Inspection on 06/06/06 for The Beeches

This inspection was carried out on 6th June 2006.

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 17/11/09

The Beeches 15/09/09

The Beeches 10/07/09

The Beeches 02/06/09

The Beeches 26/11/08

The Beeches 29/05/07

The Beeches 01/10/05

The Beeches 24/05/05

The Beeches 04/11/04

The Beeches 18/05/04

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

CARE HOMES FOR OLDER PEOPLE The Beeches West Harling Road East Harling Norwich Norfolk NR16 2NP Lead Inspector Mrs Geraldine Allen Unannounced Inspection 6th June 2006 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 DS0000027451.V299241.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 DS0000027451.V299241.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Address West Harling Road East Harling Norwich Norfolk NR16 2NP 01953 717584 01953 717886 beeches03@aol.com 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) The Beeches (East Harling) Ltd Mrs Sheila Ann Kingsmill-Brown Care Home 36 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (36) of places The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate one named person, male, under the age of 65 years and with dementia, until such time as the person reaches 65 years of age or is no longer living at the home. 1st October 2005 Date of last inspection Brief Description of the Service: The Beeches is a care home providing personal care and accommodation for 36 older people who have dementia. The home is owned by The Beeches (East Harling) Limited and is located in the village of East Harling and close to local amenities such as shops and pubs. The home consists of a two-storey, converted house that is set in its own grounds. There are four shared rooms, the remainder being single rooms. All rooms have en-suite toilets, washbasins and showers or baths. The majority of rooms are on the ground floor. There are enclosed courtyards and a private garden to the rear. An 8-bedded extension is to be added to the rear of the building and work will commence in June 2006. The Manager, Mrs Kingsmill-Brown, confirmed that the home’s fees range from social services rates up to £415:00 per week dependent upon the accommodation. Fees cover personal care, furnished accommodation, light, heat, all meals and drinks, and laundry. Health care services are obtained locally, with residents registering with a local medical practice. A dentist visits and arrangements are made for eyesight and hearing tests as need be. The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day of 6th June 2006 over a period of 8 hours. Mrs Kingsmill-Brown completed and returned a pre-inspection questionnaire before the inspection took place. A copy of the home’s first annual selfassessment and feedback from a relatives survey was also sent to the Commission. Two residents and 8 relatives/visitors to the home, completed and returned the Commission comment cards. Some positive additional comments were made, such as “The staff in this home are just great”. Other findings and comments from the comment cards will be included within this report as necessary. Information was obtained on the day of inspection by looking at some records, talking with Mrs Kingsmill-Brown, staff and residents and by observing practice. A tour of the building was made and the plans for future development of the premises discussed. What the service does well: What has improved since the last inspection? The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 6 At the inspection dated 1 October 2005, 19 requirements and 2 recommendations were made. The management and staff at the home have worked hard to meet most of these. Work is in hand to upgrade all care plans although it is acknowledged there is still much to do. The staff need to make sure they include aspects of the residents social and emotional needs and not just the tasks they need help with. Some issues raised at the last inspection about the premises have been dealt with. However, it is acknowledged that building works are due to commence at the end of June 2006 and the premises will be assessed again once building work is complete. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 Overall, the quality in this outcome area is good. Prospective residents receive information about the home that helps them make an informed choice. The home completes a needs assessment before a resident enters the home to ensure their needs can be met. This home does not provide intermediate care. EVIDENCE: The home produces a Statement of Purpose that is kept up to date and under continuous review. The information within this document is well laid out and accessible to residents and their representatives. A Resident Guide is also produced and a copy provided to all residents. Mrs Kingsmill-Brown provided copies of these documents. The care plans for 2 residents were looked at in detail. Each contained a copy of a needs assessment undertaken by the home. There was also evidence that other agencies involved in the resident’s care are involved in the assessment The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 9 process. The home is currently changing the care planning and assessment documentation to a more holistic strengths based process. This is welcomed as the current documentation is task orientated and gives little consideration to the social, emotional and spiritual needs of the person. The Beeches DS0000027451.V299241.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The overall quality in this outcome area is adequate. The health and personal care needs are set out in individual care plans, however care plans are not adequate for the social and emotional aspects of care. The home ensures all health care needs are met. An inspection of the arrangements for the safe storage, administration and recording of medicines was carried out by a specialist pharmacy inspector and found that there had been improvement in practice and record keeping. Residents feel they are treated with respect and that their privacy and dignity is protected. EVIDENCE: A t the last inspection a total of 5 requirements were made in respect of care planning. Discussion with Mrs Kingsmill-Brown and some senior staff on duty confirmed that significant work is in progress to improve the care planning process and standard of information kept. There is however still substantial work to do and progress will be assessed at future inspections. The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 11 Two care plans were looked at in detail. One was of the original documentation and the other was set out in the new format that has a more holistic approach to care. The care plan using the original documentation contained assessment records, limited life history, health & personal care needs and the involvement of other health agencies. Appropriate risk assessments were also in place. It was disappointing to note that significant information about the resident’s past were not acted upon to ensure meaningful experiences. For example, the resident had a lifelong interest in sport and had distinguished sport achievements but there was no mention of how these interests could be met in daily living. The resident’s activity log showed approximately 1 activity per month taking place, the last being highly inappropriate to the age and interests of this person. The care plans were task orientated and the daily record only detailed tasks completed by staff. There was no social, emotional or spiritual entry seen in the daily record and no care plan in place to show how these should be met. There was no photograph of the resident on the care plan. A care plan recorded on the new format was also looked at. The format was not used in its entirety, with some elements of the original format continuing in use, for example falls risk assessment and dependency rating. Although the resident had declined to give information about their life history, the care plan included some information recorded on the activity log that would have been better recorded in the life history because of its significance. There was evidence of regular, recorded reviews of care needs and how they should be met. As with the other care plan reviewed, entries in the daily record were task orientated and included nothing about the resident’s emotional well-being. A photograph of the resident was included in this care plan. Both care plans included good records about health care interventions. There was also evidence of consultation with appropriate health professionals such as the Community Psychiatric Nurse. Only 2 completed comment cards were received from residents. Both were happy with the way staff supported them. Both the Statement of Purpose and Resident’s Guide contain statements about how residents will be treated with dignity and respect and that their right to privacy will be respected. Care practice and interaction between staff and resident’s were observed throughout the inspection. Generally, staff spoke respectfully and appropriately to resident’s and expressed wishes were complied with. Eight requirements were made at the last inspection in respect of the control, storage, administration and recording of medicines. The specialist pharmacist inspector conducted an inspection concurrently and found there had been significant improvement in practice. A copy of the full report is available from the Commission on request. The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 12 Requirements and recommendations are being made in respect of this outcome group. The Beeches DS0000027451.V299241.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 The overall quality in this outcome area is adequate. Some residents were relaxed and appeared satisfied with their daily experiences at the home. However, a significant number of residents slept for long periods or were disengaged from activity around them. Where possible, residents are supported to maintain contact with relatives, friends and significant others. Where residents expressed choices or preferences, these were respected where possible by staff. Resident’s receive a diet that is varied and nutritious. EVIDENCE: Residents were seen throughout the day and were spoken to where possible. Generally, residents appeared happy and content although a significant number were either asleep in the lounge or disengaged from activity taking place around them. During this inspection, no residents were seen involved in meaningful daily activity such as dusting, laying tables or other domestic type chores. Mrs Kingsmill-Brown stated that none of the current residents were interested in The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 14 taking part in daily activity. Staff need to work pro-actively to ensure that residents are supported to maintain daily living skills that generate a sense of purpose and well-being. The benefit of encouraging such activity for older people with dementia is well researched and documented and is regarded as good practice. Residents who were mobile were able to walk freely throughout the home and were able to access the secure courtyards. There appear to be 2 focal points for residents; 1 is the main lounge and the other the area leading to the dining room. Unfortunately, the chairs in the main lounge are ranged around the walls. Mrs Kingsmill-Brown advised that residents place them this way if staff try to rearrange. It is recommended that staff persevere as the current layout is inhibiting to conversation and interaction between residents. The other focal point is enjoyed by residents, who are able to watch the coming and going of other residents and staff. Mrs Kingsmill-Brown stated that more welcoming seating is planned for this area. The television was on in the main lounge throughout the inspection and the volume was loud enough to make conversation difficult, especially as residents were seated side-by-side and not able to see their neighbour easily. At one point, the television was on in the lounge at the same time as a member of staff was playing a noisy table game with a resident, and another member of staff was engaged in a conversation with another resident. The volume of noise and visual information was excessive and would have created difficulty for some residents. Staff need to be aware that excessive noise and visual information can cause distress and a corresponding response from a person with dementia. On the day of inspection, residents were receiving aromatherapy and hand massage. This was taking place in the quiet lounge and was the first time it was being tried. It was observed that residents found the experience very relaxing and pleasurable. The aromatherapist felt the experience for the residents had been positive. The benefits of aromatherapy and hand massage are well documented and this is regarded as good practice. Nine relatives completed and returned comment cards to the Commission. These showed that they all felt welcome at the home whenever they visit. Residents are enabled to walk to the village and access local amenities on a daily basis. The home holds a summer and Christmas fair each year. Unfortunately, the summer fair has been cancelled due to building works at the home. Staff were observed offering choice for the most part and expressed preferences were respected. Staff spoken to were aware of the need to give residents choices and to ensure they are complied with wherever possible. The returned comment cards from residents showed that they felt their choices and preferences were complied with. The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 15 The arrangements in place during lunch were observed. Some good practice was seen. For example, a member of staff was seen sitting next to a resident they were assisting with their meal. The support was discreet. Unfortunately, another member of staff was observed standing over a resident and talking loudly whilst feeding him. Other residents were provided with appropriate aids to support their independence. Unfortunately, residents were taken to the dining room but food was not served until all were seated. This meant that some residents had a significant wait for their meal. On the day of inspection, no resident got up and left the room although Mrs Kingsmill-Brown confirmed that this frequently happens. There are plans to make structural changes to the dining room as part of the building development that will allow changes in practice. Mrs Kingsmill-Brown is aware that best practice ensures that residents are offered their meal as soon as they are seated at the table to ensure residents receive adequate nutrition and this will be implemented as soon as possible. On the day of inspection, it was observed that residents were not offered choice and the plated meal was placed in front of them without staff telling them what was on their plate. One resident refused their meal and was offered and given a sandwich. Residents were given tabards to wear to keep their clothes clean. One resident refused to wear the tabard and this was respected. The volume of noise in the dining room was excessive, made more significant by the playing of a DVD with a soundtrack that included sirens, exploding bombs and wartime songs. The inappropriateness of the DVD and the volume it was played at was discussed with Mrs Kingsmill-Brown. A brief discussion took place with the cook on duty. She had a good understanding of the preferences of the residents and was also conversant with special dietary needs. Food supplements are available for residents as needed. Requirements and recommendations are being made in respect of this outcome group. The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is good. The home has a complaints procedure that is well known. Residents are protected from abuse by staff who have received training in abuse awareness. EVIDENCE: 89 of relatives who returned a comment card stated that they knew the home’s complaints procedure. Both residents who returned their comment cards knew who to speak to although they did not necessarily know the complaints procedure. Both the Statement of Purpose and the Residents Guide contain details of how to complain and the response to be expected from the home. A complaint had been received shortly before this inspection and Mrs Kingsmill-Brown provided evidence that the homes complaints procedure was being followed. Issues of concern regarding the alleged abusive practice by a member of staff were raised earlier this year. A referral was made to the Adult Protection Unit in line with agreed protocols and this resulted in the dismissal of a member of staff. All staff have received adult protection awareness training as part of the action plan drawn up following the referral. Staff spoken to were very aware of adult protection issues and were conversant with the home’s whistle blowing policy. The Beeches DS0000027451.V299241.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 & 26 The overall quality for this outcome group is adequate. The home is safe and generally well maintained. Internal and external areas of the home are safe for residents to access. Resident’s bedrooms are comfortable and contain personal possessions. The home was clean although there were unpleasant odours in some resident’s rooms. EVIDENCE: Four requirements were made at the last inspection regarding the premises. Not all of these were assessed for compliance as building work is due to commence at this home at the end of June 2006 that will affect some requirements. A tour of the building was conducted but not all rooms were seen. The impending building works were discussed with Mrs Kingsmill-Brown and it was The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 18 agreed that a future visit to the home would be needed to ensure compliance with all standards. During the course of the tour, it was noted that not all doors to resident’s bedrooms have handles and bedroom doors are kept locked when the resident is not using the room. This practice was discussed and it was agreed that recognised best practice would ensure that residents have ready access to their own rooms whenever they wish. It is accepted that there may be occasional exceptions to this approach and these should be subject to risk reduction assessment before access is restricted. All bedrooms are en-suite with either a bath or shower. All except 2 of the showers are connected. A shower curtain screens the en-suite area although not all of these were in place. It is acknowledged that this aids orientation, especially at night, however several bedrooms had unpleasant odours present. Mrs Kingsmill-Brown stated that not all the rooms had been cleaned by the time the tour took place. All bedroom carpets are cleaned regularly and on a weekly basis where there is a known continence problem. However, the use of curtains to screen the en-suite will exacerbate any odour problems and the use of mechanical extraction and odour neutralisers should be considered. It was noted that the en-suites had mechanical extraction fitted but was not seen in use in any of the rooms. Use of the external space was discussed with Mrs Kingsmill-Brown. The courtyard areas provide safe, easy access to outside space for the residents. The development of sensory areas and the therapeutic benefits of sensory gardens were discussed. Mrs Kingsmill-Brown stated that she wishes to develop sensory areas in the gardens once the building development is completed. Requirements and recommendations are being made in respect of this outcome group. The Beeches DS0000027451.V299241.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The overall quality for this outcome group is good. Staff are employed in sufficient numbers to appropriately meet the needs of the residents. Staff receive training that ensures residents are in safe hands. The home’s recruitment practices protect residents. Staff receive training that is relevant to their role. EVIDENCE: Copies of staff rotas were provided prior to the inspection and a copy of the staff rota for the week of inspection was seen. The staff rota was consistent with those staff on duty at the time of inspection. The rotas show that, excluding the manager, the home employs 1 care manager or senior and 5 care staff between 0800 & 1400, and 1 care manager or senior and 4 care staff between 1400 & 2100. Three waking night staff are also employed. Information provided by Mrs Kingsmill-Brown prior to the inspection shows that 66 of staff have achieved a minimum of NVQ at level 2 or its equivalent. This is in excess of National Minimum Standards. Two staff files were looked at in detail as part of this inspection and the opportunity was taken to speak with both staff in private, plus an additional member of staff on duty. The staff files provided evidence of good recruitment The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 20 practice that helps to ensure residents are safeguarded from abuse. Potential staff are required to complete an application form, giving full previous employment detail. Two written references were seen on 1 file and had been applied for on the other. Criminal Records Bureau disclosures were also seen. Mrs Kingsmill-Brown and another senior person interview each candidate and interview notes were seen. All new staff are subject to a probationary period. Information was provided by Mrs Kingsmill-Brown regarding the training that has taken place in the last 12-months and that is planned over the coming year. Evidence of training and learning taking place was also seen on the staff training record. Commencing with induction training, staff are able to access training relevant to the client group. The home has a commitment to NVQ training and a significant number of staff have achieved this or its equivalent. Some staff spoken to described some areas of a training course that they had found difficult to appreciate the relevance of. Mrs Kingsmill-Brown is conversant with the recent development of NVQ courses specifically for staff caring for people with dementia and is also looking to attend a Post Graduate course in dementia studies. These courses are commended as highly relevant to the needs of the residents at this home and incorporate the most up to date thinking and best practice. The Beeches DS0000027451.V299241.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 The overall quality for this outcome group is good. The manager is competent and well qualified. The home seeks the views of relatives and representatives. The views of residents are sought where possible. The home does not handle resident’s money. The home has practices that protect the health, safety and welfare of residents, staff and visitors to the home. EVIDENCE: The manager is registered and a qualified nurse. Mrs Kingsmill-Brown spoke about her plans to commence a postgraduate course in dementia studies. She keeps her knowledge up to date through subscription to a professional journal and by attending update conferences. The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 22 A copy of the home’s first annual self-assessment programme has been provided and an action plan of identified issues has been developed. A copy of the summary of feedback following the seeking of views from relatives was also provided. In both cases, the action plans would benefit from more detail of action to be taken including what is to be done by whom and by what completion date. This would enable better assessment of compliance. Mrs Kingsmill-Brown confirmed that the home does not handle monies on behalf of residents. In circumstances where there are no relatives able to take on this responsibility, arrangements are made through social services to arrange an appointee. Maintenance and servicing information provided prior to this inspection showed that the home is safely maintained. Records showed that all fire safety equipment was regularly serviced and up to date. The home conducts weekly fire alarm checks. The home undertakes monthly hot water temperature checks. The central heating system was checked in January 2006. Hoists were being serviced on the day of inspection. Recommendations are being made in respect of this outcome group. The Beeches DS0000027451.V299241.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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 3 X 2 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 3 X 2 X N/A X X 3 The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 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. Standard OP7 Regulation 12(1) 15(1) Requirement Timescale for action 08/08/06 2 OP7 12(1) 3 OP7 12(1)(3) 16(n) 4 OP26 16(k) The registered persons must ensure that care plans specify exactly the things staff need to do to assist residents to meet the specified aims. Repeated Requirement The registered persons must 08/08/06 ensure that needs assessment, care plans and daily records include all needs, including emotional, social and spiritual needs. The registered persons must 08/08/06 ensure that daily activity is meaningful to the resident and in accordance with their previous lifestyle and interests. Daily activity is should be recorded in the care plan. The registered person must 04/07/06 ensure that all offensive odours in resident’s bedrooms are dissipated through the use of mechanical extraction and/or odour neutralisers wherever possible. The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 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 3 4 Refer to Standard OP12 OP12 OP15 OP15 Good Practice Recommendations It is recommended that consideration is given to how residents can be supported in meaningful daily activity that will enhance a sense of well-being. It is recommended that staff consider how noise in the lounge and dining room can be reduced. It is recommended that staff tell residents what food they have on their plate to aid orientation and enhance their pleasure. It is recommended that residents have their meal made available as soon as they arrive in the dining room to encourage good nutritional intake and to prevent the resident leaving the dining room before their meal is served. It is recommended that residents are given access to their bedrooms throughout the day if they wish. Bedroom doors should not be locked unless there is good reason to do so. It is recommended that consideration is given for to have the opportunity to study the recently developed NVQ in dementia care It is recommended that the action plans generated by the annual self-assessment programme and also the relative survey contains what action is to be taken by whom and by what date. 5 OP24 6 7 OP30 OP33 The Beeches DS0000027451.V299241.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 DS0000027451.V299241.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!