Inspection on 05/09/06 for The Beeches Nursing Home

This inspection was carried out on 5th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 Nursing Home 11/11/08

The Beeches Nursing Home 21/05/08

The Beeches Nursing Home 07/11/07

The Beeches Nursing Home 09/02/06

The Beeches Nursing Home 16/09/05

The Beeches Nursing Home 21/10/04

The Beeches Nursing Home 09/06/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Beeches Nursing Home 320 Beacon Road Wibsey Bradford BD6 3DP Lead Inspector Susan Knox Key Unannounced Inspection 08:30 5 & 6 September 2006 th 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 Nursing Home DS0000029133.V309586.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 Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Nursing Home Address 320 Beacon Road Wibsey Bradford BD6 3DP 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) 01274 608656 01274 608656 beechesch@aol.com Victorguard Care plc Care Home 64 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (1), Physical of places disability (1), Physical disability over 65 years of age (64), Terminally ill over 65 years of age (1) The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The place for MD (E) is specifically for the service user identified in the application dated 26 August 2004 The place for TI (E) is specifically for the service user named in the application dated 2 June 2006 9th February 2006 Date of last inspection Brief Description of the Service: The Beeches Care Home is a purpose built facility situated in the Wibsey area of Bradford it provides care for 64 elderly people with physical disabilities over the age of 65 yrs. The home is located in a residential area that is near to a regular bus route. There are pubs, shops and churches nearby. Adequate parking is available adjacent to the building. Accommodation is provided on two floors, in 62 single rooms. 60 have an ensuite facility. Communal space is provided in the spacious lounge/dining room on the ground floor of the home. This has panoramic views over Bradford and where residents can access the patio area. A second lounge is also located on the ground floor at the opposite end of the building. Information about the services provided can be obtained from the home in information packs that contain the Statement of Purpose, Service user Guide and complaints procedure. The weekly fees for services provided in the home vary depending on whether or not the resident is funded by the local authority, have nursing needs and fees are supplemented by the nursing care component paid by the health authority or if they pay privately. Details of exact charges can be obtained from the manager. They range from £389.75 to £512.46. The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) carries out inspections of care homes at a frequency determined by the assessed quality rating. The inspection process has become a cycle of activity rather than a series of oneoff events. Information is gathered from a variety of sources, one being a visit to the home. All regulated services will have at least one key inspection before 1st July 2007. This is a major evaluation of the quality of a service and any risk it might present. It focuses on the outcomes for people living at the home. The entire key National Minimum Standards (which are identified in each section of the report) are assessed and this provides the evidence for the outcomes experienced by residents. At times it may be necessary to carry out additional visits, which might focus on specific areas like health care or nutrition and are known as random inspections. This visit was unannounced and carried out by one inspector over two days. It started at 8.30am and finished at 4.30pm on the 5th September 2006 and was completed on the 6th September 2006 between 8.15 am and 2.30 pm. Feedback was given to the responsible person Mrs Joanne Walkden and the acting manager Mrs Michelle Shannon during and at the end of the visit. In May 2006 the long established manager retired. Two acting managers have been appointed since then currently the acting manager is Mrs Michelle Shannon. The purpose of the visit was to make sure the home was being managed for the benefit and well being of the residents and to see what progress had been made to meet requirements arising from the last inspection. Information to support the findings in this report was obtained by looking at the information supplied in the pre inspection questionnaire (PIQ). Examples of information gained from this document include details of policies and procedures in place, maintenance and safety, menus, staff details and training. Records in the home were looked at such as care plans, staff files, and complaints and accidents records. Residents, their relatives and visitors were spoken to as well as members of staff and the management team. CSCI survey cards were sent to three visiting professionals to the home and a number were left to be given to residents and their relatives. At the time of writing this report one professional had replied with positive responses. In addition a letter was received praising the staff for their respectful care of a relative receiving palliative care. The evidence gathered at this inspection means that the quality rating for this home is good. The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Personal care routines following mealtimes are too regimented although the home has taken steps to address the problems. The quality of the paperwork in care planning could be better. Care documents must be signed and kept up to date. Mealtimes were well organised but some staff were not following the procedures for recording that residents needing help had been assisted. Although regular discussions are held about meals there was evidence that some residents were not enjoying their food. Induction procedures for new staff should be reviewed to ensure this process is not rushed. Management must respond more robustly to any concerns that relate to possible abuse. The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 7 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 Nursing Home DS0000029133.V309586.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 Nursing Home DS0000029133.V309586.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable to this home. Quality in this outcome area is good. This judgement has been made following a site visit and by checking records. The manager does ensure residents are fully assessed prior to admission and that staff can meet their needs. EVIDENCE: The Statement of Purpose has to be altered to reflect the changes in management. The responsible person will ensure this is done when a decision is made about employing a registered manager. She was aware that an application has to be submitted to the CSCI so that a fit person process can be carried out. Written information is available about the home so that an informed choice can be made before moving into the home. This was confirmed in discussions with residents and relatives. On the first day of this inspection the manager had an appointment to carry out an assessment of a prospective resident who was in hospital. A preadmission assessment is undertaken to ensure the home will meet the needs The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 10 of individuals. Residents confirmed staff had visited them before moving to the home. The quality of the assessments varied in the case tracked documents. Some had been assessed prior to the new acting manager appointment. In discussions with staff and checking training records it was clear that staff are fully trained in being able to meet the needs of the residents. The Beeches Nursing Home DS0000029133.V309586.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. Resident’s care plans require further work and all documents must be up to date and signed. Health care needs are met. The procedure for the administration of medication protects residents. Residents are treated with respect and attempts have been made to deal with one on going issue. EVIDENCE: The inspector looked at care documentation and talked to residents and staff in order to track the care of four residents. The acting manager said that care documentation was currently under review. Due to repeated copying some of the forms in use were of poor quality with sections missing. Some care files could be made easier to use if some of the documents were archived. Health and personal care needs were set out in a care plan but of the four checked only one fully addressed social needs. The quality of the care documents varied dependant on the member of staff completing the record. Some had not been evaluated monthly as required. However, care plans were in place for each of the individual’s case tracked. Some work is required to The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 12 ensure all needs are identified in care planning and met. For example, one assessment showed that the resident had part dentures and own teeth. This was not fully addressed in the care plan, which only identified the dentures. The involvement of residents and relatives in agreeing to care plans must be made clearer. Where possible signatures of either or both on care plans should be obtained. Residents and some relatives spoke well about the care provided by staff. Health needs are fully met. Health care is promoted by the home including the use of equipment and up to date clinical guidance and risk assessment tools but some assessments were either undated or not signed. This oversight makes the record of little use as time progresses. All records are legal documents and must be signed by the person making the record and dated. The home does not operate a monitored dosage system for medication. Monthly stocks are delivered to the home from the local pharmacist. The deputy manager said that individual resident’s medication is reviewed by the GP more than once annually. Medication was stored appropriately in a drugs room and trolleys are used to take medication out to individual residents. The administration of medication was observed during the inspection and was satisfactorily carried out. Medication records were appropriately kept and a random check of medication including controlled drugs was satisfactory. It was clear that stock control checks could be carried out as the amount of medication received was recorded. Systems for the monitoring and recording of medications ordered, received, administered and disposed of are in place. The administration of medication is safely carried out and is according to up to date guidelines. Some residents were able to say that they were happy with procedures for administering medication. Over the two days of the inspection some time was spent in observing routines and staff interaction with residents. It was noted that staff treated residents with respect. This was confirmed during discussions with residents. One issue that was raised by residents and relatives was the occasions when residents had to wait for some time before being assisted to the toilet. During observations following meal times it was noted that residents who used wheel chairs were lined up in the lounge waiting to be assisted. In many ways this compromises a resident’s privacy and dignity. Management were fully aware of this issue and had tried different ways to address the concern. Due to the numbers of residents having to be assisted it was an issue difficult to resolve. Since the inspection this issue has been discussed in a residents meeting and additional staff have been included in the daily rota. Management are advised to refer to this at forthcoming meetings to ensure that the matter has been resolved. The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 13 Although standard 11 about death and dying has not been inspected at this visit, a letter was received by the CSCI from the relative of a former resident who had received palliative care at the home. This praised the respectful care given by the staff and that family and friends were encouraged to spend time with their sick relative. The Beeches Nursing Home DS0000029133.V309586.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home does provide choice and includes residents in decision making. The majority of the residents enjoy the meals but a definite choice should be provided at all meals. EVIDENCE: Many of the residents said they enjoyed the activities arranged by the activity organiser. A full programme is displayed in the home ensuring that residents can make their own decision about attending. Notices are displayed in various places of the home for residents and visitors to read. A notice advertising the next residents meeting was displayed also inviting relatives to attend. A coffee morning was arranged for later in the month. Outings are regularly arranged including a shopping trip to the White Rose centre, a local park and the Alhambra. The home also organises a tuck shop for residents to buy small items. Lots of photographs were displayed in the home showing residents involved in the different events. It was apparent that an ongoing programme of activities is available for the benefit of residents. Individual attention is given to those unable to participate in group activities. This comprises of nail care or hand massages. The home prints out a regular newsletter. The August 2006 edition provides news about activities and staff changes. It also informs readers that although The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 15 Roman Catholic religious needs were being met no one from other denominations visit the home. A local church has been contacted in order to address this shortfall. In discussions with residents it was said that they could make their own choices for example bed times, joining in activities, staying in their rooms if that was their preference. It was said that staff welcomed visitors and this was observed on the day. The dining room provides a pleasant setting and tables were laid appropriately. A menu board is in the dining room but the daily menu was not displayed. Breakfast times were observed on two days. This was a flexible meal starting about 8 am and lasting up to 11 am. Residents were given choice and one requested and received a cooked meal. One member of staff knew a resident preferred five pieces of grapefruit exactly. Designated staff are on duty in the dining room to ensure those residents requiring help are assisted, a senior carer oversees the meal. Help with the meal was carried out well with staff sitting at the resident’s side and not rushing them. Procedures are in place to ensure that no one is missed by staff recording who had been helped but this was not followed on the day. No resident missed a meal but one received two portions because staff had not kept the procedure up to date. The inspector sat with the residents for the midday meal. This was a light meal because the main meal apart from two days of a week is served late afternoon. A clear choice was not on offer although staff provided a sandwich for those not enjoying the meal. There was a mixed reaction when food was discussed with residents. One said the portions were too big, another said that food was usually good but not the week of the inspection. The majority said the food was good. The minutes of resident meetings in August 2006 showed that most discussion was about the meals. The cook attends these meetings. Residents confirmed that their suggestions are put into practice. The lunch on the first day was pizza this had been a request made by residents. The timing of meals later in the day especially the 4 pm time was discussed as too early, when lunch ends at 1.30 pm. Nutritional guidance recommends intervals between meals of not more than five hours. Management have held a resident committee meeting including a relative since the inspection and residents said they were happy with the timing of meals. The home intends to obtain feedback from relatives for those unable to express an opinion. In addition, a hot option will be made available at 8 pm. This will address the concern about length of time in between the last meal and the first meal the following day. It was agreed with management that a quality audit of mealtimes would be carried out including observations by an external observer. The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgment has been made using the available evidence and during a visit to the home. An appropriate complaint’s procedure is in place. Staff have received training about abuse but a more robust approach is required to allegations of abuse so that residents are fully protected. EVIDENCE: The home’s complaint procedure was displayed in the home readily available for visitors to see. The procedure is also in the Statement of Purpose/Service User guide. Residents when asked said they would speak to staff about any concerns. The pre inspection questionnaire (PIQ) returned from the home identified that the home had received one complaint. One record was in the resident’s care documentation. A separate record of complaints should be kept detailing the complaint, the investigation and any action taken to resolve the issues. Staff have attended abuse training and notices were displayed in the home for forthcoming Adult Protection training. In discussions they said they would refer any concerns about possible abuse to management. Management advised the inspector during the visit about an allegation of abuse. This was referred to the local adult protection unit during the inspection but management were informed that this should have been done immediately. Management were advised to apply to attend the local authority adult protection course that is held for both provider and manager. The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgment has been made using the available evidence and during a visit to the home when some bedrooms and communal areas were seen. The building is easily accessible for wheelchair users. The home was clean and there are good procedures in infection control. EVIDENCE: This home provides personal and nursing care. The majority of the residents are wheel chair users. The internal layout of the home is excellent for wheel chair users and the building is suitable for its stated purpose. Rooms are spacious and corridors wide. There is level access into the home. Nearby parking is available for visitors. There is a large patio area that residents said had been enjoyed in the good weather. There is a passenger lift. Notice boards were up to date and included the names of the nurses on duty. Photographs of staff were displayed ensuring that in a large busy home residents were able to identify staff. The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 18 Communal areas of dining/lounge and lounge space are located on the ground floor. There is a separate designated smoking lounge. All these areas were well-furnished and provided comfortable seating. Continence aids on armchairs were discreet. The bedrooms viewed on the day were well decorated. Personal items were seen in bedrooms belonging to service users. The majority of the bedrooms have en suite facility of washbasin and WC. Those who were able said they were comfortable in their private space. The bathrooms and WC’s are fitted with hoists, handgrips and high seats. The door locks were appropriate. There are a number of different types of hoists to use if necessary. Staff said that the company are proactive in purchasing equipment. The home has recently experienced an infectious outbreak. The Environmental Health Officer’s recommendations were discussed. The manager advised that these had been put in place. Colour coded cleaning equipment was a recommendation and this was seen during the inspection. Malodour control was good but some areas such as specific chairs were pointed out to management as a problem. During the inspection it was noted that cleanliness was to a good standard. During discussions with staff and from observations it was apparent that they had a good understanding of infection control policies and procedures. Paper towels and liquid soap were available in the laundry, kitchen, bathrooms and WC’s as required. The laundry provides two washers and two dryers. The washers conform to infection control standards and have a high temperature cycle. The room was well organised and had named baskets for resident’s individual laundry. Laundry staff and residents confirmed there were no major complaints about the laundry service. Staff work in this service from 7.30 am to 3 pm seven days a week. The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The quality of the outcome in this area is good. This judgement was made using available evidence including a site visit when documentation was inspected and discussions held with the staff on duty. Management have ensured the protection of residents by obtaining CRB checks of staff working at the home. Relevant training that matches the needs of the residents is ongoing and more is planned. EVIDENCE: The home was well staffed on the two days of this unannounced inspection. The person in charge was the acting manager. Staff were aware of their responsibilities. A copy of the rota for the week of the inspection was seen and staffing levels were appropriate. Since the inspection the home has made changes to the rota by increasing some staff hours in order to overcome the problems experienced in waiting for personal care to be carried out. National Vocational Qualification (NVQ) training is on going. The requirement is to have 50 of care staff with level 2 or above NVQ qualifications. Currently the home has twenty one care staff with NVQ level 2 training or above. This means the home has 50 of care staff with this qualification. Staff confirmed NVQ training during discussions and this was also evidenced in certificates of attainment and the pre inspection questionnaire (PIQ). Recruitment files for five members of staff were checked; two qualified nurses and two care assistants. Application forms had been completed and two The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 20 references sent for in all cases tracked. All had received references. There was evidence of verification of identity checks and Criminal Records Bureau (CRB) checks including POVA first. Staff terms and conditions were available and there was evidence that staff had received an induction into working in the home. This is as required. Discussed was the speed of the induction process. The records showed this took place over one to two days. Management should ensure that the induction is not rushed. The standard is for a initial induction to take place over six weeks and then foundation training according to Skills for Care (former TOPPS) over six months. It was evident from the records and in discussions with staff that new staff receive an induction into working in the home. Induction includes health and safety such as fire procedures. In addition it refers to resident’s privacy and independence. Evidence was available in training records, the PIQ and in discussions with management and staff that proactive training is ongoing. Fifteen staff have a current first aid certificate. Staff confirmed recent training NVQ level two and three. The PIQ confirmed recent training as fire safety, Palliative care, Moving and Handling, Falls Prevention and health and Safety. Other planned courses are Food Hygiene, Adult Protection and further training is planned. Management said that training records were currently being formatted into a more easily accessible record. It was evident that training is encouraged in order to fully meet the needs of residents and protect them. The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is good. This judgment has been made using the available evidence and during a visit to the home. The home does well in keeping residents and relatives well informed and ensures resident’s views are heard. Health and safety is very well maintained. EVIDENCE: The acting manager is a registered nurse and has been employed in the home since 2003. Staff and residents spoke well about her management qualities. Staff and residents meetings are held regularly and minutes were seen. There is a resident’s committee and a newsletter. The home has developed a number of ways to ensure that residents and relatives are kept fully informed. Appropriate quality assurance systems have been implemented and residents are benefiting from this process. The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 22 The responsible person who acts on behalf of the company owning the home submits regulation 26 reports about the conduct of the home every month. It is intended to submit six monthly general reports to the CSCI in light of the reduced numbers of inspections. The manager has undertaken appraisal/supervision training and regular supervision of care staff is ongoing. These records were available for inspection. The records for fire safety were checked. The fire alarm test is carried out weekly and emergency lighting monthly. Staff fire drills are held. These were recorded with the names of those staff that attended. Staff confirmed this during discussions. The person with responsibility for fire safety has attended relevant training. Health and safety within the home was well maintained. Staff carried out appropriate moving and handling techniques and also ensured that footplates were in use when moving residents in wheel chairs. A record was available for checking bed safety rails. One bed was seen with one rail in place as the bed was against the wall. The manager was advised to check that this was a safe procedure. Maintenance records were available for inspection. A random check showed these were up to date. Kitchen staff were recording the temperatures of cold storage and hot foods. The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 4 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X X X X 3 The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement The registered person must ensure that care documentation is kept up to date and signed by the person making the record. All care plans must address individual needs of residents. Where possible obtain the signature of the resident and/or relative as agreeing to care plans. The registered person must ensure that menus are displayed and a positive choice is available for all meals. The registered person must respond more robustly to any suspicions of abuse by contacting the local authority Adult Protection unit in the first instance. Timescale for action 30/10/06 2 OP15 12 30/10/06 3 OP18 13 30/09/06 The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard OP10 OP15 OP16 OP18 OP26 OP30 OP38 Good Practice Recommendations The registered person to ensure that the procedures for giving personal care following meals are under review. The registered person to ensure that a quality audit is carried out focusing on meals and meal times. The registered person to ensure that complaints are recorded in a complaint record rather than care documentation. The registered person to ensure that management attends the local authority adult protection training. The registered person to ensure that a spot-check of malodorous areas is carried out. The registered manager to ensure that the initial new staff induction is effectively carried out in line with Skills for Care recommendations. The registered person to ensure that the use of one bed safety rail is in accordance with the manufacturers instructions. The Beeches Nursing Home DS0000029133.V309586.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Nursing Home DS0000029133.V309586.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. 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