressure area care and pressurerelieving aids were in place. Concern was expressed to the manager that plastic draw sheets were being used over airwave pressure mattresses as this completely takes away any positive effect of the mattress. During the tour of the home it was noticed that net pants, used in conjunction with incontinence pads, were being used communally. This and the practice of recording residents’ private information in a “bath and bowel book” do not promote residents’ dignity and privacy. It was also of concern that, during the inspection visit, the home’s office was being used by the hairdresser to do residents’ hair. This resulted in the hairdresser and residents having their hair done in the room when private information about other residents was being discussed. This was observed to happen on two occasions. This was discussed with the manager and deputy manager who confirmed that this had occurred. During the inspection visit, medications for four residents were checked. Anomolies were identified with five of the medications checked. Four of the five stock balances for boxed medications did not tally with the records made for administration of the medication and medications for one resident could not be stock checked at all as no record had been made of the number of medications received into the home. One resident had said in a questionnaire that, when they are given their medication, one carer “breaks capsules so they are open when I take them”. The manager was informed of this but said that she had no knowledge of it happening. The Beeches DS0000060847.V326354.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 and 15. Quality in this outcome area is Poor. Residents’ preferred social, leisure and religious activities are not always recorded and little evidence is available to show that residents are helped to exercise choice and control over their lives. A programme of activities is not in place at the home. Meals appear to be nutritious and appetising and choice is available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s manager said that the home does not employ an activities organiser and that there is not an activities programme in place. On the day of the visit, no residents were observed to be taking part in any meaningful activities other than watching the television which, during the evening, did not have any sound on. One resident who was ill in bed at the time of the visit had a radio playing in their room but the music playing was very loud pop music. The manager said that she frequently had to remind staff about tuning into a more appropriate channel. The deputy manager said that residents had The Beeches DS0000060847.V326354.R01.S.doc Version 5.2 Page 14 thoroughly enjoyed the entertainment and parties that had been organised for them over the Christmas period. Preferred social and recreational activities are not included within care plans although, since the last inspection, an activities book has been started. Some files did not include details of the person’s religion or whether they wished to attend religious services. No evidence of involvement within the local community was seen during the inspection visit. Although one of the care plan files seen contained some information about the person’s choices and preferences with regard to their lifestyle, others did not. The home has an open visiting policy and friends and relatives can telephone to make enquiries about their relative. This was observed to happen during the inspection visit. One person said in a questionnaire that their relative is “very happy at the Beeches”. Residents spoken with said they enjoyed the meals at the home and that choice was available to them. Although the mealtime was not observed during this visit, the choices and quality of food for the midday and evening meals appeared nutritious and appetising. One resident said in a questionnaire “the meals are good”….. “staff know what I like and give me a choice”. The Beeches DS0000060847.V326354.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 and 18. Quality in this outcome area is Poor. Not all complaints recently made to the home have been acted upon appropriately. Proper procedures for protecting residents from abuse are not always being followed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four of the staff spoken with during the inspection visit were not fully aware of the home’s complaints procedure. The procedure is included in the Service User Guide but is not displayed anywhere within the home. The procedure states that the “patient, relative or authorised representative of the patient” may make a complaint. This does not include any person visiting or working at the home nor does it include current details of the Commission for Social Care Inspection. Two relatives who responded to the Commission’s questionnaires said that they were not aware of the home’s complaints procedure but one resident said that they could always speak to the manager if they had a complaint. The Commission has not received any complaints about this service since the last inspection. The Beeches DS0000060847.V326354.R01.S.doc Version 5.2 Page 16 Complaints recently made to the home have not always been dealt with appropriately as some contained allegations which should have been referred immediately under local procedures for the protection of vulnerable adults but had instead been dealt with by the manager within the home’s complaints procedures. Although the home has a copy of Wakefield’s’ Inter-agency Safeguarding Policies and procedures, it was established through discussion that some staff, including senior staff, were not fully aware of when or how to make referrals. The Beeches DS0000060847.V326354.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, 24 and 26. Quality in this outcome area is Poor. Whilst some redecoration has occurred, improvements need to be made to ensure that the building provides a safe environment and actions are needed to prevent the spread of infection within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the visit a tour of the home, including all communal areas and some residents’ bedrooms took place. All of the rooms seen were generally clean and tidy and a number of areas have been redecorated in recent months. The only bathroom in the home was inaccessible due to various equipment, including two hoists and a laundry trolley, being stored in the room. It was also noticed that windows to three upstairs rooms, which were easily accessible to The Beeches DS0000060847.V326354.R01.S.doc Version 5.2 Page 18 residents, did not have restraints fitted. This was identified to the manager as a potential danger to residents and a requirement was made that actions be taken within the next twenty-four hours to make this safe. The laundry area and a number of storerooms are situated in the cellar. Although the door to the cellar stairs was locked, all of the doors to the individual rooms in the cellar were propped open which was identified as a potential fire hazard. The laundry room was clean and tidy but the floor was very worn and in need of re-painting to provide an impermeable finish. Bedrooms were generally clean and tidy but a number of bed safety side bumpers were in a tatty state with the wipe clean covering being torn off exposing foam. Other bumpers were in need of cleaning. The pedestal of one of the toilets in an en-suite was badly cracked and in need of replacing. Discussion took place with the manager about the use of communal bars of soap being in some washbasins in communal areas. It was also noticed that the soap dispensers in these areas were situated high above the wash hand basin which would make it very difficult for a person using a wheelchair to use them. Although there did not appear to be a shortage of bed linen and towels, one bed had been made with a blanket which had been folded over to make two layers, and other bedding and towels were very tatty and frayed. The carpet in a bedroom identified to the manager was very badly stained and in need of replacement. The Beeches DS0000060847.V326354.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 and 30. Quality in this outcome area is Poor. Staff are not always available to meet the needs of residents. Some good staff training is available but residents could be placed at risk due to some staff not receiving moving and handling training. Staff commencing work before necessary checks have been obtained could place residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the visit, the home was fully occupied with nine residents receiving nursing care and 14 residents receiving residential care. The manager said that current staffing levels are one nurse with three or four care assistants on a morning shift, one nurse and two care assistants on an afternoon and evening, and one nurse and one care assistant during the night. Day staff are supported by cleaning and catering staff. Some of the staff spoken with said that they do not always feel that there are enough of them to properly meet the needs of the residents, particularly during the evening and at night, as several residents need the assistance of two staff to meet their personal care needs which means that, if the two night staff on duty are jointly caring for one resident, no other staff member is available to oversee the The Beeches DS0000060847.V326354.R01.S.doc Version 5.2 Page 20 needs of the other 22 residents. Additionally, one relative said in a questionnaire that they did not think there were always enough staff on duty. In the early evening of the visit, all three staff members on duty were observed to be sitting together in the dining room having a break. One resident was in the hallway complaining of discomfort due to their clothing being wet through and another resident in the lounge area was complaining of discomfort due to severe itching. The inspector had to alert staff to both of these residents. Discussion took place with the manager about how the staffing situation should be kept under review taking into account the changing needs of residents, staffing levels & the deployment of staff. The majority of residents spoken with were unable to comment about this but one person said in a questionnaire that, when they used the call bell, they sometimes had to “wait longer than ten minutes and I can’t ring again unless it is an emergency”. Another comment from a resident was “some carers do a very good job and others make me feel a bit of a nuisance to them”. Positively, the manager said that eight of the 15 care assistants have gained the NVQ level two award in care and another two care assistants were about to start studying for the award. The manager also confirmed that all new staff would undertake the common standards induction procedure as well as the home’s own induction procedure. During the visit, a sample of four staff files were examined. One of these files was for a member of care staff due to commence work on the night of the visit. The home had not received either a POVA (Protection of Vulnerable Adults) check or a CRB (Criminal Bureau Check) and had only obtained one reference in respect of this person. The deputy manager said that it was her understanding that as long as staff were supervised they could commence employment under supervision without these checks. It was explained that this was not the case and that, whilst CSCI could not say that this person could not commence work, the home would be in breach of regulation if they employed people without first obtaining these checks which are set to safeguard residents. All of the other files seen had the required documentation in place although some discussion took place about one reference where the referee had identified themselves as a former employer but there was no evidence to support this. Staff training records are in place and indicate that training is ongoing within the home although it was noted that some staff have not received training or updates in movement and handling. The Beeches DS0000060847.V326354.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 and 38. Quality in this outcome area is Poor. To fully comply with minimum standards, the home’s manager needs to enrol to do the registered managers award and put a structured programme in place for quality monitoring within the home. Evidence shows that residents’ financial interests are safeguarded but the health and safety of residents and staff are not fully protected by systems in the home. This judgement has been made using available evidence including a visit to this service. The Beeches DS0000060847.V326354.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home’s manager is a registered general nurse who has almost two years’ experience of managing a care home. Despite a recommendation made at the last inspection, the manager said she has not yet been able to access registration to do the Registered Managers award. Advice was given as to how she could do this. During the visit some staff expressed concern that the manager was not available to them when they needed her although was supportive of them when she was available. There was also concern amongst staff that the grievance procedure was not always followed correctly. The home manager said that some quality monitoring takes place in the home through residents’ meetings and use of residents’ questionnaires. This procedure has not yet been formalised to include the views of relatives, staff and other professionals visiting the home, with a report produced on an annual basis, which should be provided to residents. The deputy manager said that the home does not act as appointee for any residents but some people do choose to keep small amounts of money in the home’s safe. Documentation relating to a sample of these monies was checked and was found to correspond with the amounts of money held. 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 residents and staff such as fire safety, environmental health, lift and hoist checks and gas, electricity and water, are all up to date. Whilst all of these systems are in place, some of the issues identified in this report, such as lack of window restraints and problems associated with medications and staff training in movement and handling, mean that there is a potential risk to the health and safety of residents and staff in the home. The Beeches DS0000060847.V326354.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 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 1 X X X X 2 X 1 STAFFING Standard No Score 27 1 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 1 The Beeches DS0000060847.V326354.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 residents needs in respect of health & welfare will be met. All care plans must be reviewed to ensure they detail current needs and choices; and should include daily activities. Care Plans should be signed as agreed by the resident or their designated representative Previous requirements made regarding care plans with a timescale for action of 31 May 2006, were not fully met. Assessments of residents’ needs 28/02/07 must be accurate, kept under review and revised to reflect changes in circumstances. The registered person shall make 05/01/07 arrangements for the recording, handling, safe administration of medicines received into the care home. Previous requirements made regarding medications with a timescale for action of 7 The Beeches DS0000060847.V326354.R01.S.doc Version 5.2 Page 25 Timescale for action 28/02/07 2. OP8 14(2)(a)( b) 13(2) 3. OP9 OP38 4 OP10 12(4)(a) 5. OP10 12(1)(a) 7. OP12 16(2)(m)( n) 8. OP16 22(2)(5)( 7)(a) March 2006, were not fully met. The registered person must make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users. This should include: • Ensuring that information about residents is maintained in individual care records. • Ensuring that discussions about individual residents do not take place where they may be overheard. The registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. This should include: • Correct use of pressure relieving aids. • Ensuring that aftercare, as advised by medical staff, is given. The registered person must consult residents about: • Their social interests and make arrangements to enable them to engage in such activities. • The programme of activities arranged by or on behalf of the care home. The home’s complaints procedure must be appropriate to the needs of residents and must be supplied to any person acting on behalf of a resident if that person so requests. The complaints procedure must also include the name, address and telephone number of the Commission for Social Care DS0000060847.V326354.R01.S.doc 31/01/07 31/01/07 28/02/07 28/02/07 The Beeches Version 5.2 Page 26 9. OP18 13(6) 10. OP19 OP38 13(4)(a) 11. OP26 OP38 13(3) 12 OP27 18(1)(a) Inspection. The registered person must make arrangements by training staff, or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. This must include adhering to local policies and procedures for reporting suspicion of, or actual, abuse. All parts of the home to which service users have access are, so far as reasonably practicable, free from hazards to their safety. This must include: • Assessing the safety of the opening width of all first floor windows and fit restraints wherever this could compromise the safety of service users. • The bathroom must be cleared of clutter to allow safe access to bathroom facilities. • The advice of the fire officer must be sought in relation to doors to rooms in cellar being propped open. The registered person shall make suitable arrangements to prevent infection and the spread of infection at the care home. This must include: • Replacing torn safety side bumpers. • Making hand soap dispensers accessible. • Discontinuing the use of communal bars of soap. The registered person must ensure that there are, at all times, staff working in the care home in such numbers as are appropriate to the health and welfare of residents. This should DS0000060847.V326354.R01.S.doc 28/02/07 05/01/07 28/02/07 28/02/07 The Beeches Version 5.2 Page 27 13 OP29 19(1)(b)(i )(c) 14 OP30 OP38 18(1)(c)(i ) 13(5) include appropriate deployment of staff dedicated to meeting residents’ health, welfare, social and leisure needs. The registered person shall not 31/01/07 employ a person to work at the care home unless all of the information and documents specified in paragraphs 1 –7 of schedule 2 has been obtained And Is satisfied on reasonable grounds as to the authenticity of the references obtained. The registered person must 31/03/07 ensure that all staff working in the care home receive training appropriate to the work they are to perform. This must include movement and handling training. Meanwhile appropriate skill mix of staff on duty must occur to ensure the safety of residents. 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. 1 2. Refer to Standard OP10 OP24 OP27 Good Practice Recommendations Hairdressing activity should be relocated from the manager’s office to ensure that confidential information can be safely discussed. Tattered bed linen and towels should be replaced as necessary. The manager should keep under review the staffing situation within the home in order to make sure that residents’ needs are met. This should include staff availability to meet with residents’ social and leisure needs. There should be more formal procedures for addressing any concerns about references received for new staff including formal recording of discussion with the referee DS0000060847.V326354.R01.S.doc Version 5.2 Page 28 3. OP29 The Beeches 4. OP31 and with the applicant to evidence safe practice is occurring. The manager should register for the Registered Managers Award without further delay. The Beeches DS0000060847.V326354.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection 1st Floor St Paul’s House 23 Park Square South 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. 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