Inspection on 14/06/06 for The Beeches (Rowley Regis)

This inspection was carried out on 14th June 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 (Rowley Regis) 29/10/07

The Beeches (Rowley Regis) 06/12/06

The Beeches (Rowley Regis) 24/01/06

The Beeches (Rowley Regis) 22/06/05

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

CARE HOMES FOR OLDER PEOPLE The Beeches(Blackheath) 17 Waterfall Lane Rowley Regis West Midlands B65 OBL Lead Inspector Mrs Cathy Moore Unannounced Inspection 14th June 2006 07.55 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(Blackheath) DS0000066557.V298258.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(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches(Blackheath) Address 17 Waterfall Lane Rowley Regis West Midlands B65 OBL 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) 0121 744 1659 janet.wyatt2@btopenworld.com Janet Wyatt Care Home 17 Category(ies) of Dementia (17) registration, with number of places The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24/01/06 Brief Description of the Service: The Beeches is located near the centre of Blackheath and is in close proximity to a number of shops and other amenities. The Beeches is registered with the Commission for Social Care Inspection to provide personal care to 17 residents who fall within the categories of Old Age/ Dementia Elderly. The Beeches is a traditional Edwardian detached property , which has been adapted and extended for its present purpose. The grounds have mature gardens and car parking available to the front. The home is sited off a steep hill and the drive to the home is also inclined . The building is in a commanding position , with some good views of the local area and Clent hills from some bedrooms. The home offers 11 single and 3 en-suite double bedrooms, two communal lounges a dining room , two bathrooms , one shower room and five communal toilets. A shaft lift enables easy access between floors. Weekly fees for The Beeches range from £328- £410. The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on one day by two inspectors’ between 07.50 and 16.00 hours. Preparation for the inspection was done by looking at all correspondence/ information received regarding The Beeches since the last time it was inspected. Questionnaires were sent to relatives and residents. Four completed resident and eight completed relative questionnaires were received. The owner kindly completed and returned a pre-inspection questionnaire before the inspection was carried out. During the inspection the premises were randomly viewed which included looking at the lounges, dining room, laundry, garden, 6 bedrooms, toilets and bathrooms. Three resident files were examined to look at their assessment of need papers, care plans and daily notes. Eight residents’, four staff and one relative were spoken to. Time was spent observing daily routines and meal times. Medication systems were assessed as were health and safety mechanisms. Three staff files were looked at to assess recruitment processes and training. What the service does well: The registered’ owner is involved on a daily basis in the homes’ running and functioning. It is clear that she is committed to making the required, ongoing improvements to the home and the standards of care. The staff are motivated, interested in their work and are keen to meet the needs of the people in their care. They are kind and caring. A number of the staff have been employed for some time providing stability and consistency of care to the residents. The home has a good level of staff attaining N.V.Q. En-suite facilities are provided in every bedroom which aids privacy and dignity. The newly refurbished lounge and dining room are attractive, homely, bright and comfortable. The home has flexible visiting times and encourages residents’ to maintain contact with family and friends. Positive comments were received about the home in general and included; ” The Beeches is one of the better homes’”. “ Overall I am very happy with the facilities and standard of care”. “ The staff are very friendly and being a smaller home I think it helps”. “ The Beeches has a friendly, welcoming atmosphere. One of the best homes I visited”. “ The home has a friendly The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 6 atmosphere. The staff are helpful and the clients seem to be happy”. “ My overall picture is good and the staff are pleasant”. One relative said; “ Very pleased with the home, would recommend it to anyone”. What has improved since the last inspection? The registered owner has increased occupancy levels for the first time in 18 months. Occupancy has risen from 12 to 16 residents. A care co-ordinator has been employed to oversee care practices, care planning and care issues. Staff and residents are very positive about the new management and improvements in the home. Plans have been made to take a couple of the residents’ on holiday to Ross on Wye. The garden looks much better. The gardener now does more hours. The grass and borders are well tended. The garden is attractive. A number of residents’ commented on the garden saying how nice it is and how they enjoy sitting outside. The dining room has been transformed. It has been decorated in an attractive wall paper, blinds have been fitted at the windows and attractive dining tables and chairs have been purchased. The dining room now looks bright, airy and homely. Residents and staff made positive comments on how much the dining room has improved. The main lounge has been redecorated and new easy chairs purchased. Blinds have been fitted at the windows. This room looks much better, homely and comfortable. New lighting is being purchased. Again residents’ and staff commented positively about the improvements made. Seven bedrooms have been redecorated. One bedroom has been provided with laminate style flooring. The ground floor bathroom is in the process of being totally refurbished. The toilet next to the reception area has been refurbished. Staff have all been issued with new uniforms including the cook who was wearing a full set of ‘kitchen whites’. New commercial laundry equipment has been installed. This includes a washing machine and dryer. The washing machine has disinfectant and sluice cycles. A portable hoist has been purchased and is being delivered on June 15 2006. It is the first time the home has had a hoist. The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 7 A fenced area has been installed to safely keep the homes’ clinical waste bins in the garden. Food hygiene and dementia training has been arranged. All staff received fire training in June 2006. Medication systems although requiring more work, have improved since the last inspection. Staff have received medication training. Meals and menus have improved . Fresh fruit as a snack is offered to all residents’ at least daily. The cook confirmed that since the new owner has taken over the home food delivery has doubled. In addition to main meals a range of snacks and cakes are available at all times. One relative commented; “;” I feel that when the new owner took over The Beeches it was in a very run down state. She has made many improvements and has already raised the standards in the home”. Another relative commented positively about the improvements that have been made since the new owner has purchased the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Beeches(Blackheath) DS0000066557.V298258.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(Blackheath) DS0000066557.V298258.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): 2,3,4. The overall outcome for this group of standards is judged to be adequate. Fine tuning of contract/terms and conditions documents is needed to ensure that residents’ are fully informed of their rights . Asessment of need processes need further development to ensure that the home can demonstrate that the full needs of each resident can/will be met. This section is assessed as being ‘Adequate’. EVIDENCE: It is pleasing that four of the four resident questionnaires received confirmed that they had all received enough information about the home prior to their admission. It is positive that a terms and conditions document was seen on each of the residents’ files looked at. This was further confirmed by completed resident questionnaires received. Three of the four said that they had been issued with a contract. One said that they did not know. On examination of these’ contracts/terms and conditions documents however, there were missing areas examples being; they did not show room numbers or specific information concerning shared rooms as required by The National Minimum Standards. The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 10 Assessment of need documentation was not in all cases fully complete as it had not been signed and there was no evidence of resident involvement. There was no evidence to suggest that written assurance is given to each proposed new resident to confirm that they home will ba able to meet their needs. The Beeches(Blackheath) DS0000066557.V298258.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): 7,8,9,10,11. The overall outcome for this group of standards is judged to be poor. Health and personal care needs to be improved in most areas to prove that needs are being met and that medication systems are safe. This section is assessed overall as being ‘Poor’ EVIDENCE: It was positive to see that a care plan was included on each resident file examined. Care plans seen covered a range of medical and care needs. Some important areas however, were missing examples being; foot and eye care for diagnosed diabetics and special requirements for people who have dementia. It was disappointing in that there was a lack of evidence to prove that residents are being involved in their care planning process or explanation why they have not been involved. It was noted that care plans are not always being reviewed monthly as they should for instance; one care plan had not been reviewed since admission, another not, for a number of months. Although there was evidence of weight recording this was inconsistent. Two resident records showed that they had not been weighed since April 06. There was no evidence to demonstrate that a new resident had been weighed on admission. Risk assessments were not in place as they should be for all The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 12 residents’ for aggression or wandering. One tissue viability assessment document had not been fully completed. It is positive however, that control measures were in place for one resident who had been assessed as being a high risk in respect of falls. There was a lack of consistent recording of personal care delivery. It was difficult to identify how often residents had their teeth cleaned, had a shower or a bath or nail care. A comment was received before the inspection suggesting that’ baths are not available each week’. The owner did comment on this saying that bathing was a bit difficult at the present due to the ground floor bathroom being refurbished. There was written evidence to confirm that residents’ have good access to their doctors and some evidence of dentist and chiropody visits. Of the four completed resident questionnaires received three confirmed that they’ Always’ receive the care and support they need, one answered as ‘Usually’. Three confirmed that they ‘Always’ receive they medical support they need one answered as ‘Sometimes’. The question ‘ if you or your relative or friend is not able to make decisions are you consulted about their care’? in a relatives questionnaire. Of the eight responses four answered as ‘yes’, three as ‘No’ and one as ‘Sometimes’. One relative positively offered the following comment;” My ..went into The Beeches in Feb 06. He settled in well. Recently been very poorly family and friends have been impressed with the level of care shown”. Although medication systems have improved to some extent in that staff either have or are receiving accredited medication training, a member of staff has been delegated responsibility for overseeing medications, pen not pencil is now being used to write on medication records, and that eye drops are now being date labelled when opened as they should. A significant number of shortfalls were identified which included; some unwanted medications are being held by the home rather than them being returned to the pharmacy. Special instructions for medication administration are not being followed an example being; Alendronic acid. The home does not have a contract with their pharmacy provider and the pharmacy provider is not undertaking regular medication audits as they should. Medication totals are not being carried forward onto new medication records from the previous one to enable easy audit. It is positive that the preferred form of address of each resident is determined and recorded on their personal file. The care staff team were seen to be kind and considerate to residents. They were polite and respectful. It was evident that a good relationship has been established with all. Toilet doors were seen to be closed when in use to enhance privacy and dignity. Personal care and medical healthcare assessments are carried out in privacy predominantly in the residents own bedroom. It was noted that there was a lack of recording on residents’ files of their last wishes and preferred arrangements following which may cause a delay if a sudden situation were to arise. The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 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): 12,13,14,15. The overall outcome for this group of standards is judged to be adequate. Residents’ are and do maintain contact with family and friends, they are helped to exercise choice and control, meal provision is satisfactory; activity provision needs further development and improvement to ensure residents are stimulated and have satisfying recreational time. This section is assessed overall as being ‘Adequate’. EVIDENCE: Comments from completed resident and relative questionnaires demonstrated that work is needed concerning activity provision. Of the four resident questionnaires received one confirmed that there is ‘ Always’ activities arranged by the home that they can take part in, two ‘Usually’ and one ‘Never’. Comments received from relatives included; “ More attention needs to be found for activities which consists of watching television and watching tapes”. “ There is no activity programme at the present time”. It was identified during the inspection that there is not a formal activity programme in place and no formal records maintained of activity participation these areas are in need of development. Positives were however, identified concerning activity provision. One care staff described quizzes and memory The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 14 games residents’ participate in. There is a regular church service provided by a local church for residents who wish to participate. From discussion residents confirmed that they enjoyed ‘ sing-a-long’ sessions and sessions provided by the ‘exercise lady’. It was evidenced that a couple of residents had recently been taken to the Black Country Museum and that two are being taken on holiday to Ross-On-Wye. A big event is planned in the near future. One senior is getting married. This process is going to be repeated a few weeks later when a vicar will do a blessing at the home. The new bride and groom will wear their wedding attire and a party is to be held in the garden. All residents have been given an invitation to attend this event. It was noted that visiting arrangements are on display in the home and referenced in the homes’ terms and conditions document. It was obvious that the home very much encourages all residents to maintain contact with family and friends. Residents’ confirmed that they had regular visitors. One said; “ My daughter comes to see me twice a week”. Residents are encouraged to bring into the home with them personal belongings of their choosing. This evidenced during the random tour of the premises. Bedrooms seen had a range of items from pictures ornaments to photos and books. The owner told the inspectors’ that; she was in the process of obtaining literature from a range of external advocacy providers to make available in the home. To the question; ‘ Do you like the meals at the home?’ three completed resident questionnaires responded as;’ Usually’, one as ‘Always’. It is positive that the home has a menu in operation detailing 4 main meals per day breakfast, lunch, tea and supper. The menu has however, been produced in writing which may be difficult to understand by some residents who have confusion or poor eyesight. One concern about food and drink provision is that residents are not always given a drink before their breakfast even those who chose to rise early. One resident when a drink was brought to her in the dining room said;” I could really do with that”. Another said;” My tongue is hanging out”. The newly refurbished dining room is very pleasant and comfortable. With new tables, chairs, décor and blinds. Meals are managed in two sessions to allow space for all and more attention to residents who require assistance. Breakfast is very varied residents’ selected from a range of cereals, eggs, bacon or toast . Lunch was slightly different to what was stated on the menu to meet choices for that day and consisted of sausages or shepherds pie and vegetables, followed by jam sponge or bananas and custard. The meal looked and smelled very appetising. To accompany the meal residents were offered water or blackcurrant juice. It is clear that meal provision has improved since the new owner purchased the home. The cook said that food deliveries had doubled from one to two per week. That nice snacks and cakes were available at all times. That residents were all offered fresh fruit every day and that nourishing foods such as porridge were made available for breakfast. The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 15 One resident said following her meal;” I liked the food. They know what we like and don’t like”. It is positive that records are made of food consumed by residents on a daily basis however, these records are not always fully completed with consistency. It was interesting to hear from the registered provider that she has made arrangements for the catering staff to attend a nutrition course in the autumn of 2006. During the inspection the cook proudly ( and rightly so) showed us a beautiful birthday cake- nicely decorated- that she had made for a resident who had a birthday that day. The Beeches(Blackheath) DS0000066557.V298258.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): 16,18. The overall outcome for this group of standards is judged to be poor. The area of complaints and protection needs development and improvement to ensure that residents’ are fully informed and know about complaints processes. Adequate measures must be put in place to ensure that residents’ are protected and safe at all times. This section overall has been assessed as being ‘Poor’. EVIDENCE: One concern was raised by a relative about the change of the homes’ registration categories which was responded to by letter from the CSCI. Resident and relative questionnaires were sent out by the Commission preinspection. Two of the four resident responses confirmed that they ‘Always’ know how to make a complaint, one answered as ‘Usually’ and one commented that they did not know how to make a complaint. Comments received included the following;” The complaints procedure has not been adequately explained”. “ Not aware of complaints procedure”. The home does have a complaints procedure in place which is on display in the front entrance hall, although not in a prominent position for all to see. The complaints procedure has been produced in writing only, which may prevent understanding of residents’ for example; who have confusion or poor eyesight. Three complaints have been received by the home since the last inspection demonstrating that a proportion of relatives know about the complaints procedure. Evidence therefore shows that confidence and awareness of The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 17 complaints procedures is mixed. One of the complaints received was referred to and dealt with in the arena of Adult Protection. Records show that the other two complaints were responded to within a 28 day timescale as expected. One concern was raised by a relative about the change of the homes’ registration categories which was responded to by letter from the CSCI. As stated above one incident of concern that occurred between two residents’ was referred and dealt with in accordance with Sandwell Adult Protection processes. It was a concern that this referral was made by a relative not the home. Risks that may have been present due to this situation are no longer as the alleged perpetrator no longer resides at the home. It is disappointing that the home does not have readily available a copy of Sandwell Council’s Adult Protection procedures. Further, the majority of staff to date have not received abuse awareness training. The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,24,25,26. The overall outcome for this group of standards is judged to be poor. Although it is extremely pleasing that much improvement and progress has been made in respect of replacement of furniture and decoration. Concerns remain in respect of infection control and the lack of guarding to hot pipes and radiators. This section therefore, until work has been completed is assessed as being ‘Poor’. EVIDENCE: It is extremely positive that big improvements are been made to the home in respect of refurbishment. The lounge and dining room have been fully redecorated with new furniture provided. These rooms were seen to be bright, clean, attractive, comfortable and homely. Staff and residents alike are proud of these areas and were keen to show the inspectors’. One resident said; “ look how nice the dining room is now”. A decorator has been arranged to commence in the autumn of 2006 to attend to the redecoration of corridors and landings. There were a number of positive comments from relatives about the improvement to the overall environment. The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 19 The garden is being better tended on a more regular basis. It looked very attractive. A number of residents’ commented on how nice the garden looked. One said; “ I love to go and sit outside”. Garden safety however, still needs to be addressed. The owner informed that she was having some quotes for this work the following week. Seven bedrooms have been redecorated , one has been fitted with attractive laminate style flooring. Further bedrooms need redecoration. Bed linen has been purchased for a number of bedrooms and is being replaced bit by bit throughout. Full bedroom audits of fixtures and fittings in each bedroom in accordance with residents’ rights, choices and preferences have not yet been undertaken as they should be. Concern has been raised for sometime about the lack of suitable guarding to radiators and hot pipe work throughout the home potentially placing residents at risk of burning. The owner informed that the homes boilers are in need of replacement and that this work will be carried out in the next month, following this the radiators will be guarded. Ventilation systems in en-suites and bathrooms are either non-existent or not working in some. Again, the owner informed that the necessary ventilation will be installed/ mended in the near future. The owner confirmed that she is at the present time choosing new lighting for the lounge. It is extremely positive that a new commercial washing machine and dryer have been purchased for the laundry. The washing machine has both sluice and disinfectant cycles. The machine have been relocated to make more room in the laundry. The laundry needs redecoration. Infection control procedures were not available to help reduce the risk of any infection contamination. There is no sink in the laundry area. This could cause infection control problems in that staff can not wash their hands. The home does not have a cleaner or dedicated laundry staff. This could obviously could cause problems in that if care staff are busy cleaning duties would have to be neglected. In turn care staff undertaking cleaning/laundry duties depletes care hour time. One relative commented” Mothers room is rarely vacuumed even once a week”. The owner confirmed that she is to advertise for a ‘housekeeper’; to rectify this problem. A significant number of staff to date have not received infection control training. The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. The overall outcome for this group of standards is judged to be poor. Current staffing levels are satisfactory so long as staff do not attend to other tasks, depleting care time. Staff training in respect of N.V.Q is satisfactory. Recruitment processes and overall training however, require improvement to ensure that residents’ are protected. This section is assessed as being ‘ Poor’. EVIDENCE: Staffing levels appear to be adequate in terms of numbers and dependency levels of residents’ so long as staff do not attend to other tasks. Staffing is provided over a 24 hour period as follows; AM 2 care staff and a senior. PM 2 care staff and a senior. Nights 2 wakeful night staff. Two days per week an additional carer is provided to undertake a range of tasks. During business hours the new Care Co-ordinator is also on site. It appears that there have been problems with staffing at sometimes this reflected in comments received in resident/relative questionnaires. Of seven responses five said that there were enough staff two said that there were not. To the question ‘Are the staff available when you need them’? three of the four responded as ‘Always’, one as ‘Usually’. Comments were received as follows: “They could do with more help”. “ There have been shortages due to sickness”. The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 21 The owner confirmed that she will be advertising for a second cook and a housekeeper so this will free up more care staff time. She also confirmed;” if we are short staffed I am always on site and help out”. Positive comments were received about the staff in terms of their attitudes and behaviour as follows: “The staff are friendly”. “The staff are helpful”. “ The staff are welcoming, nothing is too much trouble”. Staff observed during the inspection obviously had a very good relationship with the people in their care they were pleasant and respectful. They were seen to be hard working and committed to looking after the residents’ to a high standard. The home at the present time have 50 of the care staff who have achieved N.V.Q level 2 or above in care- well done. Two staff are working towards their N.V.Q level 3. Generally for direct care staff recruitment processes were seen to be good. Three staff files were examined; all contained the required information examples being; an enhanced Criminal Records Bureau check, an application form, written references. Missing items however, were noted examples being photos for one and health declarations for all three. It was concerning however, that there were no files in place for other staff for instance the handyperson and gardener. The new owner has inherited systems that left a lot to be desired. Staff training is one area that requires attention an example of this was that there was no records since 2004 of staff fire drills. All staff need to have all of the required mandatory training. The home is registered to provide care to people who have a diagnosis of dementia, to this end staff must receive accredited dementia training. The manager confirmed that she is planning to send the new care co-ordinator on accredited training in the autumn. Staff files seen did not have a training plan to make training requirements easier to analyse. There was a lack of evidence of in-house and external induction training which is vital if staff are to be fully informed of processes and policies and how they should conduct themselves. The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38. The overall outcome for this group of standards is judged to be poor. The home does not have it’s own registered manager at the present time. Developments and improvements are needed to ensure that the home is run in the best interests of the residents; that staff are properly supervised and that it is safe. This section is assessed overall as being ‘Poor’. EVIDENCE: At the present time the home does not have a registered manager. The new owner is overseeing the management of the home herself. However, one complication of this is that she owns a second home nearby which she also has managerial responsibility for. However, the owner as previously mentioned has recently employed a care co-ordinator who she is considering putting forward The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 23 for registration in the autumn of 2006 when she has settled into the home and her new job. The owner has does some work concerning quality assurance by using resident satisfaction questionnaires. However, further work is needed to ensure that a monitoring process is in place across all of the National Minimum Standards for Older people, production of an annual appraisal system and methods to gain the views of stakeholders in the community. The home has a policy for the management of safekeeping of resident money. The registered person does not act as an appointee or agent for any resident. The home holds small amounts of money in safe keeping for residents’. Three residents’ monies were checked against records and balances where it was found that processes need improving in that; financial records were not all accurate, and a receipt for one could not be located. No transactions were verified by the two required signatures. Staff supervision is not being carried out as it should be at the present time and requires attention. The manager confirmed that a process would be put into place once the new care co-ordinator had settled in. Random service records in respect of health and safety were examined the fire alarm, emergency lighting and fire fighting systems were all serviced in May 2006. Pat testing was carried out in September 2005. The engineer carrying out the fire fighting equipment test recommended an additional extinguisher in the cellar although, sanctioned this has yet to be installed. A kit has been purchased for the testing of the homes water system. The lift was serviced on 5 June 2006. Due to the needs of some residents’ concern was raised in that there are no preventative measures to prevent residents’ who may be at risk from going up and down the stairs. It is positive that new equipment has been provided in the laundry however, to accommodate this the tumble dryer had to be placed on the washing machine. The positioning of this now relatively high which could pose as a risk to staff without effective measures being implemented when staff are loading and unloading the dryer. It is positive that the new owner has purchased a portable hoist which is to be delivered in June 2006. The home has never has this kind of equipment before. It is also positive that the new owner has replaced the previous metal bedrails with a foam type which tend to be less of a risk in terms of limb entrapment. The home at the present time is being rewired in areas where this is needed. The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 2 2 2 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 1 2 3 x x x 2 1 1 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 1 1 x 2 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 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 5(1)(b) ( c) Requirement The registered provider ensure that resident contracts/ terms and condition documents specify the following; Room number. Any specific information concerning shared rooms. The registered provider must be able to evidence that each resident was involved in their assessment of need process and that they are in agreement with the needs identified. Timescales of 22/06/05 and 24/01/06 not fully met In that there was evidence for only 1 of the 4 residents case tracked that they had been involved. This must be done in respect of all admissions from now on. Documentation must also be signed and dated by the staff member carrying out the assessment. Timescale for action 07/07/06 2 OP3 12(3) 14(1)( c) 07/07/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 26 3 OP4 14(1)(d) The registered provider must confirm in writing to prospective residents’ that having regard to the assessment the care home is suitable for the purpose of meeting their needs. Timescales of 22/06/05 and 24/01/06 not fully met. This must be evidenced at all times with each new admission from now on. 07/07/06 4 OP7 15(1)15 (2) The registered provider must be able to evidence at all times that residents’ are consulted with when their care plans are prepared and reviewed. Timescale of 13/06/05 not met. The registered provider must ensure that the resident/and or representative agrees with their care plan and signs to indicate this agreement. Timescales of 1/02/05 and 13/06/05 not met. The registered provider must ensure that a system is implemented to ensure that each service users’ care plan is reviewed at least monthly or earlier if changes occur. Timescales of 10/01/05,13/07/05 and 24/01/06 not fully met. Not for JB and nose bleeds. 07/07/06 5 OP7 15(1) 07/07/06 6 OP7 15(1)(2) 07/07/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 27 7 OP7 15(1) 8 OP8 13(4) 9 OP8 12(1)(a) 13(4) 10 OP8 12(1)(a) The registered provider must ensure that specific care plans are in place for diabetics including; Foot care. Eye care. People with dementia. The registered provider must ensure that risk assessments are carried out for all residents concerning; falls, behaviour and any other concerning areas. Risk assessment documents must be fully completed and signed and dated. The registered provider must ensure that; All residents are weighed on admission All residents are weighed at least monthly or more frequently if concerns are identified. The registered provider must be able to demonstrate on a daily basis that each resident’s full spectrum of personal care needs have been met. Documents to evidence baths, showers, washes, hair, nail, foot and mouth care, incontinence care ,continence promotion(and other areas of care that are deemed appropriate). Timescales of 10/07/05 and 24/02/06 not fully met. 07/07/06 07/07/06 07/07/06 07/07/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 28 11 OP8 12(1)(a) 12(2) 12 OP9 13(2) The registered provider must ensure that baths are offered as far as possible at least on a weekly basis- or to the required frequency of individual residents. The registered provider must ensure that medication is signed out at the point of administration. Timescales of 04/01/05, 22/06/05 and 24/01/06 not fully met as 17 initial gaps were identified since 20/05/06. 07/07/07 07/07/06 13 OP9 13(2) The registered provider must; Provide documentary evidence of planned dates of accredited medication training for All staff involved in the administration of residents’ medication. It is positive that this is now in progress. 07/08/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 29 14 OP9 13(2) The registered provider must request that the homes’ pharmacist assesses the homes’ medication policy in accordance with Royal Pharmaceutical Society of Great Britain guidance and that their view on this policy is documented within the next medication audit report. Timescales of 05/02/05,01/10/05 and 01/03/06 not fully met. The medication policy when completed must be forwarded to the CSCI. 07/07/06 15 OP9 13(2) The registered provider must ensure that medication during the medication round (administration) is not left unattended. Timescales of 22/06/05 and 24/01/06 not fully met. 07/07/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 30 16 OP9 13(2) The registered provider must ensure that ‘handwritten’ medication administration records include the name of the residents’ doctor, their date of birth and detail any known allergies. Information detailed on handwritten medication administration records must be confirmed and witnessed by two staff whose names must be evidenced. Timescales of 10/07/05 and 10/02/06 not fully met. 07/07/06 17 OP9 13(2) The registered provider must ensure that medications are not prescribed as - ‘ as directed’. Doctors must be asked to prescribe specific times. All medication administration records must be amended accordingly to comply . Timescales of 22/07/05 and 10/02/06 not fully met. 07/07/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 31 18 OP9 13(2) The registered provider must 15/07/06 request that the dispensing pharmacist provides the ‘ patient information leaflets’ that are generally enclosed within the manufacturers medication containers for each type of medication being prescribed. These must be retained and used for reference purposes. Timescales of 01/08/05 and 10/02/06 not fully met. 19 OP9 13(2) The registered provider must ensure that clear instructions are entered on medication records about ‘ short terms’ medication an example of which being antibiotics- that the start date, how many days prescribed for is entered. Timescale of 24/01/06 not fully met. The registered provider must ensure that the balance of all medications is brought forward and recorded to ensure accurate monitoring/auditing of medications. Timescale of 10/02/06 not met. 24/07/06 20 OP9 13(2) 10/07/06 21 OP9 13(2) The registered provider must ensure that a regular in-house audit of medication is undertaken to identify any shortfalls/non-conformances to medication procedures and activate corrective actions. Timescale of 15/02/06 not fully met. DS0000066557.V298258.R01.S.doc 15/07/06 The Beeches(Blackheath) Version 5.2 Page 32 22 OP9 13(2) 23 OP9 13(2) 24 OP9 13(2) 25 OP9 13(2) The registered provider must ensure that all discontinued medication or medication no longer required is returned to the pharmacy in a timely fashion. The registered provider must ensure that all homely remedies are ratified by the residents’ doctor. The registered provider must ensure that staff do not write on medication labels to obscure any instructions. The registered provider must; Provide the CSCI with written evidence of the medication trainers accreditation. Request a written contract from the homes pharmacy provider. Request that the pharmacy provider undertakes regular medication audits . The registered provider must ensure that all special instructions for medication administration for example; Alendronic Acid are fully complied with. The registered provider must ensure that the last wishes of all residents are determined and recorded. It is best that this is undertaken as part of the assessment of need process. The registered person must employ a suitable activities provider or delegate this task to a suitably trained staff member. The number of hours per week to be negotiated with the CSCI and entered on the weekly rota. Timescale of 24/02/06 not met. DS0000066557.V298258.R01.S.doc 15/07/06 07/07/06 07/07/07 15/07/06 26 OP9 13(2) 07/07/06 27 OP11 12(4)(b) 01/08/07 28 OP12 12(1)(b)1 8(1)(a) 15/07/06 The Beeches(Blackheath) Version 5.2 Page 33 29 OP12 16(2)(n) The registered provider must through consultation with the residents’ produce a programme of activities and stimulation. All activity participation must be recorded as per day and date. Timescale of 24/02/06 not met. 20/07/06 30 OP12 12(2)12 (5)(a) The registered provider must produce a schedule of resident meetings. That these are held on a regular basis and that written records are made. Timescale of 24/02/06 not met. The registered provider must ensure that; Residents do not go without food and drink longer than 10 hours throughout the night. Residents are offered a cup of tea ( or other preferred beverage) on waking. Timescale of 15/02/06 not fully met. 20/07/06 31 OP15 17(2) Sched 4(13) 15/07/06 32 OP15 12(4)(b) 33 OP15 Sched 4 (13) The registered provider must ensure that menus are produced in a format appropriate to all residents’. The registered provider must ensure that all food consumption charts are completed fully every day. 15/07/06 05/07/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 34 34 OP16 22(3) The registered provider must ensure that all staff are trained to what they must do if they receive a complaint and what processes they must follow. Timescales of 22/07/05 and 24/02/06 not fully met. The registered provider must ensure that the complaints procedure is appropriate to the needs of the service users’ ( Large print/pictorial formats). Timescales of 22/07/05 and 24/02/06 not met. 07/08/06 35 OP16 22(2) 07/08/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 35 36 OP18 13(6) The registered provider must revise the homes; Adult abuse policy in line with Department of Health guidance ’No Secrets’. And Sandwell MBC’s Adult Protection guidelines. Physical Intervention policy in line with Department of Health guidance. 01/08/06 The registered provider must ensure that the homes’ procedure on whistle blowing is expanded to give details of who staff can contact if they have concerns as to practices ( This to include the CSCI’s telephone number). Timescales of 22/07/05 and 01/03/06 not met. 37 OP18 13(6) The registered provider must obtain a copy of Sandwell Council’s Adult Protection Procedures. These must be signed and dated by all staff. The registered provider must ensure that all staff receive abuse awareness training. 10/07/06 38 OP18 13(6) 01/09/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 36 39 OP19 23(2)(d) The registered provider must ensure that all landings and corridors to include skirting board, walls, doors are redecorated. Carpets are to replaced where they are threadbare or in a poor state for example, the stairs near to the extension. Timescales of 01/09/05 and 01/06/06 not met. In the interim written risk assessments must be carried out. The registered owner confirmed that a decorator is booked for 3 weeks commencing Oct 2006. 01/11/06 40 OP19 23(2)(b)2 3(2)(d) The registered provider must secure the input of an appropriately qualified surveyor or engineer to assess the windows/window frames throughout the home ( with the exception of the few that are made from UPVC) to ascertain whether they require redecoration or replacement. A full written report must be produced by this person which highlights their findings and recommendations which must be forwarded to the CSCI office along with intended actions and timescales for action. Timescales of 01/08/06 and 01/05/06 not met. 01/08/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 37 41 OP19 13(4)(a) 23(2)(o) The registered provider must ensure that the garden area is safe for all residents’ to access when they wish. Particular areas of concern are the steps which may present as a falls risk. Timescales of 27/07/05 and 01/04/06 not met. Evidence of how you intend to meet this requirement must be forwarded to the CSCI. In the interim period written risk assessments must be carried out. The registered owner confirmed that quotes are being obtained for this work on 20/06/06. 01/08/06 42 OP21 23(2)(b) 23(2)(d) The registered provider must ensure that all toilets and bathrooms throughout the home are redecorated and fixtures and fittings are in a good state of repair/in good working order. Timescales of 01/08/05 and 01/05/06 not fully met. It is pleasing however, that this is being worked on at the present time. 01/09/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 38 43 OP21 23(2)(d) The registered provider must 01/09/06 ensure that each bedroom and en-suite is included in the maintenance programme, separately itemised in room number detailing what is to be done and when. This to include full redecoration and new carpets where required due to stain or poor state, example being rooms 3,7 and 12. Timescale of 01/05/06 not fully met. One bedroom has been replaced with laminate style flooring. 44 OP24 16(2)(c) The registered provider must ensure that all bedding and pillows are of a good standard at all times. Written evidence must be available at all times to demonstrate that regular audits of bed linen and pillows are being carried out. (Timescale of 01/05/06 not fully met). Work in progress. 01/08/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 39 45 OP24 16(2)(2) ( c) 46 OP25 13(4)(a) The registered provider must ensure that a full documented audit of each bedroom against standard 24 is undertaken. Residents and their relatives must be given the option of voicing their satisfaction or otherwise about the furniture and fittings provided. If they are satisfied then they must be asked to sign and date the audit if not then actions must be taken to resolve. The registered provider must; continue with her plans to have the radiators replaced or guarded in the springtime. In the interim period regular risk assessments must be carried out and be made available for inspection. (Timescale of 15/02/06 not met). Work will be completed when new boilers fitted. 01/08/06 15/08/06 47 OP25 13(4)(a) The registered provider must risk 12/08/06 assess each bathroom and toilet in respect of hot water pipes. These pipes must be suitably guarded. Timescale of 12/03/06 not met. The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 40 48 OP25 13(4)(a)2 3(2)(p) The registered provider must 12/08/06 ensure that ventilation extractors throughout the home are checked and cleaned on a regular basis. Documentary evidence that this is being done must be available at all times. Timescales of 15/01/05, 22/07/05 and 12/02/06 not met. The registered provider must provide adequate ventilation in all bathrooms and toilets. Timescales of 01/09/05 and 01/04/06 not fully met. 01/08/06 49 OP25 23(2)(p) 50 OP25 13(4)(a)2 3(2)(j) The registered provider must ensure that the temperatures from each hot water outlet are tested and recorded monthly. Timescales of 10/01/05 and 22/06/05 not met. An immediate requirement followed by a serious concern letter was issued to the registered provider in respect of this following the last inspection. Timescale of 31/01/06 although improved has not been done since April 06. 01/07/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 41 51 OP25 13(3) 13(4)(a) The registered provider must ensure that water from each hot water outlet remains within the scale of 38oc-43oc at all times. This to include en-suites. Timescales of 01/09/05 and 15/02/06 not met. Problems are due to malfunctioning boilers. The registered owner confirmed that new boilers will be fitted within the next month. In the interim documented risk management processes must be implemented. 15/07/06 52 OP26 13(3) The registered provider must ensure that stocks of clean bed linen/ towels are not stored in communal areas. Timescales of 01/02/05,08/07/05 and 01/03/06 not met. It is intended that cupboards with doors will be provided to house these in. The ground floor bathroom is being refurbished. The registered owner confirmed that these issues will be addressed when this work is completed. The registered provider must ensure that the laundry is redecorated and that the flooring replaced with a type that is impermeable. Timescale of 01/04/06 not met. 01/08/06 53 OP26 13(3) 23(2)(d) 01/09/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 42 54 OP26 13(3) The registered provider must ensure that ; Policies on infection control. Laundry procedures. Risk assessments for the laundry are produced. That evidence is available to demonstrate that all of these have been read by staff and when. That these policies/ processes are being consistently and diligently adhered to. Timescales of 08/07/05 and 01/03/06 not met. 01/08/06 55 OP26 13(3) 56 OP26 13(3) 57 58 OP26 OP26 13(3) 18(1)(a) 13(3) The registered provider must ensure that a second sink for hand washing purposes is installed in the laundry. The registered provider must ensure that; Mops are stored in the areas they are to be used in, for example the kitchen. Mops are cleaned to disinfectant cycles daily and that records of this are made. When not in use mop heads are stored upright to enable them to dry properly. That mop heads are changed monthly and that records of these changes are made. The registered provider must ensure that all staff receives infection control training. The registered provider must ensure that schedules for cleaning are produced for each room/area. These must be signed and dated by staff when they had undertaken each task. DS0000066557.V298258.R01.S.doc 01/08/06 10/07/06 01/09/06 01/08/06 The Beeches(Blackheath) Version 5.2 Page 43 59 60 61 OP26 OP26 OP29 13(3) 18(1)(a) 13(3) 13(6) 19(2) The registered provider must recruit a cleaner at least 30 hours per week. The registered provider must ensure that the kitchen cleaning schedule is fully adhered to. The registered provider must ensure that all information detailed within Schedule 2 of the Care Home Regulations 2001 must be obtained for all staff working in the care home and prior to for prospective staff. Timescale of 10/02/06 not met. This to include the handyperson and Gardner . Evidence of the hairdressers CRB and Public Liability Insurance must be kept on site. 01/08/06 07/07/06 30/07/06 62 OP29 13(6) 19(2) The registered provider must provide the CSCI with an up to date recruitment policy. Timescale of 01/03/06 not met. 01/08/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 44 63 OP30 13(6) 18(1)(a) The registered provider must ensure that there is; A staff training and development programme. Induction and foundation training available. Timescale of 01/03/06 not met. 01/08/06 64 OP30 18(1)(a) The registered provider must provide evidence to the CSCI of training dates confirmed for staff in respect of dementia training ( accredited). Timescale of 15/02/06 not met. The registered provider must employ a suitable manager for the home. 25/08/06 65 OP31 8,9 30/09/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 45 70 OP33 24 The registered provider must implement / continue developing the homes system for improving the quality of care in the home, this to include; Measuring success in meeting the aims and objectives of the home. Use of a continuous self monitoring tool. Production of an annual appraisal. Seeking the views of family, friends and stakeholders in the community. An annual internal audit. A proposal must be submitted to the CSCI giving realistic timescales when this requirement can be met. 01/09/06 71 OP35 Sched 4 (10) The registered provider must ensure that a list of all property brought into the home by each resident- to include furniture- is produced and maintained 25/07/06 72 OP35 13(6) 16(2)(l) The registered provider must ensure that; There are 2 signatures for each transaction of residents’ money. That a receipt is available for all expenditure of resident money. That these are numbered for ease of auditing and held on the resident finance sheet. 07/07/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 46 .73 OP36 18(2) The registered provider must ensure that all care staff are supervised at least once every two months (six times per year). Timescales of 01/09/05 and 01/06/06 not met. 01/09/06 74 OP37 17(2) The registered provider must ensure that all of the required policies and procedures are in place, are up to date and are reviewed annually. Timescales of 28/08/05 and 01/04/06 not met. The registered provider must ensure that all staff read all policies and procedures. Timescales of 01/02/05,15/09/05 and 15/04/06 not met. The registered provider must forward to the CSCI an up to date training matrix detailing each staff members name, the training they have received and the date of this training to ensure the following; That all staff have had; Food hygiene training. Moving and handling training. First aid training. Infection control training Fire safety/fire drill training twice in any 12 month period. Timescales of 20/08/06 and 01/03/06 not met. 01/09/06 75 OP37 17(2) 15/09/06 76 OP38 18(1)(a) 01/09/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 47 77 OP38 17(2) 13(4) 18(1)(a) The registered provider must 01/08/06 ensure that the health and safety poster is completed with accurate information. Ensure that the person who is named on the poster has the required training and qualifications to prove competence. Ensure that the first aid trainer details on staff certificates how long the training lasts for before expiry for example; 3 years. Ensure that the additional cellar fire extinguisher is provided and installed. Ensure that all fire drills are recorded. The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 48 78 OP38 13(4) 23(4) 79 OP38 16(2)(j) The registered provider must ensure that all electrical items brought into the home by residents are PAT tested before use. The registered provider must ensure that; The food probe is collaborated regularly and records of these are maintained. That menus are available in pictorial formats. That all short life foods such as jams and sauces are labelled when opened. Timescales of 01/08/05 and 15/02/06 not fully met. 07/07/07 15/07/06 The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 49 .80 OP38 13(4) The registered provider must ensure that sufficient systems are in place regarding all areas of risk; Risk assessments and actions must be in place in relation to; Falls, accidents, moving and handling, behaviour, fire prevention, premises, safety including adhering to COSHH Regulations. Timescales of 01/08/05 and 24/02/06 not fully met. This to include the use of the stairs/ Stair cases and risk to those residents who have dementia who could go up or down the stairs without supervision. Loading and unloading the washing machine for staff. The undertaking of monthly, recorded accident analysis. 07/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Beeches(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 50 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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(Blackheath) DS0000066557.V298258.R01.S.doc Version 5.2 Page 51 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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