Inspection on 30/08/06 for The Beeches (Mansfield)

This inspection was carried out on 30th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 (Mansfield) 11/12/07

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 59 High Street Mansfield Woodhouse Mansfield Nottinghamshire NG19 8BB Lead Inspector Stephen Benson Key Unannounced Inspection 30th August 2006 9:00 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 DS0000067639.V307847.R02.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 DS0000067639.V307847.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches 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 DS0000067639.V307847.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12/12/05 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 on 20/08/06 that the fees for the service range from £277 £319 per week depending on dependency needs. There are additional charges for hairdressing and chiropody. The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home since 1st April 2006 by The Commission for Social Care Inspection. Prior to the visit an analysis of the home was undertaken from information gathered over the last year. The site visit lasted for 6 hours and the main method of inspection used was called case tracking which involved selecting 4 residents and tracking the care they receive through the checking of their records and discussing this with them. Other residents were spoken with and additional records were seen. A discussion was had with staff on duty and care practices were observed. Relatives and a visiting health professional were spoken with. The premises were not inspected in detail but various areas of the home were visited as part of the inspection. What the service does well: The manager goes out to assess any prospective new resident before they come to the home to see if their needs can be met. Staff said they see the assessment carried out before the resident moves to the home. The evidence shows that residents are assessed prior to moving into the home to ensure that their needs can be met. Each resident has a care plan, which explains what help a resident needs and how this should be done. Staff find the plans useful. The evidence shows that residents’ health and personal needs are set out in an individual plan of care. The home liaises well with the District Nurse service and ensures any treatment is carried out. Residents well-being is watched and any service used as needed. The evidence shows that residents’ health care needs are fully met. The home was clean, tidy and fresh and staff are employed to keep the home clean. Cleaners were seen cleaning chairs whilst residents were at lunch. Residents said that it is always kept clean. The evidence shows that the home is clean, pleasant and hygienic. There are three staff on each daytime shift and two at nights. Staff said that they are able to complete their duties. Residents said that there was enough staff on duty. The evidence shows that residents’ needs are met by the numbers and skill mix of staff. All staff have either got or about to register for the National Vocational Qualification level 2. The training plan showed that staff have received the required training and it known when they require further training. Residents felt that staff are suitably trained. The evidence shows that residents are in safe hands at all times. The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 6 The manger has worked at the home for a number of years and has achieved National Vocational Qualification level 4. Staff felt the manager was good at her job. The evidence shows that there is a suitable manager employed to run the home. What has improved since the last inspection? What they could do better: The documentation in the hall about the home refers to the previous providers and there are not any details about the new providers. The evidence shows that proper information is not being provided to allow residents to make informed choices. There was some differences described as to how staff promote residents privacy and dignity when assisting them to bathe. The nighttime records showed that there could be an improvement in managing residents’ continence. Care plans did not refer to promoting residents’ privacy and dignity when providing care. The evidence shows that residents’ privacy and dignity could at times be better promoted. There was no record made of what activities residents have taken part in and the activities programme on display is not always followed. The evidence shows that resident’s lifestyle does not always match their expectations. Residents are able to make choices about their daily routine in most areas, however residents spoke of having to get up in the morning for breakfast when they would like to stay in bed longer. Breakfast was finished when the inspection started at 9.00am. The evidence shows that residents could have more control over their lives. The manager and staff were not aware of the correct procedures to follow in the event of any allegation and the Adult Protection procedures were not up to date. The evidence shows that measures are not in place to protect residents from abuse. It would be of benefit to residents if the home was able to increase the amount of storage space available as at present wheelchairs are stored in one of the lounges restricting the use of this room. The evidence shows that the home does not have sufficient storage. The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 7 The home does not have any system for seeking the views of residents about the quality of care provided. The evidence shows that residents do not have opportunities to express their views on how the home is run. Records of residents’ finances were not properly completed and there were some discrepancies between records and cash held. The evidence shows that residents’ financial interests are not being safeguarded. 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 DS0000067639.V307847.R02.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 DS0000067639.V307847.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about where they live. New residents are assessed prior to moving into the home to ensure that their needs can be met. The home does not offer an intermediate care service. EVIDENCE: There is information about the home available in the entrance hall, including the Statement of Purpose and Service User Guide, however this has not been changed to show the change in ownership of the home. The manager said that she goes out to assess any prospective residents to make sure their needs can be met within the home. A copy of the Community Care Assessment is obtained before the resident moves in. One recently admitted resident’s file was seen which had a copy of the assessment in. The manager said that she has discussed how admissions will be managed in future The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 10 with the new provider and that it was agreed that there will not be any change to the system in use. Staff said that new residents are assessed before coming to the home by the manager and they are shown the assessments before they move in, so that they know what the resident will need. Staff also said that families will come and look round the home and that they always know in advance if someone is coming. A resident said that they “cannot remember whether someone came to see me, but I know this is the home I wanted to come to as it has a good reputation” and that “I was made welcome when I moved in”. There is no arrangement made for the home to provide an intermediate care service. The Beeches DS0000067639.V307847.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal needs are set out in an individual plan of care, but lack detail of social needs. Residents’ health care needs are fully met. Residents are protected by the homes procedures for dealing with medicines. Residents are treated with respect, but their dignity could at times be better promoted. EVIDENCE: The manager said that the new provider is happy with the care planning system in use and there are no plans to alter it. Staff said that they write about each resident every shift and record anything significant, such as a doctor or district nurse visit. Staff said that they use the care plans on a regular basis to refer to and find them useful. A Social Worker responsible for reviewing all placements made by Nottinghamshire County Council was at the home and said that she was happy The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 12 with how placement aims are being achieved within the home and that there were not any concerns. A resident said “staff only help with the bits that I need”. Four care plans were looked at and these were well completed. A selection of needs identified in assessments were looked at and these had appropriate care plans and, where needed, risk assessments. There was not much detail of residents’ hobbies and interests. Residents’ comments were included when reviewing the plans, although the section for family comments had not been used and one was overdue to be reviewed. The manager said that she would ensure this was done. The manager said that residents go to an optician round the corner for routine eye checks but cannot get a dentist to carry out check ups, although one will come out if called if dental work is needed. Staff said that they tell the senior on duty if someone says they are not well or look a little under the weather, and a doctor will be called if needed. A visiting district nurse said that there was good communication between them and the home and that staff will carry out any care they ask them to. A resident said “They have made me an appointment with an optician in September” and that “staff always ask how I am”. There were separate sheets in the care plan to record any healthcare appointments and these showed that residents’ physical and psychological needs are seen to. One entry in the daily log noted a resident had a rash and a doctor visited on the next working day. Staff said that only trained staff give out medication and they always watch that it is taken. A resident said “staff give me my tablets and make sure I take them, I know it is for my own good”. There is an assessment included within the care plan as to whether a resident is able to self medicate. At present there are not any residents who have been assessed as being able to self medicate. Medicine Administration Records were fully completed and had a photograph of each resident to help with identification. All medicines are stored in a lockable drugs trolley, which is kept in a locked room when not in use. Staff were observed giving out medication and were seen to watch that residents took their medication before leaving them. Staff said they always knock on residents’ doors before entering and described how they closed doors and drew curtains when providing personal care. There were some different practices described as to how assistance is given when helping residents bathe, some of which better-promoted residents privacy and dignity. The manager said that all staff should know best practices and said she will remind staff of this. The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 13 The log book showed that residents’ continence is not being managed well during the nights. This was bought to the attention of the manager who said that she had already raised this concern with the senior staff on night duty and was looking for an immediate improvement. A resident said “staff just carry on normally, I don’t worry about privacy and am happy with the help that I get, they look after us well. Care plans described how staff should provide personal care, but did not include any details as to how privacy and dignity should be promoted. The Beeches DS0000067639.V307847.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents find the lifestyle experienced in the home does not always match their expectations. Residents maintain contact with family and friends. Residents could have more control over their lives. Residents receive a wholesome and balanced diet. EVIDENCE: There is little detail in care plans about residents’ interests and hobbies and a record is not kept of when residents have joined in an activity. It was not therefore possible to see which residents have had opportunities to take part in an activity. The manager agreed that it would be helpful to keep a record. Staff said they had been looking at some photographs with a resident that morning. A resident said “they had a sing song yesterday and that a choir sometimes comes to visit” and “we can have a game if we want one”. Another resident said “we don’t play dominoes”. Residents also said they had enjoyed the recent garden party. The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 15 Relatives said that they had not seen any activities taking place when they visited. There is an activities programme displayed on a notice board in the hall, showing an activity each morning and afternoon, which staff said that they try to follow but this does not always happen due to other pressures. The programme also shows an entertainer comes to the home monthly and there is a fortnightly church service. There is a selection of tapes, compact discs and digital versatile discs of music and old films, although the only thing playing was the television, which residents did not appear to be watching. The manager said that music is meant to be playing in the entrance hall and the lounge. There is a selection of books on a bookcase in the lounge, which includes some large print books, however this is difficult for residents to reach as wheelchairs are stored in front of it when they are not in use. Staff said that the manager takes residents to the cinema and there are trips out to a local café and shops. Staff also said that visitors can visit at anytime although it is best to avoid mealtimes. A resident said “my grandson came to see me at lunchtime”. Relatives spoken with said they are able to visit when they want and often go to their relative’s room rather than sit in the lounge. Staff said that residents choose when they go to bed, but did not say that they choose when to get up in the morning. Residents said that they are able to choose what they want to wear each day and go to bed when they want, but said that they are told when to get up in the morning in time for breakfast. A resident said “I would like to get up later, but have to get up” and another said “I don’t get up when I want, staff say what time I get up”. Relatives said their relative had said previously they would like to stay in bed later. All residents except one, who was in bed poorly, were up, dressed and had finished breakfast when the inspection started at 9.00am. The manager said that residents can chose to get up later if they wish and she would ensure that staff are aware of this. A new cook has just started following the retirement of the previous one and said she was settling well and learning what the residents liked. A resident said “I have toast every day for breakfast and I would like to have some egg and bacon sometimes”. Another resident said “you can’t grumble at the food, there is plenty to eat and the variety is good. The meat today was a little tough”. The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 16 Residents were seen eating lunch and said that they had enjoyed it. There was a choice of juice provided and one resident had a cup of tea. A weekly menu is displayed in the hall and this shows a varied and nutritious diet is provided, although a choice is not provided alternatives are available on request, including a vegetarian option. The manager said that a daily menu will be on show shortly. The home alternates each week between soup before lunch and a pudding. The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are confident that their complaints will be listened to. Measures are not in place to protect residents from abuse. EVIDENCE: One complaint has been received by The Commission for Social Care Inspection which is currently being investigated by Social Services. A record of this complaint was in the complaints book, but there were some complaints made by residents seen in the daily log, which had been correctly dealt with but had not been recorded in the complaints book. Staff said that they pass any complaint onto the senior on duty and there is a complaints book to record any complaint in. A resident said that the provider and manager are easy to talk to and if you just mention something to one of the carers and it is sorted out. I mentioned something, don’t want to say what it was, and it was made right straight away”. Relatives said that the staff had been very helpful when their relative had lost some jewellery There was a copy of the Adult Protection Procedures in the office, but these were not up to date. The manager and staff said that they have not had any training on adult protection and felt this would be of benefit as they have to ensure that residents are protected from any form of abuse. A resident said “you won’t get mistreated here” The Beeches DS0000067639.V307847.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained environment. The home is clean, pleasant and hygienic. EVIDENCE: The home is well laid out and is accessible to wheelchair users. There are two lounges and additional seating in the large entrance area where some residents like to sit. The manager said thought is being given to the layout of the larger lounge to make it more suitable for residents to use. The furnishings and décor are in good condition and homely. There is a lack of storage facilities resulting in equipment being stored where it can, like in the corner of rooms. The manager said that the provider had prepared a list of things to be done, some of which have been started on. This includes new first floor windows. Staff said that the new provider has carried out a number of improvements and there are more things to be done. The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 19 A resident said “It’s our home, we have everything we need” and another said “its good, I like my room and have put up my own pictures”. The home was clean, tidy and fresh at the inspection. The home employs a housekeeper and separate cleaning staff who were seen cleaning during the inspection. When residents went through to lunch the armchairs were cleaned and tidied. The laundry is sited away from the main building and is well organised. There were supplies seen of protective clothing and staff were seen wearing these when needed. Relatives said that they thought the home was “kept lovely”. A resident said “my word, it is kept clean”. The Beeches DS0000067639.V307847.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the numbers and skill mix of staff. Residents are in safe hands at all times. Residents are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. EVIDENCE: The home provides three care staff during the day and two at night. In addition the home employs a cook, housekeeper and cleaners. Staff said they felt there is enough staff on duty. A resident said “staff are always fully occupied, but I just have to press a button and somebody comes”. The manager said that there are four staff enrolling on National Vocational Qualification level 2 this month and the rest of the staff have all completed it. A member of staff said that they had completed National Vocational Qualification level 2. A resident said “staff know what they are doing and look after us very well”. The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 21 There have been some new staff appointed recently and a sample of staff files were looked at. These contained an application form, two references, a Criminal Records Bureau check and a health questionnaire. The manager showed the training programme, which lists training done by staff, and shows when further training is required. Staff said that they are encouraged to take up training opportunities and that they had received all the required training. A resident said that “staff are definitely trained to do their job”. The Beeches DS0000067639.V307847.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a suitable manager employed to run the home. Residents do not have opportunities to express their views on how the home is run. Residents’ financial interests are not being safeguarded. The health, safety and welfare of residents are protected. EVIDENCE: The manager has worked at the home for a number of years and has a clear understanding of her role. The manager has successfully completed National Vocational Qualification level 4. The manager said that the change of ownership of the home had gone well and she has a good working relationship with the new providers. The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 23 Staff said that they think the manager is good at her job. The home does not have a quality assurance system in place so residents do not have opportunities to comment formally on the services provided within the home. The manager said that the provider had identified this as something that needs to be done and was seen on the list of things to do prepared by the manager and provider. The home will assist any resident with managing their personal allowance if they wish. There is a book to keep a record of all money looked after, and any expenditure made, and where a receipt has been given this is also kept. However the record book was not being properly completed and there were a number of transactions made that were not witnessed by a second person. The amounts shown on some records did not match those with the money held. The manager said that she would get this sorted out straight away. All the required safety checks and tests were being carried out at the correct frequency. A residents said “I hear the fire alarm go off sometimes”. The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 4 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 X 2 X 3 The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 25 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 OP10 Regulation 12 Requirement The registered person must ensure that residents’ privacy and dignity is promoted at all times The registered person must ensure that all residents have opportunities to participate in activities The registered person must ensure that residents are able to exercise control over their lives The registered person must ensure that staff are able to protect residents from abuse The registered person must ensure there is a system in place for reviewing and improving the quality of care The registered person must ensure that residents personal allowances are properly looked after Timescale for action 01/10/06 2 OP12 16 01/11/06 3 4 5 OP14 OP18 OP33 12 12 24 01/10/06 01/11/06 01/01/07 6 OP35 12 01/10/06 The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 26 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 Refer to Standard OP1 OP7 OP15 OP16 OP19 Good Practice Recommendations The registered person should update the home’s Statement of Purpose and Service User Guide to show the change of ownership The registered person should include details of residents social needs in care plans The registered person should consult with residents about their mealtime preferences The registered person should ensure that a record is made of all complaints in the complaints book The registered person should consider ways of improving storage facilities The Beeches DS0000067639.V307847.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 DS0000067639.V307847.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!