Inspection on 11/12/07 for The Beeches (Mansfield)

This inspection was carried out on 11th December 2007.

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 (Mansfield) 30/08/06

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE The Beeches (Mansfield) 59 High Street Mansfield Woodhouse Mansfield Nottinghamshire NG19 8BB Lead Inspector Susan Lewis Unannounced Inspection 10:30 11 December 2007 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 (Mansfield) DS0000067639.V349258.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 (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches (Mansfield) Address 59 High Street Mansfield Woodhouse Mansfield Nottinghamshire NG19 8BB 01623 421032 01623 421234 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) Justcare Homes Ltd Mrs Susan Ann Wagstaff Care Home 26 Category(ies) of Dementia (26), Dementia - over 65 years of age registration, with number (26), Old age, not falling within any other of places category (26) The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2006 Brief Description of the Service: The Beeches is a care home providing personal care and accommodation for 26 older people, including up to 8 beds that can be used for people with dementia over the age of 55. The home provides short term, long term and respite care and can accommodate emergency admissions. The home is owned by Justcare Care Homes who purchased it in April 2006, and is run as a small business. The home is located in the centre of Mansfield Woodhouse close to shops, pubs, the post office and other amenities. The home was opened in 1989 and consists of a house with an extension all of which are listed.24 of the homes bedrooms are single, and all of the bedrooms have en-suite facilities. Bedrooms are located on 2 floors and there is a passenger lift. The home has well appointed gardens that are well maintained and easily accessible. There is car parking available for 12 cars. The manager said the fees for 2007 range from £280 to 330 per week depending on dependency needs. There are additional charges for hairdressing and chiropody. The last inspection report is available in the reception area of the service. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection involved one inspector; it was unannounced and took place over 7.5 including lunchtime. The main method of inspection used was called ‘case tracking’ which involved selecting three residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. We were unable to effectively understand and communicate with some of the people living at the home, therefore some judgements in this report are drawn from our observation of staff and resident interactions. Two members of staff and two sets of relatives were spoken with as part of this inspection. In addition the views of three other residents who were not part of the “case tracking” were sought to form an opinion about the quality of the service. Documents were read as part of this visit and medication was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken, all communal areas were seen and a sample of bedrooms to make sure that the environment is safe and homely. A review of all the information we have received about the home since the last inspection was considered in planning this visit and this helped decide what areas were looked at. The registration document was also reviewed as part of this inspection to ensure it was up to date and in line with current legislation. Any changes necessary will be sent to the proprietor. What the service does well: The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 6 The service is very well maintained and staff receive good support from the management to enable them to do a good job and ensure residents live in a home with a lovely atmosphere where they feel safe and well cared for. Residents are assured that their needs are going to be met before moving to the home by a staff team who are well trained, competent and experienced. Over half of the staff have achieved their National Vocational Qualification to make sure they are trained to meet the needs of residents who need care. Complaints are documented, investigated and complainants are responded to, ensuring that their concerns are addressed. All residents know who to speak and feel confident that any concerns will be dealt with promptly. The manager is qualified experienced and was praised highly by residents, staff and visitors as being kind, helpful and approachable. Residents’ finances are securely held and properly recorded to make sure their interests are protected. The tests and servicing of equipment at the home is done at the intervals suggested and this ensures that residents and staff have their health and safety protected What has improved since the last inspection? The new proprietor has started a programme of refurbishment and new windows to the front and rear of the building have been installed as well as new carpets to some areas of the home. The management have now employed an activities organiser 4 mornings a week to support residents to have a more active life in the service. Residents feel more able to have control over their day to day life particularly in such areas as what time they get up and go to bed. All staff have either had safeguarding adults training or are due to attend early in 2008 this ensures that staff understand and can recognise what abuse is and how to protect residents in their care. Although the quality assurance questionnaire is not fully functional as yet there are significant systems in place to ensure that the home is run in the best interests of the residents. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 7 The residents’ finances are now properly monitored and residents are protected from financial wrongdoing. 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 summary of this inspection report can be made available in other formats on request. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Residents are only admitted to the home following an assessment and the manager is sure that they have the skills and experience to meet the person’s needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Intermediate care is not provided at the home and this standard is not applicable Four care plans were viewed including the last person to be admitted to the home to make sure they had been properly assessed before being admitted to ensure needs could be met. All plans had evidence that assessments were carried out prior to the admission. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 10 The staff who were spoken with said although they don’t have anything to do with admissions they were aware that the manager visited residents before they moved in and she shared information about new residents to enable them to support the person settling in to the home. Pre inspection information provided by the registered manager said that prospective residents were invited to spend time in the home prior to them moving in and making their final decision. Most residents spoken with could not remember whether they had taken this option up or not. The manager said that residents are admitted to the home if she feels confident that staff have the skills and experience to meet their needs. Residents spoken with said that the manager had talked to them about what help they needed before moving to the home and made them feel safe that staff could help them. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. The service has a strong belief that it is essential to involve residents in the planning of care that affects their lifestyle and quality of life. Staff support residents health care needs to ensure they are able to see a health care professional when they need to. Medication records are generally up to date but some gaps and poor recording have led to errors and place residents at potential risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of the “case tracked” residents were inspected to make sure that they contain enough detail about people’s needs to properly guide staff. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 12 The service has recently changed the format it uses for care plans and the quality of the information on the new system was not to the same standard as the previous system used. Where residents had needs identified in the assessment no care plan existed this included where a resident had diabetes this potentially placed the resident at risk. However the manager produced the old plans and all this information was still held in these all identified needs had a care plan. Staff spoken with had mixed views of the new system some liking the new system saying it was easy to read whereas others didn’t feel it gave enough information. All staff knew the residents needs and residents spoken with said that staff were supportive and always knew what they needed to do. In further discussion with the manager after the inspection visit she said that they were now returning to the old system as they felt it ensured that all needs were identified with a care plan. Residents spoken with said that staff did talk to them about their needs but were not always sure what a care plan was. Visitors spoken with said they understood that the manager talked to other relatives about their loved ones care needs. Staff spoken with said that they talk to residents when reviewing care plans and diary notes did show that this was the case. Residents spoken with said that they see a doctor when they need to and diary notes showed that other health care professional such as district nurses and chiropodists were involved where necessary with residents support. Records showed that residents had their weight monitored regularly and action was taken if significant weight loss was noticed. Specialist equipment was available in several bedrooms where residents had assessed needs such as pressure ulcers or mobility issues. The manager said that the proprietor has recently bought some specialist beds that lower to the ground and then rise up to enable staff to provide the care needed. These were also seen during the tour of the service. A medication round was observed during the inspection visit to check the systems in place are safe and protect residents. Staff who administered the medication ensured residents took their medication before signing to say it had been taken. The Medication Administration Record showed evidence of several gaps, which had not been explained by staff. If medication is missed this could place the person at some risk of ill health. There was also evidence that there was a tablet, which is a Controlled Drug The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 13 was not counter signed on several occasions and due to poor recording an error had occurred in the overall tally. Although no tablets were missing it was confusing and could lead to further error, again placing residents at risk. Staff spoken with who administered medication were able to discuss how to give medication and understood the importance of good practice, only senior trained staff were able to administer medication. During the course of this inspection an observation of staff and residents was done to consider the impact of the interactions between them and how this affected the care received. Overall staff interacted in a positive manner with residents and spoke in a pleasant friendly manner to all residents. Visitors said that they felt staff were very nice with residents and residents spoken with said that staff treat them well and are ‘lovely’. Staff spoken with knew of the policy on privacy and dignity and were able to say what should be done to support residents. During the morning staff were assisting residents to have a bath and were observed to brush a residents hair in the lobby of the service. This does not support the person privacy, as all personal care should be done either in the person’s bedroom or in the bathroom. This was requirement at the last inspection and is not fully met. It has been agreed by the Commission to allow the management of this service more time to ensure that this requirement is fully met. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. Residents are able to enjoy a full and stimulating life style with a variety of options to choose from. . Routines are very flexible and residents can make choices in major areas of their life. The menu is varied, balanced and nutritious. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents were seen throughout the day engaging in a variety of activities such as watching a film or playing dominoes. An activities organiser has recently been employed four mornings a week and residents spoken with said that they could take part in activities if they wanted or not as they chose. ‘I can have a game of dominoes if I want to, some activities I don’t want to do but I can choose. I can go outside in the warmer weather and my children visit regularly I am not unhappy with anything’. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 15 A requirement was made at the last inspection to ensure that all residents have opportunities to participate in activities. From evidence seen in observation and discussion with residents this is now met. Residents spoken with said that they were able to get up and go to bed when they wanted to and on arrival at the home at 10:30 residents were seen still having their breakfast and others getting washed and dressed with staff support. A requirement was made at the last inspection to ensure that residents are able to exercise control over their lives. In discussion with residents they confirmed that they could spend the day as they wanted including getting up and going to bed. ‘I spend my day as I want to. I like it here staff are kind I get up and go to bed when I want to’. Visitors to the service said that they were made to fell welcome by the staff and manager and could come any time. They could either see their loved one in the lounge or their bedroom. Residents said that they had been able to bring personal possessions to the home and this was confirmed during a partial tour of the home where a selection of bedrooms was looked at. The midday meal was observed and it was appetising and appeared nutritious. Residents spoken with mostly said that the food was good and there was plenty of it as well as a choice. Only one person said that the food wasn’t what he was used to. Staff spoken with said that they were aware of supporting residents to have a choice and if they didn’t like a meal to make arrangements for alternatives. The cook was spoken with regarding residents dietary needs particularly those who had special diets she understood diabetic diets but when asked about pureed meals said that they were served all mixed together. The kitchen was well ordered and clean. There was plenty of food available including fresh fruit and vegetables were delivered daily and fresh meat was delivered from the butcher weekly. This ensures residents are provided with a balanced and nutritious diet. The Beeches (Mansfield) DS0000067639.V349258.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Residents and relatives are confident that when they make a complaint it will be dealt with promptly and efficiently. Staff understand the importance of protecting residents from abuse and procedures are in place to ensure that this happens. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Commission has received no complaints about this service since the last inspection. From pre inspection information received from the manager it showed that the service received only one complaint in the last 12 months and this was resolved using the service’s complaints procedure. The complaints policy was on display in the home and residents spoken with knew who to speak to if they were unhappy, as did visitors. All felt that the manager would deal with it promptly and would listen to them. ‘I am not unhappy with anything I would speak to the manager if I were’. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 17 Staff spoken with understood how to support residents to make a complaint and that if the complaint involved the manager they knew who they needed to speak to for further information. Residents spoken with said they felt safe and visitors said that they felt their loved ones were looked after in a pleasant and safe environment by staff who cared. Staff spoken with said that they had either been on training or booked to attend in 2008 but all understood what constituted abuse and what they had to do if they suspected it. Staff said that this was taken very seriously by all staff and discussed at meetings including supervision. Staff said they could not imagine their colleagues not passing any concerns on to the manager or proprietor. A requirement was made at the last inspection to ensure that staff are able to protect residents from abuse. From evidence seen in training records and from discussion with staff and residents this is now met. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Residents live in a very well maintained, safe, comfortable, attractive and clean home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the building took place to ensure that the home was suitable for the needs of the residents. Parts of the home have been re carpeted, new windows have been fitted to the front and rear of the building. This is part of the on going refurbishment that the new proprietor has started since taking over the service. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 19 Rooms viewed were clean and well maintained and clearly personalised residents spoken with said that they had been able to bring in items from their home and one resident said that he had been able to have a phone installed in the bedroom. The home was accessible to wheelchair users and residents had plenty of space to use for a variety of activities, the dining room was pleasant and spacious and the garden accessible and well maintained. The pre inspection information sated that there is a maintenance plan and staff spoken with said that maintenance was regularly carried out and any problems dealt with promptly. The home was clean and fresh smelling throughout and visitors said that they it never smelt unpleasant. The laundry was suitable for its purpose and had surfaces that could easily be cleaned to minimise infection. Staff spoken with understood infection control and staff had attended infection control training ensuring residents were supported appropriately to minimise any risk of cross infection to them. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. Residents have confidence in the staff that care for them. Management recognises the benefits of a skilled, trained workforce in providing good quality care to residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoken with said that they felt there were enough staff on duty to meet the needs of all the residents. Residents spoken with said that staff were available to help them and they didn’t have to wait all that long before someone came to them. Pre inspection information indicated that 3 care staff were employed during the day with 2 at night and rotas were seen to confirm this. Pre inspection information stated that over 50 of all staff have National Vocational Qualification inn Care Level 2 or higher. This ensures that staff have training to a minimum competency level to meet the care needs of residents. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 21 Staff files were checked to ensure recruitment was robust and protected residents. Files viewed had Criminal Records Bureau checks and two references. This shows that the manager carries out all appropriate checks before staff are confirmed in post. Files also included evidence of training attended. Staff spoken with said that training was encouraged and they were given time to attend any course they needed to. Any new staff have induction training and were supervised until competent and knew the residents needs. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. The registered manager has the required qualification and experience, is highly competent to run the home. There is strong evidence that the ethos of the home is open and transparent with the views of both staff and residents listened to, and valued. The health and safety of residents and staff is maintained and supported by good maintenance systems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has managed this service for fourteen years and residents, staff and visitors spoke positively about her. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 23 Residents felt confident in her ability to ensure their safety and staff said that she was open, supportive and approachable. Visitors commented on the pleasant atmosphere in the home and that the manager was friendly. The manager undertakes regular training to maintain her knowledge within the care sector. Staff also spoke positively of the proprietor and the general management of the open saying they felt it lead to a well run home. Staff said that the proprietor visits two to three times a week and has a good understanding about what is happening within the home. During the proprietors visits the manager tours the service with him to check for the environment to ensure it is to standard and what maintenance issues there may be. Residents’ surveys are now being sent out but as yet this information has not been collated to inform the action plan. Residents and relatives do not have their own meeting to give further feedback to manager regarding the service they receive, however the manager routinely talks to all residents to obtain their views. Residents spoken with confirmed this. The senior carers have a weekly meeting with the manager, minutes of this meeting are available and shared with all staff. All staff receive regular supervision which looks at different issues each month such as policies and procedures safe guarding adults and fire training. A requirement was set at the last inspection to ensure there is a system in place for reviewing and improving the quality of care. From all the evidence seen this is now met. Staff helps residents who need support with their finances. All residents’ monies are stored securely and records are kept of all transactions they showed what the money was for and each transaction had two signatures to maintain security. The systems in place protect residents from any financial abuse. A requirement was made at the last inspection to ensure that residents personal allowances are properly looked after. From evidence seen in records this is now met. Maintenance records were viewed to check if everything was up to date and health and safety was being maintained. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 24 Fire records showed that training and fire drills were being done regularly. All equipment is checked according to manufacturers instructions. The lift and heating system maintenance records were viewed and showed that these were done routinely. The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 2 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 3 3 X X X X X X 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 3 X 3 X 3 X X 3 The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement The management of medication must improve as follows: The Medication Administration Record must be fully completed, if any medication is not given there must be an explanation for the omission. This is to ensure that residents get their medication as prescribed by their Doctor. There must be an accurate record of all Controlled drugs (or those to be treated as Controlled Drugs) to ensure that these are being administered safely and according to the residents’ prescription. 2 OP10 12 The registered person must 01/03/08 ensure that residents’ privacy and dignity is promoted at all times. (This is an outstanding requirement from 1/10/06) Timescale for action 01/02/08 The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 27 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 Refer to Standard OP9 Good Practice Recommendations Hand written entries on Medication Administration Records could be signed and countersigned to minimise the risk of error when transferring information from source to another. Pureed meals are served in identifiable portions, as this is more appetising. 2 OP15 The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Beeches (Mansfield) DS0000067639.V349258.R01.S.doc Version 5.2 Page 29 - 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. 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