Inspection on 06/01/06 for The Beeches

This inspection was carried out on 6th January 2006.

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

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

Other inspections for this house

The Beeches 29/07/08

The Beeches 10/07/07

The Beeches 08/06/06

The Beeches 06/07/05

The Beeches 21/02/05

The Beeches 19/07/04

The Beeches 20/01/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE The Beeches 163 High Street Hanham South Glos BS15 3QZ Lead Inspector Odette Coveney Unannounced Inspection 6th January 2006 10:20 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 DS0000003332.V273666.R01.S.doc Version 5.1 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 DS0000003332.V273666.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Beeches Address 163 High Street Hanham South Glos BS15 3QZ 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) 0117 9604822 0117 9857190 Miss. Julie Alexandra Windows Ms Janet Margaret Windows, Mr. Mervyn Roy Windows Ms Sheila Margaret Windows Care Home 23 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (23) of places The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th July 2005 Brief Description of the Service: The Beeches is an extended, detached Victorian building situated in Hanham High Street. There is parking to the front and a small parking area to the side of the house for three or four cars. There is a small garden to the rear with a patio area. The larger of the gardens has been built upon and the former garden has been reinstated. The home is close to local shops and amenities and is also on a main bus route between Bristol and Bath. The home is arranged on two floors. The home has two double bedrooms, both with en-suite facilities and nineteen single bedrooms, seven of which are ensuite. There are two lounges and two dining rooms one of which has a small conservatory leading from it. The home is managed and owned by three generations of one family. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process to examine the care provided and monitor the progress in relation to the nine requirements and the two recommendations from the last inspection that was conducted in July 2005. The inspection took place over one day with two inspectors. During the process seven residents, three staff, the registered provider, registered manager and the trainee manager were spoken with. The inspector looked around the building and a number of records were examined. The inspector was informed at the last inspection that the home had plans to re-furbish the kitchen, a requirement was made that the home must forward an action plan to the Commission re the arrangements for meals/drinks during the kitchen re-furbishment, this was received by the commission and following a subsequent visit to the home this confirmed that the action plan had been implemented and had caused minimal disruption to the residents. What the service does well: What has improved since the last inspection? Of the nine requirements made at the previous inspection seven of these have been fully met, two are outstanding. The home has demonstrated a commitment in meeting the Care Homes Regulations and the National Minimum Standards. Information for residents and their representatives on the services and facilities provided at The Beeches has improved as the home has updated the statement of purpose in order to reflect staffing qualifications and their relevant experience and knowledge. Information on forthcoming social events and activities held within the home were improved when the home displayed a poster outlining forthcoming entertainment. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 6 There have been a number of environmental changes since the last inspection the kitchen has been re-furbished making a better environment in which to prepare meals and drinks for those living at the home. Health Hygiene and safety at the home has improved since the home have eliminated an odour and cleaned a carpet in a residents bedroom, risk assessments and manual handling assessments have been completed and also since recording on medication records has improved. What they could do better: In order to ensure a holistic picture of the needs of residents is maintained the quality of information contained within care plans must be improved by recording individuals wishes and choices along with clear information on how needs will be met. This was a requirement at the last inspection and no significant improvements in this area have been made. The inspector has arranged to re-visit the home on February 6th in order to review the four care plans seen at this inspection. It was required that these must be improved by this date. Other residents care plans and the monthly care plan review records must also fully reflect individual’s needs and wishes and must also record how these will be met. It is also required that daily records for residents must contain only factual information and staff must ensure that they ‘own’ any entries they make. A recommendation was also made that staff undertake care planning training in order that they are equipped with the information they need in order to complete these competently. In order to fully demonstrate that individuals are supported with identified health needs it is required that health care charts such as weight and nutritional supplements are maintained with evidence of how individuals are supported. It is also recommended that the home provided additional information on the meals and nutritional policy to demonstrate how individual’s nutritional needs are identified, supported and met. Residents would benefit from effective recording measures and medication would be audited more effectively if stock medication records were dated and also if the returned medication records contained a staff signature. To demonstrate that equipment provided for residents and staff use is safe and has been maintained it is required that the home forward certificates of testing which has been completed by an appropriate contractor. Residents would be supported by a suitable qualified manager if the home had in place a manager with the appropriate required qualification for such a position of responsibility and accountability. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 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 Beeches DS0000003332.V273666.R01.S.doc Version 5.1 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 DS0000003332.V273666.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 5 Prospective residents, their relatives and professionals have the information they need in order to make an informed decision on whether the home is able to meet an individuals needs. Individual’s needs are assessed prior to their admission into the home, they and their relatives are given the opportunity to visit the home and assess the quality, facilities and suitability of the home. EVIDENCE: At the previous inspection it was found that the homes Statement of Purpose was found to be fully comprehensive and contained the relevant information required as stated in Schedule 1, Regulation 4(1)(c). The Statement of Purpose contained the aims and objectives of the home and spoke of treating individuals with dignity and respect, to promote independence and encourage individuals to make choices with aspects of their lives. The document also contained the range of needs that can be supported at the home, the complaints and admission procedures along with fire precautions, however, the information outlining the relevant qualification and experience of the staff team The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 10 had not been updated for some time and did not reflect the situation at the home, therefore a requirement was made that this document is updated in order that information provided for residents, prospective residents and their carers is accurate and up to date. A review of this document found that it had been updated and the standard had been met. During the inspection there was a relative who was looking around the home, looking for a place for their relative. They were given a tour of the home and had the opportunity to ask questions. This person was also given a copy of the homes Statement of Purpose. The home has a brochure, which also provides information about the services and facilities provided at the home. Mathew Windows said that the home was considering developing a website in order to reach a broader market of prospective residents. The inspector will look forward to reviewing progress in this area at the next inspection. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 Information on individual’s health, personal and social care needs are not recorded. There is also not enough information on how individuals will be supported. Appropriate medication systems are in place however improvements to medication records in respect of returned medication and stock medication are required. Evidence is in place to show that individuals are treated with respect with their rights of privacy and wishes in the event of their life being upheld. EVIDENCE: At the previous inspection a requirement was made that the home must ensure that care plans fully reflect individuals needs and wishes and must record how these would be met. Care planning information was provided to the home after the inspection, and the Inspector offered to meet with staff to provided further guidance in relation to care file recording, this offer was not taken up. Four residents care records were reviewed at this inspection and the inspectors were concerned to find that significant assessed needs had not been included. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 12 Significant information in respect of mental health, pain control, risk of falls, communication and dietary requirements were not recorded fully with not enough information to demonstrate if needs have been identified within the home and if they are being met. It is required that care plans must fully reflect the individuals needs and choices and must record how these are met. The inspector has arranged to re-visit the home on February 6th to look at progress in this area. Care plan reviews are undertaken on a regular monthly basis however these require more detail in order to provide clear direction and guidance to staff. It is also recommended that staff undertake care-planning training in order that they are given the information and skills to equip them to complete these fully. A recommendation was made at an inspection undertaken in January 05 that staff should make their names identifiable on entries they make in care records in order to ‘own’ what they had written, the inspector saw that improvements had been made in this area at the July 2005 inspection and recorded on that inspection report that this is an area which would be monitored at future inspections. The inspectors were disappointed to find at this inspection that not all entries were clear as to who had written them and also saw that some comments written about residents were extremely negative and subjective. Minutes of a staff meeting held in October showed that management had provided staff with clear instruction as to what is and is not acceptable recording within care documentation. However inspectors were disappointed to find unnecessary comments in resident’s daily records that had been written in November, these were pointed out to Ms Windows. A requirement was made at this inspection that daily entry records must contain factual information. The home has in place a copy of the guidelines produced by the Royal Pharmaceutical Society of Great Britain for the administration and control of medicines in care homes. It was noted at the previous inspection that within individuals daily records of medication, three separate entries had been altered and it was unclear as to whether this medication which was required to be given ‘as and when’ had been given, therefore a requirement to improve medication recording was made at that inspection. Systems of medication administration and recording were reviewed at this inspection and this requirement was found to have been met, records were clear. A recommendation was made at the last inspection that stock held medication should be recorded and audited, Sheila Windows told the inspector that this was being undertaken at the home however the book with evidence of this could not be located therefore this recommendation will remain and will be reviewed at the next inspection. A medication returns book is in place however this only contains the signature of the receiving pharmacist, in order that the home can backtrack what they have retuned it is required that a staff member signature of what medication is being returned is also in place. Sheila Windows said that there are currently no residents at the home who administer their own medication but that should this change individuals would The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 13 be supported with this and that there are lockable facilities provided within individuals rooms for medication to be stored safely. Healthcare records must be improved to demonstrate that that appropriate support is being provided. Upon examination of individual’s daily records, correspondence and care planning information it was clear that individuals have been well supported with areas of their health and that the home had made arrangements for the appropriate support from health professionals and that the advice given had been responded to. However, it had been recorded that concerns had been raised over a residents weight, yet charts monitoring this had not been maintained, The same individual had been prescribed ‘build up’ drinks in order to supplement their diet yet there was very little evidence to show that this was being given. It was required that healthcare charts must be maintained. The home has a policy on meals and nutrition, this mainly refers to meals and it was recommended that this document is expanded to include information on how the home would refer to specialists for further advice, that specialist diets are catered for and how individuals health in respect of nutrition is monitored and reviewed. Since the last inspection the kitchen has been re-furbished creating an improved environment in which staff work. Lunch being served was fish, chips and peas with macaroni pudding for dessert, one of the residents said that they ‘enjoyed the food’, that it was ‘varied’ and ‘enough of it’. Julie Windows told the inspectors that she had sought the wishes of individuals in the event of their death and had spent time with residents discussing this sensitive area with them, records seen confirmed this. Ms Windows also gave an example of where she had advocated on behalf of a resident in order to ensure that their wishes were upheld and respected. It was found at the last inspection undertaken in July that one resident who had experienced falls did not have a manual handling profile in place and a requirement was made that this must be completed. Also at the last inspection it was required that the risk assessment for a resident with sensory impairments be expanded upon, this was found to have been completed. One risk assessment identified that a resident required support with stairs and evidence was in place to show that the concern had been discussed with a family member and it had been recognised the importance of sharing the risk assessment with family and that they were going to be asked to sign the assessment as acknowledgement of the risk and what the home were doing to support the resident, this had not been signed. The home should endeavour to obtain this. It is noted that differing types of format are used to record risks and the home is advised that they may wish to consider a consistent recording approach in this area. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 14 The home’s Statement of Purpose records within its aims and objectives that the rights of residents to be treated with respect and dignity would be upheld. The inspector saw that the home has a number of policies in respect of rights, such as dignity and privacy, choice and that residents are to have full civil rights. Mathew Windows confirmed that these are areas covered with staff during their induction programme. The inspector noted that during the inspection when private conversations took place about residents Julie Windows and Mathew Windows ensured the door was shut. It was seen in supervision records that this is an area which is discussed with staff to ensure that they are fully aware of their responsibility in this area. Ms Windows was asked where do residents see health professionals or receive medical treatments, she confirmed that residents are taken to their own room, or if a room is vacant and this is more convenient for the resident then this would be used. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15. Resident’s lifestyle at the home matches their expectations and preferences; individuals are supported to participate in activities of their choice. EVIDENCE: During the inspection residents were seen participating in a game of bar skittles, others were seen reading, knitting and chatting with others. A recommendation was made at the previous inspection that the home displays a poster of forthcoming social events, this was seen in the entrance hall to the home and provided information of events held at the home, it was noted that this poster related to events in December and was out of date. The diary and an entertainment record at the home confirmed information provided by Julie Windows about the activities and entertainment. Residents have been supported by staff to participate in board and card games, bingo, and quizzes. Film shows take place at the home and there are regular entertainers who perform. Residents told the inspector that they enjoyed the Christmas party and a 50’s party that was held at the home. Julie Windows informed the inspector during the inspection undertaken in July that the home was planning to re-furbish the kitchen. A requirement was made that the home forward to the commission a copy of the action plan and what actions will be taken during this time. This was received and a monitoring visit The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 16 to the home undertaken showed that the action plan was being followed and that there was minimal disruption for the residents and food and drink were being provided The home has in place a policy on meals and nutrition, the information within this focussed mainly on meals, it was recommended that the policy be expanded to include information on how healthcare advice would be sought for individuals and how the home would ensure that recommendations would be followed and also that special diets are catered for at the home. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Complaints are handled objectively and individuals can be confident that their concerns will be taken seriously, listened to and actioned. The home does have in place measures to ensure that individuals are protected from abuse. EVIDENCE: The home maintains a complaint logbook at the home; the last recorded complaint was in December 04. Julie Windows discussed that residents or relatives may bring concerns directly to her in order that they may be resolved. Some examples were given with information of how issues have been resolved. A member of staff told the inspectors about their understanding of their responsibilities should they believe a resident was being abused, they were clear about their responsibilities and reporting procedures. The home has clear polices and procedures in place in respect of adult protection and in order that staff can ‘whistle blow’ on poor practices. No complaints about the home have been received by the CSCI. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25, 26 Some improvements have been made in respect of redecoration of areas within the home EVIDENCE: The Beeches is a residential care home for older people. The home is registered to provide care for up to twenty three older people including one with Dementia. The home is located at Hanham high street and is within close proximity of local shops and amenities. Janet and Julie Windows informed the inspectors of the improvements to the environment since the last inspection; the home has had some new windows fitted to the front of the property, second-hand chairs have been purchased for the dining room and the kitchen has been refurnished. Janet Windows showed the inspectors some resident’s rooms, which have been redecorated, and have had new carpets fitted. At the time of the inspection it was seen that an upstairs landing was being repainted. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 19 It was noted at the previous inspection that a residents room had an odour and the carpet was stained, a requirement was made at the inspection that the odour must be eliminated and the carpet be cleaned or replaced. The room was re-visited at this inspection, there was no odour present and the carpet was clean. The home was found to be clean and tidy at the time of the inspection with no odours present. Resident’s bedrooms are appropriately furnished with residents being encouraged to bring in personal effects in order to make their room more ‘homely’. Rooms seen had appropriate furniture and fittings with photographs, plants, pictures and ornaments enhancing these rooms. The home provides bathing, toileting and manual handling aids. The home was unable to locate the most recent survey report for the hoist. It is required that a contractor’s service/maintenance record for hoist equipment is forwarded to the inspector. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 Residents living at The Beeches are supported by appropriate staff in respect of numbers, skill mix, and competency. EVIDENCE: At the time of the inspection there were sufficient staff on duty in order support the residents and to ensure the continuity of service provision. Since the last inspection there have been some changes to the staff team, an assistant manager has left the home and two experienced staff members have been promoted to senior staff and have taken on some additional responsibilities due to this. One of the staff members who has been promoted was spoken with and they spoke very positively about their job and the satisfaction they obtained through working with the residents at the home. Each individual has a key worker to support them with the manager being involved with the overall monitoring of individual care. One member of staff has achieved a National Vocational Qualification in care at level 2 and level 3. 5 members of staff have NVQ at level 2 with a further two staff currently undertaking the award. A member of staff was proud that they had completed their award within six months and is looking forward to undertaking this care award at level 3. The atmosphere at the home at the time of the inspection was calm and relaxed with individual’s looking clearly at ease and ‘at home’. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 36, 38 There is a well-established management structure at the home however the home must make arrangements to have a suitable registered manager in place. Health and safety of those living and working at the home is well managed EVIDENCE: Ms Julie Windows, Ms Janet Windows and Mr Mervyn Windows are the registered providers of the home, with Sheila Windows being the registered manager. The Windows family have been at the home for over 17 years. Both Julie, Sheila and Janet Windows have extensive experience in the management of residential care for older people, however they do not have a National Vocational Qualification at level four in care management (or equivalent). Therefore a requirement has been made at previous inspections that the home must have in place a manager with an appropriate qualification. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 22 Mr Mathew Windows has worked at the home for many years and has been taking on a number of management responsibilities. Matthew Windows has achieved an National Vocational Qualification at Levels two and three and is currently working towards his registered managers award, Mr Windows is aware that in order to be the registered manager of the home he is required to undertake an NVQ at level Four in care and has registered to undertake this when he completes his RMA. On Monday 9th January an application pack and information relating to a criminal records bureau check has been forwarded to Mr Windows and the process for his management registration has been discussed with him. Once the application is complete a ‘fit persons’ interview will be arranged with Mr Windows. The home has developed a questionnaire for residents, relatives and staff and asks for their opinion about the services and care provided at the home. The inspectors saw that this audit was undertaken before Christmas and covered areas such as social and leisure activities, any areas of complaint, if people are given appropriate levels of privacy, quality of the food and the arrangements for visitors. Mathew Windows said that staff have supported those residents who needed assistance to complete the forms. The completed forms indicated that people are satisfied with services at the home. Mathew Windows said that an audit of the received form will be undertaken and any required actions will be undertaken and that results of the audit will be circulated. The inspector viewed the fire logbook for the home. The home was completing the appropriate checks on the fire equipment and the recording of training, fire drills and the testing of equipment were satisfactory. Avon Fire Brigade undertook a fire safety inspection at the home in April 2005 and also in April 2005 the home achieved a food hygiene award issued by South Gloucestershire Council. Evidence was seen that the lift had been serviced in October 2005. However no evidence was available to show that hoist equipment had been serviced or maintained by a contractor and therefore a requirement was made that a copy of the most recent certificate be forwarded to the inspector. Regular staff meetings are held at the home with the most recent having been held in October, minutes of these meetings showed that these forums provide an opportunity to ensure consistency of service delivery and continuity of care for those living at the home. The meeting provide an opportunity for staff to air their views and also for the management to discuss policies, procedures and staff practice within the home. Both Julie and Mathew Windows came across as committed to ensuring accountability within the home and improving and raising standards. The inspector viewed the organisational policies and procedures in place at the home, these provide sufficient information in order to direct and guide staff practice. The policies seen were appropriate to the service provided at The Beeches. These documents had been recently reviewed with evidence to show The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 23 that staff had been made aware that these were available to them for reference. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 2 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X X 3 X 2 The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 25 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. 2. 3. 4. 5. Standard OP7 OP7 OP8 OP8 OP7 Regulation 17 (1) a 15 17 13(2) 15 Requirement Daily records must contain factual information and staff must ‘own’ entries. Care plan monthly reviews must contain sufficient information. Health care charts must be maintained. The medication returns book must contain the signature of a staff member of the home. Care plans must fully reflect individual’s needs and wishes and must also record how these needs will be met. To have in post registered manager with the appropriate qualifications. Certificate of maintenance by a contractor of the hoist equipment must be forwarded. Timescale for action 06/02/06 06/02/06 06/03/06 06/02/06 06/02/06 6. 7. OP31 OP38 19(2)(b) i 23(2) c 30/06/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 26 No. 1. 2. 3. Refer to Standard OP7 OP15 OP9 Good Practice Recommendations Care staff to attend care planning training. The home’s policy on nutrition and meals to be expanded. Stock held medication records must be dated when audited. The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Beeches DS0000003332.V273666.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!