Inspection on 04/04/07 for The Beeches Residential Home

This inspection was carried out on 4th April 2007.

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 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 Residential Home 03/04/08

The Beeches Residential Home 04/10/06

The Beeches Residential Home 07/03/06

The Beeches Residential Home 17/02/05

The Beeches Residential Home 18/08/04

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

CARE HOMES FOR OLDER PEOPLE The Beeches Residential Home The Beeches 39 High Street Ixworth Bury St Edmunds Suffolk IP31 2HJ Lead Inspector John Goodship Unannounced Inspection 4th April 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Beeches Residential Home DS0000047597.V335609.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 Residential Home DS0000047597.V335609.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Residential Home Address The Beeches 39 High Street Ixworth Bury St Edmunds Suffolk IP31 2HJ 01359 230773 01359 233117 the.beeches@btconnect.com Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) S & A Care Ltd Manager post vacant Care Home 35 Category(ies) of Dementia (35), Dementia - over 65 years of age registration, with number (35) of places The Beeches Residential Home DS0000047597.V335609.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th October 2006 Brief Description of the Service: The Beeches Residential Home is owned by a limited company S & A Care Ltd, and registered to provide care for 35 people who have dementia. Located on the main street of Ixworth, the home consists of one adapted large period building, with a purpose built extension to the rear of the home. Village amenities include a Public House, Post Office, Doctors Surgery, and food shop. There are 25 single and 5 shared bedrooms. Of these 19 of the single bedrooms and 3 of the shared bedrooms have en-suite facilities. Communal bathrooms and toilets are situated close to bedrooms and day rooms. Residents have a range of day rooms to choose from, these include 2 dining rooms, lounges, and large conservatory overlooking the mature gardens. Residents are able to access all areas of the home by using stairs, passenger lift or chair lift. However some bedrooms and ensuite facilities are unsuitable for wheelchair users. The Beeches Residential Home DS0000047597.V335609.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a weekday and lasted five and three-quarter hours. The manager and the deputy manager were present throughout, together with staff on the morning shift and, later, those on the late shift. The inspector toured the home, and spoke to some of the residents, and also spoke to staff, in particular with two staff. The inspector also examined three care plans, two staff records, maintenance records and training records. A questionnaire survey was sent out by the Commission before the visit to residents, to relatives, and to staff. Four residents responded with the support of a carer, four relatives and four staff. Their answers to the questions and any additional comments have been included in the appropriate sections of this report. The current owner of the home, S and A Care Ltd, had taken it over at the end of November 2006. They inherited a significant number of requirements imposed after the key inspection on 4 October 2006. They appointed the current manager on 31 January 2007. Progress had been made to implement those requirements by the time of this inspection. This is recognised in this report. Some matters remain to be completed, and others have just been introduced and have not yet developed consistent trails of evidence to prove they are embedded in the policies and procedures of the home. What the service does well: Many relatives were complimentary about the way their relative was cared for. Relatives also described the staff as friendly and caring. “I am happy with the care that all staff have given to my relative over the last few years.” “My relative is clearly loved by everyone and is very happy and settled at The Beeches.” “We are always made to feel very welcome.” “Staff always consider the individual, and care passionately about the people they care for. They listen to what each person wishes to do or say, with so much patience.” “Staff care about everyone with much dignity.” “My relative has flourished in the care of The Beeches.” The home was clean and free from odours. A relative commented: “The home is always clean and there are never any unpleasant smells.” Staff are able to support people to go outside, into the garden or further. The Beeches Residential Home DS0000047597.V335609.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home failed to meet the hot water temperature standard on the day of the visit. Although regulators have now been installed, regular checks must be made to ensure safe temperatures are maintained. The home should continue to develop the range of activities both inside and outside the home offered to residents, according to their needs and wishes. There should be a review of how appropriate the current care plan format is for caring for people with dementia. Risk assessment covering the home and outside should be in place. The training of staff should be developed into an annual programme that tracks staff progress to ensure all areas of competence are covered. The temperature of the drug room should be controlled at or below 25°C. The Beeches Residential Home DS0000047597.V335609.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 summary of this inspection report can be made available in other formats on request. The Beeches Residential Home DS0000047597.V335609.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 Residential Home DS0000047597.V335609.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): 1,2,3. Standard 6 is not relevant to this home. Quality in this outcome area is good. People who are looking for a suitable home are given the information they need to make a choice, and are assessed to ensure that the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The newly revised statement of purpose and service users’ guide were seen. These had been sent to the Commission for Social Care Inspection as part of a requirement from the previous key inspection, and were now complete and upto-date. The file for an admission earlier in the year was examined. It contained the assessment by the manager prior to the admission. This was conducted while the person was in hospital awaiting discharge. The hospital discharge information sheet was also in the file. This confirmed the particular form of dementia from which the person was suffering, as well as their medication and The Beeches Residential Home DS0000047597.V335609.R01.S.doc Version 5.2 Page 10 allergies. There was also a family biography which relatives were asked to complete, giving information about the person’s life, work and interests. The Service Users’ Guide contained an example of the form of contract and a schedule of fees. One relative had commented that the detail in the contract was helpful as it ensured everything was clear from the start. The Beeches Residential Home DS0000047597.V335609.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): 7,8,9,10. Quality in this outcome area is adequate. People who use the service have their health and personal care needs adequately identified and met, although the care plan does not provide scope to track the specific needs of people with dementia. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were examined, one for a resident admitted in 2007, one for a resident admitted in 2006, and one for a resident admitted in 1997. All care plans used a system of pre-printed pages and sections. The sections of these plans were adequately completed but left little scope for narrative information that was outside the format. It was not easy to identify how a person’s needs had changed and how their care should be adjusted to meet these changes. Plans were checked and updated every four to six weeks by the team leader, principally from the daily diary. There was no keyworker system in operation. However there was an instance in one plan where a short-term change to the The Beeches Residential Home DS0000047597.V335609.R01.S.doc Version 5.2 Page 12 care plan had been written, to support a resident on their return from hospital with changed and reduced mobility needs. Plans included information about the monitoring of residents’ levels of nutrition and their weight. The manager reported that she had ordered a weighing chair to enable non-weight bearing residents to be weighed in a more dignified manner than on the hoist. One care plan evidenced concern about the weight of a resident and gave staff guidance on encouraging the person to do some exercise and to avoid extra helpings. The weight record of this person showed a slight decrease between February and April. Advice was given to another resident about healthy eating and staff were advised to offer them healthy alternatives to items that they wished to buy from the village shop. Staff commented that this person chose not to follow the advice all the time. The daily diary included details of checks by night staff, usually two hourly or as required. The content of the diary by all staff had improved since the last inspection, and gave much fuller information about the care given, any activities a resident had participated in, and any untoward incidents or accidents. Specific risk assessments for each resident were kept inside the wardrobe door in the resident’s room. Risks covered included falls, mobility, moving and handling. One assessment had led to the installation of bed rails. The manager stated that the resident’s relative had consented verbally to these, but there was no written record of this. Another relative had given consent to a resident wearing gloves in bed to prevent harm. Again this had not been confirmed in writing. There were no generic risk assessments for the home, for areas that residents could access, and for outings to the local shops. All new residents were required to register with the local surgery if they were not already registered there, as no other practice covered Ixworth. A doctor from the practice attended the home each Monday morning. A list was prepared of residents needing to be seen or to be discussed with the GP. The manager stated that the home received an excellent service from the surgery. The home had changed recently to using the pharmacy at the GP practice to supply all medication, including tablets in blister pack format. Medication records were examined. Medication Administration Records (MAR) sheets were examined and were generally in order, apart from one gap in signatures. One medication stock was checked against their recorded administration and the correct number of tablets remained. The Controlled Drugs (CD) cupboard was checked. Only one item was in there. This had been correctly entered in the CD book. Medication being given at lunchtime was observed. The carer put the tablets for one resident in a pot in the drug room, took them to the resident and then signed the MAR sheet on return to the drug room. This room was secured by a The Beeches Residential Home DS0000047597.V335609.R01.S.doc Version 5.2 Page 13 keypad device. The small drug fridge had been moved since the last inspection from the office to the drug room. It had a thermometer fitted and displayed the correct temperature. It was recommended that a wall thermometer should be fitted to the drug room to monitor that the temperature did not go over 25°C. It was observed that interactions between staff and residents were polite and respectful. Distraction and encouragement were seen to be used to support residents to prevent inappropriate behaviour or actions. A relative wrote in their comments that “staff treated residents as individuals, and with respect.” The Beeches Residential Home DS0000047597.V335609.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): 12,13,14,15. Quality in this outcome area is good. People who use the service are supported to make choices about their daily lives, and are being offered a wider range of activities to meet their social and recreational needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One of the carers had done a course on “Therapeutic Recreational Practices”. They were developing a wider range of activities for residents to suit their abilities and wishes. A relative confirmed that this wider range had started to happen. The manager had encouraged staff to take residents out more, to the local shop, or on outings to Bury St Edmunds. There were photos on the walls of some of these outings. The home had hired a minibus for outings but was planning to buy its own, for greater flexibility. A member of staff said that this was the area that they felt the home could do more of. However one resident put in their questionnaire that: “They’re always wanting you to do something, too much sometimes.” There was a Social Activity Plan in each care plan, but in addition the organiser kept a log of all activities with the names of those who participated. The Beeches Residential Home DS0000047597.V335609.R01.S.doc Version 5.2 Page 15 The manager had introduced new menus giving more choices, with more fruit always available. The menu was on a three week rotation. Residents were asked to make their choice the day before supported by a carer. Lunch was observed in the three dining areas. It was taken in a calm and unhurried manner. The rooms were light, and set out in small tables, except for one table capable of seating six. This table allowed staff room to assist two residents to eat. Relatives commented that staff always made friends and family feel very welcome. Local priests visited the home regularly. Holy Communion was given to those who wished. Two members of the Salvation Army were visiting a resident during the inspection. They said this person was very well looked after. “They look well, don’t they?” The Beeches Residential Home DS0000047597.V335609.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): 16,18 Quality in this outcome area is good. People who use the service and their representatives feel assured that their concerns can be raised with staff, and they will be better protected as staff training in safeguarding becomes a regular part of the training programme. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There was a complaints procedure incorporated into the Statement of Purpose and Service Users’ Guide. The home had now prepared a complaints log, although there were no records of any complaints under the new ownership. Relatives who replied to the survey wrote that they had never had to raise a concern, but staff had always been able to answer questions, and had shown a detailed understanding of individual needs. Thirty carers had attended an in-house training session on the protection of vulnerable adults in February 2007. This was assessed and certificated by an external training provider, but no certificates had yet been received by the home. However, several members of staff confirmed their attendance and were able to identify the circumstances and the process by which they would report allegations. The Beeches Residential Home DS0000047597.V335609.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,25,26. Quality in this outcome area is adequate. The residents generally live in a safe environment with the introduction of a planned maintenance and redecoration programme, although the temperature of hot water has only just been regulated. Residents’ safety would be better assured with environmental risk assessments. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home had failed to comply since the last key inspection in October 2006 with the National Minimum Standard that all hot water outlets must be controlled by pre-set valves to provide water close to 43°C. This level interprets Regulation 13(4)(c) which requires the registered person to ensure that…..”Unnecessary risks to the health and safety of service users are identified and so far as possible eliminated.” In October 2006 the inspection found four outlets with temperatures significantly above 43°C, one as high as The Beeches Residential Home DS0000047597.V335609.R01.S.doc Version 5.2 Page 18 54°C. A random inspection on 19th January 2007 found two outlets above this level, the highest one being on the same outlet tested in October. This current inspection found another outlet at 52°C. The maintenance man adjusted this at once. Since January, the maintenance man had been taking weekly readings of all hot water outlets. Readings showed outlets were reasonably stable close to the required temperature, except for Bathrooms 3 and 4, whose readings varied between 44.5°C and 47.4°C. No regulators had yet been fitted to these outlets. The manager said that daily readings would now be taken until all valves had been fitted. The manager also said that no residents used the washing facilities without staff support. However as some residents were quite mobile on their own, the risk was present. The owner had sent to the Commission on 26th March 2007 the quote from the plumber for fitting the pre-set valves but could not give a start date. On inspection, it was reported by the manager that the plumber had started and had completed the fitting of half the 20 valves. This work was due to finish on 12th April. (Completion was actually confirmed by the manager on 11th April.) Soap dispensers and paper towels holders had now been fitted in all communal washing facilities, thus improving the control of cross-infection. No bars of soap had been left in bathrooms. There were no offensive odours present. Of the twenty-five single rooms, nineteen had en-suite facilities. Three of the five shared rooms had en-suite facilities. Those bedrooms visited showed that they had been personalised by the residents with photos and items of significance to them. Residents were able to go into the garden, which was secure. It was set out to enable residents to walk around it, and included an aviary. One relative pointed out that the path, which was formed of irregular shaped flagstones, was uneven in places, causing their relative to trip. The manager agreed to have this checked. There were no risk assessments for residents’ use of the garden. The home now had an on-going programme of refurbishment and redecoration. Quotes had been received for the redecoration of the hallway and entrance hall, Bedroom 1 and the outside of the building. New curtains had been ordered for Bedrooms 1,6 and 19, and for the front dining room and quiet room. New tablecloths and napkins had been received on 27 March and were in use. A new cooker and a new dishwasher had been fitted. The manager was intending to replace the chairs in the front entrance hall, and the lounge. The Beeches Residential Home DS0000047597.V335609.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is adequate. People who use the service are supported by adequate numbers of staff, but they cannot be assured that these staff are appropriately trained and kept up-to-date until a formal programme of training is in place and evaluated. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Relatives commented that there always or usually seemed to be sufficient staff on duty. The pattern was for eight on in the morning and six in the afternoon/evening. The home had no vacancies at the time of the inspection. The number of staff holding NVQ Level 2 and above was now over the 50 level. Where certificates were available, some were inspected, and staff confirmed their status as well. Four staff had NVQ Level 3, and the deputy manager had completed Level 4 but their certificate had not yet arrived. The owner had forwarded to the Commission a list of staff who had completed in-house training on dementia care and the protection of vulnerable adults. This consisted of watching a video and completing a questionnaire supplied by an external training provider. The manager was waiting for the assessments to be returned from them. Non-care staff had also watched the dementia care video. A staff member wrote in the Staff Survey that they had only started receiving planned training since the new manager had been appointed. For a The Beeches Residential Home DS0000047597.V335609.R01.S.doc Version 5.2 Page 20 home specialising in dementia care, this is a minimal level of training, and would need regular refresher sessions. This was not programmed. The manager and deputy were seeking to attend a more in-depth training course run by a local college. Two staff files were inspected. Both contained the required pre-recruitment information and identity checks. The most recent appointee also had an induction checklist in their file, signed by the staff member. Training certificates obtained in a prior employment were in the file for one person. A care assistant was able to confirm that they were studying for NVQ Level 2. They had started in September 2006. They had had two supervision sessions to date. They said that the home was a good place to work. Another staff member had written in their Staff Survey that: “I enjoy working at The Beeches. Staff are really friendly.” The Beeches Residential Home DS0000047597.V335609.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38. Quality in this outcome area is adequate. People who use the service are already benefitting from an experienced but not yet fully qualified management team, and from the quality assurance process being put in place. People will be better protected when records have been improved. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The current owner of the home took over the company in November 2006. The current manager was appointed at the end of January 2007. She had worked at the home for many years. She had NVQ Level 3 and was seeking a place on the Registered Managers Award course. The manager stated that an application would shortly be made to the Commission for her to be registered. The manager was the nominated moving and handling trainer for the home. She attended an updating course in January 2007. Staff who replied to the The Beeches Residential Home DS0000047597.V335609.R01.S.doc Version 5.2 Page 22 survey said that they received good support from the manager. “I can speak to her whenever I need to. She is always ready to listen.” A deputy manager had also been appointed at the same time. She had had experience of being a carer both at this home and at another home. Both the manager and the deputy were intending to do a Dementia Care Awareness modular course with a local college. This would underpin the brief training sessions run in-house for staff. The home used a variety of means to involve staff and residents in the running of the home. A successful residents and relatives coffee morning had been held in February. 14 residents and 7 relatives had attended. Notes of the meeting showed that the manager introduced the management and care staff team, gave information on future activities, and explained the increased choice on the menus. Relatives gave feedback on the standard of care, praising the home. Other sessions were being planned at different times to allow more relatives to attend. The manager said that the owner visited the home regularly. However no copies of the Regulation 26 monthly visit reports were available for inspection. Staff meetings were held monthly; the minutes of the last one on 21 March were available for inspection. The accident record and the fire log were examined. Both were fully completed. The inspector was shown a list of staff who had undertaken internal fire training in January. The inspector was also shown the Fire Risk Assessment. This brief document did not comply with the requirements of the Fire Precautions (Workplace) Regulations 1997. It did not identify general and specific hazards, level of risk, current control measures, and any further measures needing to be taken. A programmed system of formal staff supervision was in place. Staff confirmed that these sessions were taking place. A schedule showed that all staff had had one session between 29 January and 16 March, with the dates of the next session indicated. The manager advised that residents’ monies were not held by the home. They or the funding authority are billed by the company for their care and any additional expenditure which included hairdressing, chiropody and toiletries. The home used a care planning record which did not suit the identification and planning of care needs for people with dementia, as described under Outcome Group “Health and Personal Care”. The Beeches Residential Home DS0000047597.V335609.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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 3 X X 3 1 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 X 3 The Beeches Residential Home DS0000047597.V335609.R01.S.doc Version 5.2 Page 24 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. 1. OP25 13(4) The temperature of all hot water outlets accessible to residents must be controlled to provide water close to 43(C) at all times, to prevent the risk of harm to residents. This is a repeat requirement from the random visit of 19/01/07. The Commission must be sent copies of the temperature monitoring logs for two months from the date of the inspection, together with copies of the monthly visit reports for that period showing that management is monitoring the situation. 04/04/07 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 OP7 Good Practice Recommendations A review of the suitability of the care plan format should be undertaken, to ensure that residents receive the best DS0000047597.V335609.R01.S.doc Version 5.2 Page 25 The Beeches Residential Home 2. 3. 4. 5 OP9 OP30 OP38 OP33 practice in dementia care. The temperature of the drug room should be controlled so that it does not exceed 25°C, to prevent damage to medication. A training programme to keep staff refreshed and updated in dementia care should be developed, to ensure that staff are competent to care for people with dementia. Risk assessments should be done for the generic risks inside and outside the home, to protect residents from harm. The Commission must be sent copies of the Regulation 26 visit reports since the change of provider and for the two months after this inspection. The Beeches Residential Home DS0000047597.V335609.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Residential Home DS0000047597.V335609.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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