Inspection on 06/07/05 for The Beeches

This inspection was carried out on 6th July 2005.

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 06/01/06

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 Announced 6 July 2005 09:30 th 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 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 D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Beeches Address 163 High Street Hanham South Glos BS15 3QZ 0117 9604822 0117 9857190 Miss. Julie Alexandra Windows Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Sheila Margaret Windows Care Home for Older People 23 Category(ies) of OP Old age for 23 registration, with number DE(E) Dementia - over 65 for 1 of places The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21st February 2005 Unannounced 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 en-suite. 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 D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection conducted as part of the annual inspection process to examine the care provided, and monitor the progress in relation to the eight requirements and three recommendations from the last inspection that was conducted in February 2005. Prior to the inspection the inspector received a completed pre inspection questionnaire which gave information about the establishment, policies and procedures, information about residents, staffing and visiting professionals supporting individuals at the home, information provided was verified as part of the inspection process. Also prior to the inspection the inspector received seven comment cards, four from residents, one from a general practitioner and six from relatives, comments from these have been fed back to the management of the home and have been incorporated within this report. The inspection took place over seven and a half hours. During the process eight residents, three care staff, the registered provider, managers at the home and visitors were spoken with. The inspector looked around some of the building and a number of records were examined. Following consultation with the manager and the staff team it was agreed that those living at the home would prefer to be referred to as residents within the inspection report, rather than service users and therefore this has been reflected within this report. The Commission for Social Care Inspection has produced a leaflet for those living in care establishments entitled ‘Is the care you need, the care you get?’; copies of these were forwarded to the home to be put on the homes notice board. What the service does well: The home currently provides residential care for 23 older people, in a wellmaintained, comfortable environment. Residents and visitors spoken with made positive comments about the staff. One resident said that the staff support and help me and listen to me, another said that staff were caring and kind, a visitor to the home felt that the home supported his mother well, that they were consulted and kept informed of their parent’s well-being. Robust staff recruitment procedures are in place including a protection of vulnerable adults check, a criminal records bureau checks and two references The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 6 are obtained before new staff commence employment to ensure residents are adequately protected. What has improved since the last inspection? What they could do better: Information for residents and their representatives on the services and facilities provided at The Beeches would be much improved if the home updated their statement of purpose in order to reflect staffing qualifications and relevant experience and knowledge. In order to ensure a holistic picture of the needs of residents is maintained the quality of information contained within their care plans must be improved by recording individuals wishes and choices along with clear information on how their needs will be met. 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 D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 7 Residents would be living in a safer environment and would be better protected in the event of a fire if the fire door identified during the inspection was not wedged open. Arrangements for meals and refreshments for residents would be better coordinated if an action plan was completed in respect of the forthcoming refurbishment of the kitchen, this must be forwarded to the Commission for Social Care Inspection. The home would be a better environment for residents to live in and staff who support them to work in if a bedroom area of the house is kept free from offensive odours. Potential hazards for residents may be avoided and staff would be better informed if further risk assessments were in place to record the needs of residents. Residents would benefit from effective recording measures and medication would be audited more effectively if stock medication records were dated and if medication records were clearer. Residents and their visitors would be better informed of forthcoming social events and activities if the home produced a poster and put it in a location where people can see it. 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 D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 4, 5. Information is available to residents and their representatives about the home and the admission processes provide adequate safeguards for all, however improvements are required for the Statement of Purpose. Clear contracting arrangements are in place for all residents. EVIDENCE: The Statement of Purpose was in place and this 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 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. The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 10 In place is an admission questionnaire that had been completed with residents upon their admission to the home and obtains information on individuals preferred routines this provides additional information in order to ensure a smooth transition for new individuals to the home. Julie Windows was able to fully explain the admission process for residents admitted into the home and emphasised that the admission is tailored to the individual needs of the resident. Julie Windows told the inspector that the home will visit individuals at home or at hospital prior to their admission in order to ensure the home are able to meet individual needs. Ms Windows also was able to demonstrate what needs were able to be met at the home and those which are not and spoke of extending individuals trial periods to a period of up to three months to ensure that the home was the appropriate placement for the individual. Records of care management assessments and minutes of care management review meetings were seen by the inspector, views of the resident, views of their representative and the provider were all recorded and included amendments required to the care plan The inspector viewed all of the contracts of residency in place for those living at the home, these are a statements of terms and conditions between residents/their representative and the home. All of the documents had been recently reviewed and dated to evidence this. Information within these documents includes individuals fee arrangements and what these do and do not cover, insurance arrangements at the home, individuals valuables, termination of placement and complaints, information was on record to show that copies of these had been forwarded to individuals relatives. The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 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 standard(s) 7, 8, 9, 11. The healthcare and medication needs of residents are generally well met and relationships between residents and staff are well established, however, the care planning system in place does not adequately provide the information that staff need in order to satisfactorily meet the needs and choices of residents. Information is recorded on the wishes of individuals in the event of their death. EVIDENCE: Care plans do not contain sufficient information on the specific needs, wishes, routines and choices of residents. Information supplied by residents had not been recorded on care plans and the inspector arranged with the home to forward some care planning information and some care plan formats and has offered to spend time with the staff and management in this area in order that information can be better recorded. Daily records of residents activities were viewed and appropriate information and language had been recorded, a recommendation was made at the last inspection undertaken in January 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 and will be monitored at future inspections. It was noted at the previous inspection that one resident was experiencing a high level of falls and it was recommended that the home seek the views of the The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 12 individual’s general practitioner in order to enquire if the individual would benefit and their health protected if they wore hip protectors, the inspector saw at this inspection that the home had sought advice in this area and health professionals had advised that this would not assist this individual. The inspector saw that this individual had risk assessments in order to support them in the area of potential falls however due to the individuals impairments these are required to be expanded upon to ensure the individual is supported within a safe environment. The inspector noted that residents had manual handling profiles in place and these had been recently reviewed, it was found that one resident who had experienced falls did not have a manual handling profile in place and therefore a requirement was made that this must be completed to ensure that the residents are supported and assisted in a safe manner. There was a record of visits to the doctor and these were up to date and sufficiently detailed. The inspector saw correspondence from health professionals, including consultants to evidence that advice is sought when necessary from specialists. The inspector saw that support is also accessed from specialist services, when required. Systems of medication administration/recording and storage were reviewed at this inspection, a monitored dosage system of medication was found to be in place and was found to be an effective, safe method. Medication was found to be securely locked in a metal cupboard. A staff member was able to speak with clarity on the systems in place and method of medication administration. A recommendation was made at the previous inspection that the home must ensure that medication entering the home is appropriately recorded, the inspector saw that this has been undertaken at the home and clear records in respect of this are in place, however this was not the case in 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 this inspection. The inspector saw that residents were treated with respect, staff spoke to individuals in a caring manner and spoke to individuals using their preferred form of address. The home has sought individuals wishes in the event of their death and specific requests of individuals are recorded, some discussion took place with Julie Windows surrounding the issue of ensuring that individuals expressed wishes are respected and acted upon, Ms Windows came across as committed to ensuring that wishes were adhered to and the importance of this to individuals. The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15. The meals in the home are good offering both choice and variety along with catering for special dietary needs. Activities are arranged and provided at the home on a fairly regular basis. EVIDENCE: Comment cards received from residents prior to the inspection recorded that residents like living at the home, they are treated well, they feel safe and know who to speak with if they are unhappy. This information was also confirmed throughout the day from the numerous comments received from those living at the home. A visitor to the home told the inspector that staff are always polite and welcoming and that they have been kept informed of their parents health and well-being. The inspector saw on a notice board in the front entrance a list of social events and activities that have taken place and that are planned at the home, the inspector saw that a banjo player, singers and religious support is provided at the home. Residents told the inspector that they enjoy the entertainers who visit and also events that staff organise within the home such as impromptu musical events and reminiscence sessions. One comment card received from a relative was that there are no activities or trips arranged by the home, the home were advised to display in a prominent area a poster notifying residents The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 14 and visitors of events. Ms Windows confirmed that no recent outings have been arranged for residents, this must be considered by the home and may be facilitated on a more individualised basis. The inspector saw residents enjoying their lunch on the day of the inspection and that a resident with poor sight had been provided with appropriate aids to support them with this. Residents told the inspector the meal was tasty and that they had sufficient quantity. A requirement was made at the previous inspection that the home must maintain levels of food hygiene by ensuring that dry food stored are clearly labelled, the inspector saw that this has been undertaken and evidence is in place when food has been opened. Julie Windows told the inspector that there are plans to re-furbish the kitchen which will incorporate a new boiler, Ms Windows told the inspector of the arrangements which will be made in order to ensure that the supply of hot/cold food and drinks for residents is not disrupted and that appropriate health and safety matters are addressed, it is required that the home forward to the commission a copy of the action plan and what actions will be taken during this time. The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 Complaints are handled objectively and residents are confident that their concerns will be taken seriously, listened to and actioned. The home does have in place measures to ensure that residents are protected from abuse. EVIDENCE: Information on how to make a complaint was seen on display in a communal area of the home. The home has in place an Adult Protection policy and also a copy of South Gloucestershire’s Protection of Vulnerable Adults Policy; staff spoken with was conversant with its contents and of the significance to them within their role. The registered provider has contacted the Commission for Social Care Inspection to inform of incidents that have affected the wellbeing and safety of those living at the home. The inspector saw that accidents had been recorded correctly and appropriate action to support individuals had been sought. The inspector saw that a number of staff have undertaken Protection of Vulnerable Adults training ensuring heightened awareness of their role and responsibility in this area. Information obtained from the pre-inspection comment cards were as follows: Four residents said that if they were unhappy they would know who to speak to about this, three relatives were aware of the homes complaints procedure, The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 16 three others were not, all six said they had never made a complaint, a general practitioner said that they had not received any complaints about the home. Regular residents meetings are held at the home, individuals spoken with said that this is a useful opportunity to raise any issues they may have or they would speak with their key- worker. The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23, 24, 25, 26. The quality of furnishings and fittings in the home is good. Overall a warm comfortable environment has been created ensuring individuals needs are met. Arrangements must be made to ensure that areas of the home are odour and risk free. EVIDENCE: The Beeches is a spacious residential home and is furnished to a high standard; the home is situated in Hanham and blends in with the local community. Overall a comfortable environment has been created ensuring individuals needs are met, using good quality furnishings however more effort must be made to ensure that all areas of the homes are hygienic and odour free, a partial tour of the premises found that all communal areas of the home were clean, tidy and odour free, however this was not the case in one of the individuals private rooms, one resident’s room had a strong smell of urine, Ms Windows explained the efforts made by the home to maintain a hygienic and odour free environment however it is required that the carpet is clean and odour eliminated or the carpet must be replaced. The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 18 The home has an array of comfortable spaces for shared use, residents were seen relaxing and making full use of these areas. The home has a garden to the rear of the property, these were seen to be well tended. There are a number of toilet, washing and bathing facilities provided at the home that are available for residents use, these are within close proximately to residents private accommodation. The number of facilities available are sufficient for the numbers of resident’s accommodated at the home. The home is appropriately adapted to meet the needs of the current resident group. Specialist equipment has been obtained for individual residents following identified need; examples of these include mobility, sensory and safety equipment. Risk assessments are in place for some residents activities, however further assessments are needed to ensure that all activities are appropriately risk managed. The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 The arrangements for the recruitment, selection, training and induction of staff are good with the staff demonstrating a clear understanding of their role. EVIDENCE: Robust systems are in place to ensure that staff are recruited and given clear information on their role and responsibilities. Observation of staff practice demonstrated that they were approachable, good listeners and communicators and were comfortable with residents who were at ease with them. All residents and visitors spoken with commented on the caring approach, kindness and patience shown to them by the staff. One resident said that they were happy with the support they received from staff. The recording of staff training has improved since the previous inspection where it was required that staff must receive a minimum of three days paid training per year, upon examination of staff records the inspector was satisfied that staff have received appropriate and sufficient training which has included infection control, first aid, safe handling of medicines and food hygiene. The inspector examined the induction programmes for the most recently recruited staff members to the home and saw that the content of this training included exploring the care and support needs of residents, work routines, reporting and recording, health and safety and the importance of confidentiality and how staff ensure these practices within their role. The inspector also spoke with a The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 20 new staff member to the home who told the inspector of their induction process and of the skills they have developed since working at the home and of the personal rewards they have gained through working with older people. Records viewed showed that supervision sessions are structured and covered areas of specific responsibility including key worker role and allocated duties, supervision discussions include training needs and as a result of the discussion an action plan is set. Staff signed supervision documentation to confirm what has been discussed in their supervision session. The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 36, 38. The home is well managed ensuring resident’s interests are promoted and protected by a confident, supported staff team, within a safe environment. EVIDENCE: Both Julie and Janet Windows have extensive experience in the management of residential care for older people, however they do not have an National Vocational Qualification at level four in care management (or equivalent). Therefore the requirement made at the previous inspection that the home must have in place by December 31st 2005 a manager with an appropriate qualification remains and will be a focus at the next inspection. Matthew Windows has achieved an National Vocational Qualification at Levels two and three and is currently working towards his registered managers award, however the home are reminded that National Vocation at Level four in care is what is required, information about registered manager appropriate qualifications has been forward to the management of the home. The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 22 Throughout the inspection process Mrs Janet Windows, Ms Julie Windows and Matthew Windows were able to demonstrate that they are competent and experienced to run the home and meet its stated purpose in addition to its aims and objectives. Evidence in place demonstrates that regular staff meetings are undertaken and that appropriate agenda items are discussed in order to develop the service and also to develop and meet the skills of individuals. The inspector had seen at the last inspection that the home has in place a comprehensive range of in house and organisational policies and procedures; these are discussed with staff during team meetings and supervision. 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. The inspector saw the fire panel in working order. The most recent fire drill undertaken in the home took place on 15th April 2005, seven staff members took part. A requirement was made at the last inspection that the home must ensure that records of fire drills include the names of those who have attended, the inspector saw that this had been done for the most recent drill, but had not been recorded for previous ones and will be monitored at future inspections. The inspector saw that the home had achieved a food hygiene award issued by South Gloucestershire Council on 26th April 2005. The homes lift was inspected by an appropriate contractor on 8th April 2005. The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 x x x 3 3 1 The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 24 Yes Are there any outstanding requirements from the last inspection? 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. Standard OP 24 OP 1 OP 15 Regulation 13(3) 4(1)c 16(2) Timescale for action Odour to be eliminated, carpet to 08/06/05 be cleaned/replaced. Statement of Purpose to be 07/08/05 updated Action plan to be forwarded to 07/08/05 the Commisssion re the arrangements for meals/drinks during the kitchen refurbishment. Medication must be recorded 07/08/05 correctly. Fire door must be kept shut or 07/08/05 automatic release fitted. Manual handling risk assessment 07/08/05 to be completed. Risk assessments for individual 07/08/05 with poor sight to be completed. Care plans must fully reflect 07/10/05 individuals needs and wishes and must also record how these needs will be met. To have in post registered 31/12/05 manager with the appropriate qualifications. Requirement 4. 5. 6. 7. 8. OP 9 OP 38 OP 38 OP 7 OP 7 13(2) 23(4)c 13(4)b 13(4)c 15 9. OP 31 19(2)(b)i The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP 9 OP 12 Good Practice Recommendations Stock held medication records must be dated when audited. Poster to be displayed of forthcoming social events. The Beeches D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection 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 D56 D05 S3332 The Beeches V228749 060705 Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!