Inspection on 07/03/06 for The Beeches Residential Home

This inspection was carried out on 7th March 2006.

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

The inspector 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 04/04/07

The Beeches Residential Home 04/10/06

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 Mary Jeffries Unannounced Inspection 7th March 2006 2:15 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.V286093.R01.S.doc Version 5.1 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.V286093.R01.S.doc Version 5.1 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 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 Mr Allan Harold Johnson 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.V286093.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: none Announced 12/07/05 Additional 19/09/05 Date of last inspection Brief Description of the Service: The Beeches Residential Home is owned by a limitied 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.V286093.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during an afternoon in March 2006, and took five and a half hours. The home had 4 vacancies at the time of the inspection, 31 service users in residence, none were in hospital. The Registered Manager and their business partner were spoken with, and staff on duty participated in the inspection. Three members of staff were spoken with individually. A group of service users were spoken with, and service users were observed throughout the inspection, including at teatime. What the service does well: What has improved since the last inspection? What they could do better: Only two of nine requirements made at the last announced inspection were demonstrated to have been met. The home must comply with regulations. The home does not yet provide a Statement of Purpose and Service User Guide that meet regulations. There has been no evidence of formal supervision occurring in the home on a regular basis. Staff recruitment records did not comply with regulations. The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 6 There was one requirement made in respect of medication, and the responsible persons must ensure that any omissions in medication recording are picked up and rectified immediately. Training had not been provided in Protection of Vulnerable adults, and there was no evidence of the carer providing manual handling training having received an update since 2003. No specialist training in dementia care has been delivered to staff. An infection control audit is required, and appropriate update training for staff. Service users files must contain a photograph. The home’s restraint policy requires updating. A record of all people visiting the home should be maintained. 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 Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,4 Prospective service users and their relatives do not have all the information they require to make an informed choice about coming to live at the home. EVIDENCE: Standards 3, 4 and 5 were inspected at the previous inspection and were found to be met. It was also established that the home does not provide intermediate care on that occasion. A requirement was made in respect of standard 1 at the Announced inspection in 2005, that the home must provide a Statement of Purpose that contains all the information in Schedule 1 of the Care Homes Regulations 2001, and also a suitable Service User Guide. Once completed a copy must be forwarded to the CSCI, and made available to residents and visitors. The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 9 The Registered Manager advised that all service user’s had a service user guide in their drawers. A Statement of Purpose was on display, dated 7/07/05 which did not contain all of the required information. A requirement was made at the additional inspection which took place in September 2005, that the home must be able to demonstrate that they can safely meet residents changing mental health needs. Where it is identified that a resident’s behaviour puts others at risk, a re-assessment and review must be arranged, which includes the residents representative, Health & Social Professionals to identify if the resident’s mental health needs can be safely met at the home. Staff spoken with advised that they did not have any service users who were displaying challenging behaviour. The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Service users can expect to have a comprehensive care plan that sets out their needs and which is regularly reviewed. EVIDENCE: Standard 11 was inspected at the previous inspection and found to be met. A requirement was made in respect of standard 7 and 8 at the last announced inspection, that all care records be looked at, to ensure that they are being regularly reviewed, information is being recorded correctly, and gives staff clear guidance on dealing with residents physical and behavioural care needs. Four care plans were inspected and were found to be satisfactory. All four service users files inspected had been reviewed within the last six months. The record of one concurred with a regulation 37 report sent to the CSCI. There were clear instructions for staff on file on dealing with resident’s physical care needs. Staff spoken with advised that there were no residents with challenging behaviour accommodated at present. This was observed to be the case. One of the service users files inspected showed a recent appointment at the hearing clinic. Records of pressure areas and sores, and treatment or The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 11 instructions for staff were present on two. Nutritional risk assessment were on file. There were no photographs on two of the four service users records inspected, and there were no photographs of service users on their medication records. A requirement was made in respect of standard 9 at the last announced inspection, that the home must ensure there is a safe system of dispensing and transporting of medication around the home. An additional visit was made to the home by the inspector and the pharmacist on the 19th July 2005, following a complaint that involved medication issues. On that occasion the home was found to be introducing the Boots medication system, which addressed some of the previous concerns. However, three other requirements were made then as a consequence of two elements of the complaint which related to medication being upheld. The home was asked to take immediate action to ensure full and accurate records for the receipt and administration of medicines are kept at all times, and to ensure that medicines are administered only in line with prescribed instructions at all times. Urgent action was also required to ensure oral medicines are safely administered and supervised to ensure residents have taken (swallowed) medication given. Ten people had teatime medication; the medication round was observed. The carer had an unhurried manner. Each time a rack was removed from the locked cupboard, it was replaced when one service users medication had been put into the pot and the cupboard was locked. The carer advised that all staff who do medication had in house training provided by Boots when they went over to the Boots system. When they could not get one tablet out of the blister pack, they put on rubber gloves to remove it. One service user chewed their tablet, the carer ensured the service user had enough to drink and waited to observe the service user had finished. Medicine Administration Record (MAR) sheets had started three days before the inspection, those seen were all complete. The previous months MARS sheets were inspected. 8 gaps were found within the month’s records, 1 was for senna, 1 was for eye drops. The other two were for Gaviscon, which the manager advised the service user does not always have. This was not marked a PRN. Four of the gaps were for frusimide, a diuretic; there was no entry for a prescribed dose on two two-day periods. The home had a record of medications received in and returned, which the partner in the company completed. A group of service users spoken with agreed with the main spokesperson for the group who said that they felt that they were treated with respect by staff. A member of staff spoken with advised that they felt that this was strong point of the home, and gave an example of how this was demonstrated by saying that staff never speak over a service user when they are talking. All The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 12 interactions observed between staff and service users was polite and respectful. One service user kept returning to shift a pot plant on the windowsill in the veranda, which annoyed another. Staff who were sat talking with service users deflected the attention from the activity, and reassured the other service user that it didn’t matter. The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 13 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): 14,15 Service users can expect to be assisted to exercise choice and control in their daily living regimes. EVIDENCE: Standards 12 and 13 were inspected at the Announced inspection and were found to be met. Standards 14 and 15 were both found to be met when they were inspected in the previous year’s inspection programme. Service users were seen to move freely round the home. They had a choice of several areas where they could sit. Some were seen enjoying assisting folding linen during the early afternoon, whilst some others had a post meal nap. A member of staff advised that they start getting people up at 7.30 am, and finish by 8.30, that no one regularly has a lie in, but that if someone didn’t want to get up they leave them. They advised that had service users had their own preferred bed times, but that everyone is usually in bed by 10 pm, before the late shift finishes. There was a record of the times when service users rose on the day of the inspection; times varied between 7.15 am and 10.15 am. One service user who staff had described as being the one who preferred to go to bed the latest had risen at 9.55 am. The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 14 On the day of the inspection, service users had jam sandwiches and cakes at teatime, and their main meal at lunchtime. The atmosphere was pleasant, with some quiet talk occurring. All service users had serviettes and the room was attractive. One service user who was asked if they would like a drink said that they had already had one, but they hadn’t. The carer persisted gently. Staff spoken to described encouraging service users to do as much as they could for themselves. The manager advised that one service user was a vegetarian, but the cook advised that the service user often choose the meat option. The main mid day meal was recorded in the cook’s diary; it had been stuffed marrow or meat loaf, with vegetables and potatoes, followed by trifle. The Sunday joint the previous weekend had been roast pork. The manager advised that the home was in the process of reviewing menus. The teatime menu for the week was inspected and included fish paste, luncheon meat, lemon curd and dairy lea sandwiches followed by cakes on various days. On one evening there was ravioli. A milky drink and biscuit is served at suppertime. A member of staff was asked if service users ever had a cooked breakfast, they advised that they sometimes did, but not often, and that if so it would be an egg or porridge. The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 It cannot be guaranteed that staff would know how respond appropriately should an allegation or suspicion of abuse arise. EVIDENCE: As noted under standard 9, an additional visit to the home by the inspector and the pharmacist had been undertaken on 19th September 2005, following a complaint that involved 2 elements about medication practices which were found to be upheld. The complaint also contained two other elements, one, that the home had not taken appropriate action to keep relatives updated on a residents changing mental health needs, was upheld. None of the current service users were exhibiting challenging behaviour, and therefore it was not possible to ascertain whether this requirement had been taken on board. Another element concerning the management of a service users admission to hospital was not upheld, however, although the complaint was not upheld, it was noted that the home had not kept detailed records of the events leading up to the admission, or consulted with the resident’s family. The home was asked to take immediate action to ensure records they kept accurate care records. No reply had been received by the CSCI in response to this. The manager advised that they had not received any complaints since this, but that they did not maintain a log. The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 16 A requirement was made in respect of standard 18 at the Announced inspection in 2005. The Protection of Vulnerable adults Policy was inspected. This was dated 22/2/06, it was generally good, and noted that Social Care services were the lead agency. The manager and the working partner advised that they went on the Suffolk County Council Course on Protection of Vulnerable adults in 2002, and showed the booklet they had, which was dated 2002. None of the four staff files inspected included any record of PoVA training, although three held NVQS, one at level 3. The home had a good whistle blowing policy. The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 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): 19,26 Risks to service users are not minimised by the home’s infection control policy and practices. EVIDENCE: Standards 20, 21 22 and 23 were inspected at the Announced inspection in 2005 and were found to be met. Standard 19 was found to be met when it was inspected in the previous years inspection programme. The home was clean and attractive and adequately maintained. There was a large fish tank providing some interesting sensory stimulation. Some bedrooms were seen and found to have alarm systems that detected movement, and all required furnishings. The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 18 A requirement was made in respect of standard 26 at the last that inspection, for an infection control audit to be carried out, and staff training provided, as it had been found that: • Dirty laundry were being put directly on the floor • Items of clothing soiled with bodily fluids were being soaked • Staff were not using Alginate bags as part of infection control • Disposable gloves and aprons were not easily available • Staff carrying around gloves in their waist bands – which has come in contact with their skin On this occasion the laundry was seen to be clean and in good order, no dirty laundry was seen on the floor, and there were no plastic bowls in sight. Each service user had an individual “pigeon hole” for their laundry. The sluice room was locked, but was seen to contain gloves and aprons. The home’s communicable disease and infection control policy was inspected, however the policy was not dated. The policy stated that Yellow sacks are top be used for clinical waste. A member of staff was asked how soiled linen is carried in the home. They advised that it was carried in black bags. The member of staff was asked if these had to be tied, as they did not provide this information, and they advised that they had not been told so. There was no evidence of recent training in infection control on the four staff files inspected. The toilet next to the front door did not have liquid soap or paper towels available. Two other toilets were checked and this was also found to be so in this case. Towels and bars of soap, which pose an unnecessary risk of cross infection, were available. A resident spoken with confirmed that they were satisfied with the cleaning standards in the home. The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 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): 28, 29,30 Service users cannot be assured that they are protected through the homes recruitment practices or staff training. EVIDENCE: Standard 27 was inspected at the Announced inspection in 2005 and found to be met. There are no senior carers; instead one member of staff is delegated to give out the medication each shift. With no senior carers or team leaders, the owners take on all the management responsibilities themselves. There were four staff on duty during some of the time of the afternoon of the inspection, 5 at others. There were no obvious short falls in care; when a call bell was tested, a prompt response was achieved. A requirement was made in respect of standard 29 at that inspection. Staff files for four of the five staff on duty during the afternoon were inspected. Three of these had commenced work prior to the last announced inspection, however one had commenced work a couple of days afterwards. There were no references on file for this carer, and although the manager advised that they had employed the worker before, there had been a two and a half year gap. An immediate requirement notice had been left at the inspection of 12th July 2005, stating that this must not occur. In addition, the files of the two most recent members of staff were inspected specifically for Criminal Records Bureau checks and Pova First checks, in the The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 20 context of their start dates. One of these files showed appropriate and timely a Criminal Records Bureau checks in place. The other showed that for a worker who commenced in November 2005, the CRB and PoVA first had not been received until January 2006. An immediate requirement notice had been left at the inspection of 12th July 2005, stating that this must not occur. References were not checked for these two workers. The home did not have a training analysis. Three of five members of staff on duty on the afternoon of the inspection held NVQs. The manager advised that three members of staff were due to commence NVQ2 within a couple of weeks. A member of staff who advised that they were the coordinator for workplace manual handling was spoken with. They advised that they have to review all staffs’ certificates on an annual basis, to ensure they are up to date, and that updates are given every six months. This coordinator advised that they attend regular training at Kerrison for manual handling this, and that they like to go through it on a six monthly basis with staff as they may have learnt something new at Kerrison. The last training certificate on file for this workers own manual handling refresher, was dated December 2003. There was no evidence that the worker had been trained to deliver manual handling training. Three of the four staff files inspected included a record of Boots medication training in August 2005, including the carer who administered medication on the day of the inspection. A member of staff advised that the had had no specialist training in dementia, and there was no evidence of any training in dementia in the four staff files inspected. The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 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): 31,35,36,38 People using the service can expect an approachable staff team, who are committed to running the home, in the best interests of the residents. However the owners must acknowledge, the importance of not only providing a caring environment, but as registered persons taking appropriate action to address requirements made, within given timescales. This is to ensure the safety and wellbeing of all people living and working in the home at all times. EVIDENCE: Mr Johnson, the manager of the home, and a co-owner of the establishment, is a Registered Mental Nurse, Registered General Nurse and holds a Cert Ed. In partnership with Mr Read, he has been operating The Beeches for approximately 20 years. Mr. Read advised that that they held City and Guild Certificates in Management for care and advanced Management for care. The matter of the requirement for Registered Manager’s to have a qualification at level 4 NVQ in management and care or equivalent by 2005 was discussed The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 22 with Mr Johnson in 2004, and at that time, since each bring separate experience to the operation of the home and the inspector had asked them to think about whether joint registration would be a solution to the problem. No further action had been taken on this by the manager. The manager had not implemented a large number of requirements made at the last announced inspection. The home’s office appeared to lack some organisation. An inspection report was in the lobby, but this was dated February 2005; the previous main inspection took place in July 2006, and a pharmacy inspection took place in it September 2005. Reports from these inspections were not on display. No reply had been received by the CSCI to either of these inspection reports which were initially sent to the home in draft form, and no action plans had been received. A number of requirements from the last inspection had not been met. The manager acknowledged that he had found some of the paper work involved in regulation challenging, but advised that they did want to meet the requirements we had made. They advised that they felt that they had found some energy to address the outstanding issues. The manager and the business partner had a good knowledge of individual service users, they advised that they both spent considerable time at the home, and their lives were built around it as they found the care side very rewarding. The home’s policy on physical intervention was dated July 2005. It referred to legislation but the most recent legislation referred to was 1986.The policy did include the need for risk assessments where any form of restriction was used, but did not include any reference to this being signed by other parties involved in the service users care. The policy did not refer to the need to keep records on any form of restraint used. The manager and staff advised that no restraint was used, and no bedsides were in use. The Inspector was advised by a carer that lap belts were not used for any service user. None were seen in use. The manager advised that service users monies are not held by the home. Services users are billed by the company for their care and any additional expenditure which included hairdressing, chiropody and toiletries. The chiropodist provides a receipt, and the hairdresser completes a book listing those whose hair has been done. Accounts for three service users were checked, and the most recent invoices sent. Two had one charge for hairdressing, one had chiropody, and a receipt was in place. The hairdressing was only evidenced by the hairdresser’s entry in the book. Many of the service users appeared to have had their hair done by a hairdresser. Standard 36 was found not to be met at the Announced inspections in 2005, and had not been met at previous two inspections. A member of staff was asked what sort of supervision they receive. They advised that every day one member of staff is highlighted, who they could turn to or ask. They were asked The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 23 where they discuss their work on an ongoing basis, and advised that they didn’t have regular meetings for this purpose. The manager advised that regarding the requirement made, they had “nothing to show”, when asked for access to records of supervision. The manager advised that they had borrowed a sheet to record information. Of the four staff files inspected, only two had any record of supervision, these had one entry each for a date in 2004. The home’s Certificate of Registration was correctly displayed. There was no record kept of people visiting the home. The manager advised that they did not think this was necessary. A requirement had been made at the previous announced inspection. Fire extinguishers were marked to show that they had been serviced in August 2005. A resident who was spoken with said that she had heard the fire bells go off. The fire logbook showed a list of entries of fire training given to individual members of staff, there were eleven entries for December 2005, and had a record of fire drills undertaken every 3 months. Emergency lights and the fire alarm system were recorded as having been tested in February 2006. Records were maintained of fridge and freezer temperatures and meat temperatures. The manager advised that a health and safety visit from environmental health officer recently but had not yet received a report. The District council have subsequently confirmed that a visit took place in November 2005 when it had been found that the kitchen very clean, no problems. A subsequent visit had taken place on 20th March 2006. The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 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 2 X X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 X 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 2 3 The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 41S1,345, 11,1215,1 6 Requirement The home must provide a Statement of Purpose that contains all the information in Schedule 1 of the Care Homes Regulations 2001. They must also provide a suitable Service User Guide. This is a repeat requirement (18/8/04, 17/2/05) which was not fully met. Once completed a copy must be forwarded to the CSCI, and made available to residents and visitors. This is a repeat requirement. Service users records must contain a photograph. Action must be taken to ensure full and accurate records are kept for the administration of medicines, including details why, if any dose is not recorded as given. This is a repeat requirement. The home must provide written guidance and training for staff in the Protection of Vulnerable Adults (POVA). This is a repeat requirement which was not fully met (18/8/04, 17/2/05) DS0000047597.V286093.R01.S.doc Timescale for action 13/05/06 2. 3. OP7 OP9 17,1,a Sch 3 13,2,17,1 01/06/06 07/03/06 4. OP18 13,6,18,1 07/06/06 The Beeches Residential Home Version 5.1 Page 26 5. OP26 16 6. OP26 13,3 7. OP29 19 Sch2 8. OP29 19 Sch2 9. OP30 18,1,c 10. 11. OP30 OP36 18,1,c 18,2 12. OP33 12,1 13. OP37 17, Sch4,17 The home must arrange for an Infection Control Audit and training of staff in infection control procedures, to be undertaken by a trained and experience person. This is a repeat requirement. All shared toilets facilities must have liquid soap and paper towels to minimise the risk of cross infection. Staff must not start work until POVA First or CRB Clearance has been obtained by the home. This is a repeat requirement. The home must obtain two references, which they have validated, prior to staff starting work at the home. This is a repeat requirement. The home must provide evidence of recent manual handling refresher training for the workforce Manual Handling trainer who trains other care staff, and ensure that they have been trained to deliver manual handling training. Staff must receive some specialist training in dementia care. The Registered Persons must ensure that a formal supervision is undertaken and a record of staff supervision is maintained. The home’s restraint policy must be reviewed in the light of recent legislation including the mental incapacity Act 2005. The home must keep a record of the names of all people visiting the home, which is kept available for inspection. This is a repeat requirement. 07/06/06 15/03/06 07/03/06 07/03/06 30/06/06 31/07/06 30/05/06 30/06/06 15/04/06 The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard OP15 OP16 OP30 OP31 OP35 Good Practice Recommendations The introduction of photographic menus should be considered. The home should maintain a complaints log. A training analysis should be drawn up, to assist the home in monitoring training required and provided. The Home’s Registered Manager should have a management qualification. A member of staff should countersign chiropodist’s receipts or management to confirm the service had been received, and hairdresser’s entries of a service provided should also be countersigned. The Beeches Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Residential Home DS0000047597.V286093.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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