Inspection on 07/09/06 for The Beeches

This inspection was carried out on 7th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Beeches 10/06/09

The Beeches 23/06/08

The Beeches 06/06/07

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Beeches 6 Brunswick Terrace Wednesbury West Midlands WS10 9DA Lead Inspector Mr Jon Potts Unannounced Inspection 09:55 7 & 8th September 2006 th 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 DS0000066611.V311592.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 DS0000066611.V311592.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Address 6 Brunswick Terrace Wednesbury West Midlands WS10 9DA 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) 01952 583807 Asha John Mr Dennis Valentine John Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16/3/06 Brief Description of the Service: The Beeches has been in operation as a care home since 1985 but in May this year has continued under new ownership. It is located in a cul de sac very close to Wednesbury town centre so it is in reach of numerous facilities including shops and main bus routes. The house is a large traditional property that has been extended in the past to its present size and layout. All bedrooms are sited on the first floor of the house and can be accessed by a shaft lift. There are a number of toilets on the ground and first floors with bathrooms (including assisted facilities) on the first floor. The ground floor also houses the lounge, dining room, kitchen, laundry and office. Ramped access is now available to the rear of the property, this a valuable addition to the facilities on offer and greatly assists access in and out of the home for frailer residents. The home is managed on a day-to-day basis by a joint provider/manager who is supported by care staff (some seniors) cooks and domestics. As would be expected in a home of this size the manager is involved in hands on care as well as management tasks. The home offers predominately long stay accommodation but has offered some short-term care in the past. The charges for accommodation are £328 per week with the only additional charges for hairdresser, chiropody (if not health service), papers and toiletries (although basics of the latter are provided). The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection of the home under its new ownership and the focus of the inspection was on the progress made by the new owners since takeover in respect of key national minimum standards. One inspector carried out the inspection over two days and evidence was drawn from case tracking the care for three residents this involving review of all their care documentation, discussion with/observation of the residents and interviewing staff. There was also review of some policies/procedures, health and safety documentation, staff files and associated records in conjunction with a tour of the premises. There were numerous discussions with the manager, who also provided information via a pre inspection questionnaire, this in conjunction with feedback forms from residents/relatives. The residents, staff and joint provider/manager are all to be thanked for their ready assistance with the inspection process. What the service does well: What has improved since the last inspection? The most significant visible improvement seen was the addition of the wheelchair ramp at the back of the building, although there have been other works carried out that are not so obvious, but have a clear bearing on safety (for example securing sinks and toilets, completing a robust risk assessment of the hot water system etc). There was evidence that the documentation in the home is staring to improve with some case files having new care plans and other health a safety documentation been put in place. The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 6 Staff also presented as having a far better understanding of infection control, despite limited formal training in this area to date. This was clearly the result of guidance from the manager/provider. A number of staff have also commenced accredited medication training. 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 DS0000066611.V311592.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 DS0000066611.V311592.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): 1,2,3,5 The outcome for this group of standards is judged to be adequate. Prospective residents and their representatives do not always have written information needed about the home, although are given the same verbally. The process by which resident’s needs are assessed needs improvement and contracts are to be issue to all residents in the near future. EVIDENCE: The service has a statement of purpose and service users guide although this has not been revised since the service changed ownership and copies of the same have not been made available to prospective service users. Residents have not been provided with contracts previously, although the manager was able to readily evidence that this were drawn up and he was in the process of issuing these to residents or their representatives so that they were able to read, agree and sign them. The manager has revised the home’s assessment process for residents, this much improved over the existing system although still needing to refer to weight (on admission), history of falls, continence and cultural needs. It was of The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 9 concern that recent admissions had not been subject to the home receiving assessments and care plans from the service users social workers, this meaning the manager only had the information from the home’s assessment on which to make a decision as to whether the home could meet their needs. Service users had not received written confirmation of the homes ability to meet their needs prior to admission from the home either. There was no evidence in case files of on going social workers reviews of residents care and the manager/provider was advised to contact the purchasers and request reviews as soon as possible. Discussion with residents recently admitted to the home did however evidence that they had ample opportunity to view the home prior to admission and had been given sufficient verbal information, in their opinion, to enable them to make an informed and positive choice. Both stated that they still felt they had made the right decision at the time they spoke to the inspector, this up to a month after admission. The Beeches DS0000066611.V311592.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 outcomes for this group of standards is judged to be adequate The health and personal care, which a resident receives, is based on their individual needs. The systems for the management and control of prescribed medication leave much room for improvement and potentially put residents at risk. The principals of respect, dignity and privacy are put into practice by staff through their care practice. EVIDENCE: Each resident has a care plan, although many of these were of poor quality, this an issue recognised by the manager as they were being updated. The updated plans, whilst brief were a significant improvement, and tracking of the information within them accorded with the information sourced from staff, residents, the manager and other records. Resident’s knowledge of the plans evidenced their involvement in the formulation of these although there were no signatures to evidence this involvement. The more up to date plans did include an element of risk assessment although this needs expansion to consistently include assessment of tissue viability, risk of falls, nutrition and any other risks presented to the individual (i.e. independence v risk). There was clearly a commitment to reviewing the plans on a monthly basis. The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 11 Residents have access to health care services, this access supported by staff at the home. There was evidence that there was access to opticians, chiropodists (private if a resident wished) and dentists. There was some evidence in the care plan of health care treatment and intervention, including weights and nutritional assessment in some cases (notably residents at higher risk and of greater dependency). The home has a medication policy, although staff could better access this by placing it in with the resident’s medical administration records (MARS). There was concern that whilst some of the medication is controlled through a monitored dosage system other residents have medication that is secondary dispensed into dosset boxes. The manager agreed that it would be better to have all medication controlled through the monitored dosage system and stated would action this. It was also noted whilst observing staff giving medication that the MARS were not sign at the point medication was administered, this increased the risk of errors when filling these records out. A number of MARs sheets had handwritten information in respect of medication and dosages and whilst most of these corresponded with the printed labels on bottles/packets one did not, with the handwritten entry indicating a different dosage. Whilst no concerns were raised at the last contracted pharmacist visit carried out in January 2006, a further visit is required based on the concerns raised above. The manager stated that he intends to put photos of residents on MARS sheets and was also advised to list those staff that administer medication in the Medication folder against their initials (as they would appear on the MARS records). The staff that administer medication confirmed that they were currently undertaking accredited medication training. Staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for the residents to enjoy the privacy of their own rooms and provides screens in those that are shared. Residents confirmed that they are happy with the way that the staff deliver their care and respect their dignity citing examples to the inspector as to how this is done. The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 12 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 outcomes for this group of standards is judged to be good Residents indicated that their experiences within the home allowed them to live their chosen lifestyle and they had an acceptable level of choice and control over their lives. Diets available were appealing, balanced and allowed residents choice. EVIDENCE: The routines of the home are planned around the resident’s needs and wishes. Staff enable the service to be flexible and changed to meet individual wishes. Residents have the confidence to discuss what makes them happy and comments where improvements can be made. The home takes residents feedback seriously and makes changes wherever possible. Staff listen to residents and make considerable effort provide a flexible service, which enables them to enjoy a better quality of life. Resources are provided to allow time for activities and stimulation, residents spoken to indicating that they were able to direct how these were managed, and make choices as to their level of involvement, an example of this given by one resident as the domino games they enjoyed playing every evening. The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 13 Residents are encouraged to retain their involvement within the community where they have existing contacts such as lunch clubs, with acknowledgement that residents have the right to independence. Visitors are able to see their relatives at the home at any time although it is preferred that they avoid meal times, this to protect the privacy of the residents. Whilst there is no separate visiting areas, the dining room is available to visitors or the resident can use their bedroom if wished. Maintaining independence and enabling residents to make their own decisions about how they live is a key objective of the manager/providers and the home. Residents where able are encouraged to take control of their finances and any decisions about their life with support from staff. Where residents need assistance with finances they can receive support from outside agencies, such as the local authority. Residents are able to bring in their personal possessions into the home with them and keep these within their rooms within space and health and safety restrictions. The homes policy does promote residents access to their own records and underlines their rights in this area. Food and meal times are treated as an occasion and something to be looked forward to with tables neatly presented and the environment seen to be suitably relaxing and unhurried during meal times. Residents spoken to were positive about the food in respect of choice and content, and sampling of a meal by the inspector provided first hand evidence of its quality. The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 14 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 The outcomes for this group of standards is judged to be adequate Residents have access to a robust, effective complaints procedure, feel they are listened to and feel safe at the home. Staff awareness of adult protection issues could be improved. EVIDENCE: The service has a complaints procedure that generally meets the national minimum standards and regulations. The complaints procedure is available within the home. Residents and others associated with the provision understand how to make a complaint and those spoken to stated that the manager is approachable and will listen to any concerns. Further to this staff had an awareness of the need to pick up any concerns from general conversation with residents. The policies and procedures regarding the protection of adults are satisfactory and are updated and reviewed in line with regulations and other external guidance. Within the policy it is clear when incidents need external input and who to refer the incident to. Links with external agencies are satisfactory and include CSCI, police and adult protection teams, although further training to assist with staff awareness would be beneficial as some staff knew they needed to deal with issues, but were unsure as to what external agencies they should approach if necessary. Residents at the home state that they are satisfied with the service provision, and feel safe and supported. Records in respect of residents’ monies in safekeeping could be improved with the use of two signatures to verify all transactions however, this in turn protecting any staff handling monies. The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 15 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, 25, 26 The outcomes for this group of standards is judged to be adequate The physical design and layout of the building has improved, and whilst in need of further improvement, is safer than at the time of the previous inspection. The home does however present as homely and comfortable. EVIDENCE: The service provides a homely environment. It does not however have an up to date, timed rolling programme to improve decoration, fixtures and fittings although the manager/provider was clear as to what works needed immediate attention. A list of proposed works was drawn up prior to the new owners registration, this subject to some change as more important improvements and repairs have required work, many of these related to health and safety. There are a number of single rooms, a few double rooms some with ensuite facilities. Discussion with some residents that shared rooms indicated that this was a choice they accepted and were comfortable with. Residents can, and The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 16 were seen to have, personalised their rooms and were able to choose where they spent time, either in their room or in communal areas. Residents spoken to were happy with their bedrooms although one did state that the addition of a lockable door would be of benefit to them. Residents stated that they were comfortable, the home is clean, warm, well lit and there was sufficient hot water. Whilst there are some issues in respect of the hot water storage system the manager/providers have been pro-active in the use of a specialist company to carry out a risk assessment and identify the necessary works, which it was stated would be carried out as soon as possible. There were sufficient toilets close to communal areas and bedrooms although bathrooms, whilst spacious required some updating. It was evident from discussion with the manager and staff that the manager has focussed on instructing staff in good basic hygiene practices, providing the necessary protective equipment and making sure sufficient cleaning materials are available. The manager had a very good awareness of infection control procedures and from discussion with staff this was evidently filtering through to them. There were areas that posed some potential risk to residents but these had been identified by the provider and based on the risks that had been identified and addressed at the date of the inspection (i.e. loose toilet bowls, loose taps, tripping hazards) the inspector was reassured that the manager was prioritising works on the basis of risk. The most significant addition was the building of a ramp at the rear of the property that allowed wheelchair access to the building possible. Proposed works need to be included in the homes programme of planned refurbishment. The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 17 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 outcomes for this group of standards is judged to be adequate Staff in the home have some training but have experience of care. They are able to meet the changing needs of most residents and are available in sufficient numbers to fulfil the aims of the home EVIDENCE: Residents are generally satisfied that the care they receive meets their needs. They feel the staff are trained and able to deliver their care needs. Staffing rotas try to take into account the times of high and low activity and the manager was seen to be ‘hands on’ with involvement in the care provided, this stated to be useful as it assisted with contact with residents and on going assessment of staff. In addition to care staff there are ancillary staff to deal with the cleaning and catering. The manager recognises the importance of training, and intends to deliver where possible a programme that meets any statutory requirements. This is something that is yet to be drawn up and is to detail training staff hold, and training needed, with the dates for the training to be provided. A copy of the same is to be supplied to the CSCI. Discussion with the manager indicated areas he felt were priorities this including Moving and Handling; accredited medication training; First aid; Health and safety and NVQ level 2. The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 18 Staff spoken to stated that when the new manager/provider took over they had found it difficult as they were given the space and trust to use their own initiative. It was stated that they now feel more comfortable with this approach and one in particular highlighted that time conversing with residents was acknowledged as part of the job role. It was judged that staff are becoming clearer as to what was expected of them in respect of their day-to-day role. Residents reported that they were satisfied with the staff and the care provided with the case tracking exercise clearly evidencing that staff are carrying out documented care instructions. The new manager/provider has only employed one member of staff since purchase of the home yet the recruitment practice was found to be satisfactory with the exception of a more in-depth induction, which the manager/provider needs to ensure, is to Skills for care standards. A basic two-week induction was however seen to have been offered and the member of staff had been employed less than six months (the length of time allowed for a full induction to expected standards). The manager/provider stated that a full induction would be provided, this therefore not a requirement placed on the home at this time. Examination of other existing staff files showed that there were areas where more information was needed such as a full record of staff member’s working history, although this applied to staff employed prior to the recent change of ownership. The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 19 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, 33,35,36,37,38 The outcomes for this group of standards is judged to be adequate The management and administration of the home is based on openness and respect, although there is at present no effective quality assurance system in place and other management tools need to be developed further. The manager of the home is however deemed to be competent and aware of the areas that need developing. EVIDENCE: The manager is a qualified nurse and stated that he has nearly completed the appropriate vocational management qualification required by the national minimum standards. It was evident from discussion with staff that he is trying to develop them to work in an environment where their skills are acknowledged and their judgement trusted, with residents reporting that he is easy to approach and has demonstrated to some that he is effective in resolving issues that have arisen, this underlining the aim to create a user The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 20 focussed service. Discussion with the manager did indicate that equality of provision was seen as an area of critical importance. There are many areas that still need to be developed, although the manager/provider was notably very open to the inspector about the areas of the services weaknesses and spoke of how it was intended that these would be put right. Priority must be given to creating established formalised procedures for one to one staff supervision/appraisal and implementing an appropriate quality assurance/monitoring system in accordance with the expectations of the National Minimum Standards. The manager/provider was acutely aware of the need to plan the business activity of the home, and manage the finances and resources to deliver the same, but was open as to the fact that the many issues that had arisen since the purchase of the home (i.e. areas of risk) had drawn financial input away from areas that he wanted to develop. Whilst it was acknowledged that the providers aim of creating an excellent service may take longer than first thought, it was still a target that he was confident would be reached. This enthusiasm is to be applauded. Residents have the opportunity to manage their own money if they wish although the only facilities for safekeeping are centrally controlled and not through lockable boxes in bedrooms. The records of the money managed by the home are in place and up to date but the manager must ensure that all records in respect of resident’s monies in safekeeping are verified by two signatures at all times. The manager does not act as an appointee for any resident. Checks show that the records in generally are improving although there were significant shortfalls still in some of the documentation as mentioned elsewhere in this report. The provider must also ensure that a recent photograph is maintained for each resident on each case file (or medication record). The provider has commenced work on risk assessment and was advised to continue this improvement of risk assessments in respect of all potential hazards related to safe working practices and the premises, especially in regard to fire safety (as there was no assessment available at the time). There were seen to be a few issues in respect of safe working practices in the kitchen (incorrect storage of raw meat as one example) and the provider/manager was advised to request a visit from Environmental Health. The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 21 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 1 2 1 x 2 x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 X X X X X 2 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 1 x 2 1 2 2 The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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 OP4 Regulation 14 Requirement The manager must contact the funding bodies for residents to request formal reviews of their care. Social work assessments and care plans must be obtained prior to the admission of any local authority funded resident. The provider must confirm in writing to any prospective resident or their representative that the home is fully able to meet their assessed needs. The provider must clarify with an appropriate person as to whether The needs of any residents with dementia can be met at the Beeches. The manager must continue with work to revise all residents care plans so that they are in accordance with the expectations of Regulations and guidance. The home must continue to improve individual residents risk assessments these to include such as moving and handling, tissue viability, falls, nutrition, DS0000066611.V311592.R01.S.doc Timescale for action 31/12/06 2. OP3 14 31/12/06 3. OP3 14 & Care Stn Act 31/12/06 4. OP7 15, 17(1) a 31/01/07 5. OP7 13,14,15, 17(1) a 31/01/07 The Beeches Version 5.2 Page 23 6. OP7 12,15 7. 8. OP9 OP9 13(2) 13(2) 9. OP9 13(2) 10. OP9 13(2) 11. OP19 23 (2) 12. OP26 13(3) 23(2)d non-use of footrests on wheelchairs, going out unescorted and so on. All care plans must be consistently signed by the resident or their representative to show agreement. All medication must be signed out at the point it is administered. To request an audit of the homes systems for the storage, control and administration of medication from the home’s contracted pharmacist and forward a copy of the subsequent report to the CSCI. Any information handwritten on medication records must be verified as accurate by the directions printed on the container by the pharmacist or a copy of the appropriate prescription. If this differs there must be clear evidence of the prescribing doctor having authorised the change (i.e. initials on the medication records) To use a monitored dosage system (blister packs) for all prescribed medication (where it can be stored in such packaging), this to avoid secondary dispensing. To devise a refurbishment and redecorative programme that identifies works on an on going basis and the timescales in which these will be addressed, this to include the fitting of locks to bedroom doors and securing of wardrobes (based on risk assessment of their need). To refurbish the drying/bed linen storage room so that it is appropriate for its purpose (i.e. paint the walls so washable/ DS0000066611.V311592.R01.S.doc 31/01/07 15/12/06 15/12/06 15/12/06 15/12/06 31/01/07 31/01/07 The Beeches Version 5.2 Page 24 13. OP30 13, 18 provide appropriate flooring). A training plan must be developed that shows how and when staff are to be formally trained in all areas including the following: Moving and Handling: First aid; Health and safety; NVQ level 2. Adult Protection The plan must detail training staff hold, and training needed, and the dates for the training to be provided. A copy of the same is to be supplied to the CSCI. To implement an appropriate quality assurance/monitoring system in accordance with the expectations of the National Minimum Standards. All records in respect of resident’s monies in safekeeping must be verified by two signatures at all times. Inventories of resident’s valuables must be drawn up and maintained. To develop a system for regular and effective one to one supervision and appraisal of staff. The provider must ensure that a recent photograph is maintained for each resident on each case file (or medication record). To continue improvement of risk assessments in respect of all potential hazards in respect of safe working practices and the premises. 31/01/07 14. OP33 26 30/03/07 15. OP35 13(6) 15/12/06 16. 17. OP35 OP36 13(6) 18(2)a 15/12/06 28/02/07 18. OP37 17(1)a 31/01/07 19. OP38 13 31/12/06 20. OP38 23(5) The manager must also draw up a risk assessment focused on fire safety. To request a visit from 31/12/06 DS0000066611.V311592.R01.S.doc Version 5.2 Page 25 The Beeches Environmental services in respect of the homes catering services. 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. 5. 6. 7. Refer to Standard OP1 OP2 OP9 OP9 OP9 OP26 OP38 Good Practice Recommendations The homes statement of purpose and service users guide must be reviewed and issued to every resident All residents should be issued with a written terms and conditions of residency at the point of admission to the home. To put a copy of the homes medication policy in the front of the medication folder to assist staff access. To list those staff that administer medication in the Medication folder against their initials (as they would appear on the MARS records). To consider the use of a lockable medication trolley. To purchase an industrial dryer. To obtain an accident book that complies with the expectations of the Data Protection Act. The Beeches DS0000066611.V311592.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 DS0000066611.V311592.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. 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