Inspection on 22/06/05 for The Beeches (Rowley Regis)

This inspection was carried out on 22nd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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) 14/06/06

The Beeches (Rowley Regis) 24/01/06

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

CARE HOMES FOR OLDER PEOPLE The Beeches 17 Waterfall Lane Blackheath West Midlands. B65 0BL Lead Inspector Cathy Moore Unannounced 22 June 2005 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 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 E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Beeches Address 17 Waterfall Lane Blackheath West Midlands. B65 OBL 0121 559 5055 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BMI Homes Ltd. Mrs Anne Jolly Care Home 17 Category(ies) of OP Old Age (17) registration, with number of places The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Nil Date of last inspection 04.01.05 Brief Description of the Service: The Beeches is located near the centre of Blackheath and is in close proximity of 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 categorey of Old Age. 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 ensuite 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. The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by two inspectors on the 22nd June 2005 between 08.10 and 15.20 hours. The inspection included a random partial tour of the premises looking at communal areas, toilet and bathing facilities, the laundry and a number of bedrooms. Three residents were selected for case tracking purposes , their personal records were perused and they were spoken to. Four other residents were spoken to in addition to three visitors to determine their perceptions of the home in general. Two staff files were examined and three staff were spoken to in detail. Records and systems were assessed pertaining to medications, complaints , infection control and health and safety. What the service does well: Positive comments about the home were received from a number of residents one commented ,“ The food is good”. Another said “ The carers are very kind”. “ I am happy with the care provided”. One resident said ”I am happy now”. Care staff appeared to be kind and caring, motivated and committed to looking after the people in their care. All bedrooms are provided with en-suite facilities. Residents are encouraged by the home to maintain contact with family and friends. One resident said” My daughter lives in Canada but she phones me every day”. One resident attends external meetings three times a week”. The home has an open visiting policy. Relatives said “ We can visit when we want to”. The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: This home has endured a lack of financial investment for a number of years resulting in the premises being in many areas, of an extremely poor standard, with decaying windows, poorly decorated and maintained bathrooms, bedrooms and communal areas. The registered provider and manager were given the opportunity by the Commission for Social Care Inspection (CSCI) to undertake their own audit of fabric replacement and decorating needs and produce a maintenance programme to address premises shortfalls. This has not been done. Premises seen during the inspection were concerning. The French windows in the big lounge leading to the garden were rotten and decaying, windows in many rooms in a poor state of repair the state of the dining room carpet the worst seen in any care home by the inspectors. The carpet was stained black and sticky underfoot. All chairs assessed in both lounges had thread bare arms. One visitor commented, “ The premises are rough”. The registered owner and manager appear to be complacent about the poor standard of decoration and the home in general. This evidenced by the lack of action plans following the last two inspections, lack of pro-activity and initiative, unsafe medication systems , continued breach of Registration Regulations, lack of observance to health and safety issues, inadequate care planning and poor record keeping. These shortfalls do not give confidence in terms of their ‘ fitness’ as registered persons. Activity provision was summarised by one resident who said, “ Activities? Not a thing. Nearly everyone goes to sleep all the time”. The home has been issued with over 100 requirements, a proportion of these are outstanding from previous inspections. Twenty two of the thirty eight National Minimum Standards for Older People were assessed during the inspection, only two of these are being met. The home is not complying with the Care Standards Act 2000 and is in breach of a significant number of the Care Home Regulations 2001. The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 7 The registered persons must address and meet all requirements made and respond/ attend to the serious concern letter sent to them by the CSCI within the timescales set in these documents. Non- compliance with requirements made and their attached timescales may result in enforcement action and or prosecution. The CSCI will closely monitor this home. Additional monitoring inspections will be undertaken in between statutory inspections to determine progress or otherwise. 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 E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 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 standard(s) 2,3,4,5 A contract was not available for one self funding resident. Terms and conditions documents require further development. The assessment of need process in operation lacks resident input. Residents entering the home are not assured that their needs will be met. Prospective residents have the opportunity to visit and asses its quality, facilities and suitability before they are admitted. EVIDENCE: Of the three residents files examined two included a terms and conditions document. These documents did not detail residents’ room number and the fee shown was not the present rate. The terms and conditions document intimated that the home is registered by a ‘registration and inspection unit ‘, this has not been the case since April 2002. The third resident who was self funding a respite stay, had not been issued with a contract. An assessment of need document was seen on residents files. This documentation has been updated in the last year. The document for the latest admission was more comprehensive and detailed. However, there was no evidence to demonstrate that the residents was involved in their assessment of The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 10 need process. Not all files included an assessment carried out by the funding authority. The home for some considerable time has been breaching Registration Regulations. A number of residents have dementia type symptoms. One staff member informed inspectors that ” five residents have dementia “. The home is only registered to provide care to older people, not residents who have dementia. Requirements have been made following at least the last two inspections for this situation to be addressed and rectified. To date the CSCI has neither received any confirmed diagnosis for two residents previously highlighted during inspections nor a variation application. There was no evidence available to demonstrate that the new resident had been given written confirmation that the home could meet her needs. The new resident and her family confirmed that they had visited the home prior to her admission. An entry was seen in the homes communication records reflecting this visit. A trial period is in operation for all new residents giving them the opportunity to determine the suitability of the placement before it is made permanent . The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 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 standard(s) 7,8,9 Residents health, personal and social needs are not all reflected in their individual plan of care. Residents’ health care needs are not being fully met by the home. Shortfalls in medication systems, poor medication administration and lack of accredited medication training are potentially placing residents at risk. EVIDENCE: Two of the three residents’ files viewed included a care plan. Care plan content was lacking in many areas needs not reflected therein. (L.K) a letter from the hospital dated 25 May 2005 instructed “ fluids must be pushed” , yet there was no mention of this in her care plan. (L.K) has vascular dementia, hypertension and has a tendency to wander at night into other residents bedrooms. Her notes written on the 2 May 2005 stated “( L) out of bed on staircase several times in and out of (I’s) room” and 4 May 2005 “ Slept well until 4 A.M then wandered into (I’s) room”. There was no mention of these diagnoses or risks detailed in her care plan potentially placing (L.K) at risk. Lack of appropriate management at night is contributing to other residents’ sleep being disturbed. There was no care plan at all for the new resident (M.H). The manager said “ A senior has got all information at home and will produce the care plan”. This The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 12 resident had been at the home for 9 days up to that time and was due to go home three days later. Care plan reviews were seen to be basic and not always consistent. There was no evidence available to demonstrate that residents’ are consulted with when their care plans are prepared or reviewed. There was no evidence to demonstrate that the new resident had been weighed on admission. Other residents’ had been weighed monthly for a time however, there were no weights available after December 2004. One resident (G.S) weight was recorded as 8 stone 3 lbs. in November 2004 and 7 stone 8llbs in December 2004. There was no weight recording after this time and no evidence to demonstrate that she had been referred to her doctor or to a dietician regarding her weight loss. The home does not have in operation a nutritional or tissue viability assessment tool although requirements have been made following previous reports for these to be implemented. There was no evidence to demonstrate specific falls risk assessments or risk assessments due to concerns in behaviour or otherwise have been carried out. There was evidence of some access to healthcare services, the chiropodist for example, however records in respect of (G.S) revealed the last time she saw a chiropodist was February 2005. There was no evidence to suggest that (G.S or L.K) had been seen recently by a dentist or optician and no evidence of an annual health care review from their doctor. Daily notes seen did detail some personal care delivered . This however, was inadequate and did not detail for example hair care, foot care, oral care or incontinence care or continence promotion. The home had a new pharmacy provider in January 2005, training was given by this pharmacy provider on the new medication system to be implemented. It was concerning that one staff member who has responsibility for medication and medication administration said “ I do not think I have had medication training, if I have I can not remember. I don’t do the medications at times when there is a lot to give, it scares me”. There was no evidence to demonstrate that staff have received accredited medication training. The home had been provided with a medication trolley by this new pharmacy provider which had arrived a few days previously. The manager told inspectors that medication systems had been audited The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 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 standard(s) 13 There was ample evidence to demonstrate that the home encourages service users to maintain contact with family and friends. EVIDENCE: The home has a visiting policy which was on display in the front entrance hall. The homes visiting times are open and flexible, but advices what time meals are served. Relatives commented that they could visit the home whenever they wanted to. One resident said” my daughter lives in Canada but she phones me every day”. Another resident who was a Jehovah’s Witness said “ I go to meetings every Tuesday, Thursday and Sunday”. The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 14 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 standard(s) 16 Complaint procedure format and content is inadequate. The homes present complaints processes do not give any confidence that residents’ and others complaints will be listened to, taken seriously or acted upon. EVIDENCE: The home has a complaints procedure. A copy of which is displayed in the front entrance room above a large electric organ thus making this inaccessible and impossible for some residents/ relatives to read. It was noted that a complaint from a relative had been recorded in the daily notes not the complaints log. There was no evidence available to demonstrate that this complaint had been investigated or responded to. The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19,20,21,22,24,25,26 Due to the neglect of the premises service users live in an environment which is not well-maintained. The home has sufficient toilets and washing facilities in terms of numbers, they are however, poor in terms of their standard. Approved specialist bathing and hoisting equipment is lacking. Bedrooms are adequate in size but require redecoration. The environment is not comfortable, safe or hygienic. EVIDENCE: Lack of financial investment over past years has resulted in the premises being in a very poor state. Window frames in all rooms with the exception of the extension are decaying. The large window frames in the dining room in a poor state of repair. A number of catches on window frames missing. The French windows in the big lounge were seen to be rotten at the threshold. An up to date redecoration and replacement of fabric programme was not available. The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 16 Décor in the ground floor areas is very poor. Doors, skirting boards and walls badly in need of renovation or redecoration. The premises overall give an impression of neglect. The home has a good sized garden. The grass was newly cut. A ramped paved area runs down one side of the garden. The garden could be hazardous to service users as there are a number of walls and steps. The front drive is of a steep incline. One relative summarised the standard of the premises as “ rough”. Another resident attempted to be positive by saying; “ I’ve been in a worse home than this”. The home has two lounges and a dining room. All of these rooms are in a poor state in respect of décor. Curtains in the communal areas are past their best. The carpet in the dining room the worst seen in any care home by the inspectors concerned. It was stained black and sticky underfoot. The carpet in the big lounge had areas that were bald. Every chair in both lounges had thread bare arms, decorative fabric trim not intact. Dining room furniture was also in a poor state of repair. Both tables in the lounge had cracked tiles. Two lights had no light bulb. The reception area has no window dressings and the carpet in this area is in need of stretching. The stair carpet treads leading to the extension were threadbare in areas. Toilets and bathrooms were seen to be in a poor state in respect of flooring and decoration. The toilet in the bathroom where the air raiser is situated was without a seat. The toilet door by the reception area is warped and is difficult to open or shut. This was identified during the previous inspection and has not to date received remedial work. Raised toilet seats and grab rails were available in toilets. The home does not have any moving or handling equipment with the exception of an ‘air raiser.’ One resident when asked said “ they have to physically lift me in and out of the bath.” Which potentially has safety implications not just for the resident but also the staff. The home provides a passenger lift. All call systems checked were seen to be working. There is however, no call point in the dining room. A number of residents’ bedrooms were viewed. Beds, mattresses and bed linen seen was satisfactory with the exception of (A’s). One of her pillows was ripped, her sheet threadbare. There was no evidence to demonstrate that residents have been given the opportunity to state their satisfaction or otherwise in terms of furniture, fittings and fixtures provided in their bedrooms. The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 17 A number of radiators throughout the home were seen unguarded or not of the low surface temperature type. A number of beds are positioned against radiators potentially presenting a hazard. Lighting throughout the home appeared dim. In double room 12 there is only one overhead light provided. In the en-suite of room 3 there was no light fitting. Two lights had no light bulb. The light in the toilet next to the reception room was not working. Water from hot water outlets in a number of en-suite rooms remained cold even when run through for two minutes. There was no recent evidence that water temperatures are being taken and recorded. It was identified that there is no mechanical ventilation provided in communal bathrooms and toilets. Infection control processes have not improved and continue to be inadequate thus presenting the risk of contamination within the home. The laundry is located in an area, which is a thoroughfare from the front of the home to the office and vice versa. The layout of the laundry is unsatisfactory. Hand washing facilities were seen to be lacking as were instructions for staff to follow aimed to prevent infection transmission from soiled laundry to clean laundry or other areas of the home. The laundry walls are in need of redecoration the flooring requires replacement. The laundry was seen to be insufficiently clean, a large build up of dust and debris was identified on and around the tank/storage vessel on the wall. Cleaning schedules in respect of the laundry were not available to peruse. The home does have a washing machine with a sluice wash cycle. Clean laundry, an example being towels, were seen stored in communal bathrooms and toilets. Personal care products examples being talc, deodorant a nail brush and a bar of soap were seen in a communal bathroom. Bags of unused incontinence pads were stored on the toilet floor next to the reception room. There were no’ hand wash’ signs in bathrooms, toilets or other high risk areas. Bathrooms and toilets lacked liquid soap and paper towels. The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 Care staff are being provided in sufficient numbers. The home lacks a maintenance person and dedicated laundry staff. To ensure residents are fully protected recruitment policy and practices must be improved. EVIDENCE: The home does not have a permanent , substantive maintenance person or any dedicated laundry staff. The homes cleaner was not available on the day of the inspection yet her hours had not been covered. The home has a written rota care hours appeared to be satisfactory during the day, two staff are provided during the night. However, due to care staff having to attend to cleaning and laundry duties their hours are not always a true reflection of the total care hours being provided. Staff appeared to be kind and caring. They also appeared to be motivated and committed to providing a good standard of care to the residents accommodated. Recruitment processes within the home were seen to be inadequate and potentially unsafe in respect of adult protection. The two staff files assessed were are not in any order. One staff file included two written references however, these were from the same person, another file included only one written reference. Health declarations are very basic and not informative. Neither of the files viewed included a photograph. Employment history for one The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 19 just stated the number of years she had worked for example ‘three years’, not the specific years she had worked for any employer, for example ‘20032005’.There was no evidence that staff have been issued with General Social Care Council codes of conduct and practice, no interview records for example when the interview was held, who the interviewer was, questions asked or the answers to these. There was no contract or job description included on one staff file. There was no recruitment policy available to peruse. The enhanced disclosure for one staff member was dated 10/03 when records showed that her start date was 5/03. The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,37,38 Residents do not live in a well run and managed home. From evidence gained it appears that the manager is not able to discharge her responsibilities fully. The home is not run in the best interests of the residents. Record keeping in all areas is poor. Policies and procedures require significant improvement. The health and safety of residents is potentially at risk. EVIDENCE: The manager appears to have a good professional relationship with staff. One commented” The manager is brilliant”. The manager during the inspection appeared to be tired and disinterested in her work. Systems require significant improvement to meet National Minimum Standards, the manager is not demonstrating any pro- activity or initiative to address this. The manager has not date attained the required qualifications. There are no formal quality assurance or quality monitoring systems in operation in the home. The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 21 Records in general are of a poor standard. Shortfalls in a number of areas from care planning, staff recruitment to maintenance and health and safety were seen to be inadequate. Records are disorganised. The manager unable to retrieve many records asked for. Health and safety lacks procedures policy, records and systems. Maintenance / fire safety records that should have been in place were not, examples being electrical appliance testing records, gas safety records and evidence that the weekly and monthly tests of the fire system are being carried out. Risk assessment and systems to ensure resident safety require development. Staff training records were not all available, there was evidence however, to confirm that most staff have received recent fire safety/ drill training. A number of shortfalls were identified in respect of kitchen systems and hygiene. The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 2 1 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION 1 1 1 1 x 1 1 1 STAFFING Standard No Score 27 2 28 x 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x x 1 x 1 x x x 1 1 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 23 Yes Are there any outstanding requirements from the last inspection? 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 OP2 Regulation 5(1)(b) Requirement The registered provider and manager must ensure that all residents are issued with either a terms and conditions if funded by a local authority or contract if self funding at the time of admission. The registered provider and manager must ensure that all information included in the residents terms and conditions or contract is valid and accurate. The content of the residents terms and conditions ( or contract) must include all areas detailed in standard 2.2. The registered provider and manager 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. The regsietered provider and manager must ensure that where care management arrangements apply a copy of the assessment and care plan as completed by the admitting social worker is obtained prior to Timescale for action 22.06.05 2. OP2 5(1)(b) 5(1)(c ) 10.07.05 3. OP3 12(3) 14(1)( c) 22.06.05 4. OP3 14(1)(a) 22.06.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 24 admission. 5. OP4 14(1)(d) Timescale of 21.1.05 not met. The regsietered provider and manager must confirm in writing to prosopective residents that having regard to the assessment the care home is suitable for the purpose of meeting their needs. The registered provider and manager must clarify the primary needs of (G.S) and (P.P)( and now also L.K, M.H and K.T) diagnosed with dementia . If the primary need is confirmed as dementia a variation to the homes registration categories must be requested from the CSCI. In the case of P.P confirmation must be obtained to determine if her primary need or diagnosis is dementia or her visual impairment. Her doctor must be asked if she has been issued with a form BD8 by a consultant. Timescale of 1.2.05 not met. Previous requirement made prior to this date also not met. The registered provider and manager must ensure that a care plan is prepared for each resident ( even those accommodated for respite stays). The registered provider and manager must be able to evidence at all times that residents are consulted with when their care plans are prepared and reviewed. The registered provider and manager must ensure that the resident / and or representative agrees with their care plan and 22.06.05 6. OP4 14 01.08.05 7. OP7 15(1) 13.06.05 8. OP7 15(1) 15(2) 13.06.05 9. OP7 15(1) 13.06.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 25 signs to indicate this agreement. 10. OP7 15(1) Timescale of 1.2.05 not met. The registered provider and manager must ensure that care plans are further developed so as to address all of the expectations of the National Minimum standards This including: Greater detail in respect of individuals psychological and emotional health and welfare . Timescale of 1.2.05 not met. Examples given in respect of (L.K) 13.07.05 The registered provider and manager 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. Timescale of 10.1.05 not fully met. The quality of these reviews must also be enhanced. The registered provider and manager must ensure that specfic falls risk assessments are carried out in respect of each service user and that these be reviewed regularly with the findings reflected in their care plan. Timescale of 5.2.05 not met. The registered provider and manager must ensure that there are tissue viability assessments in place for all service users. Timescale of 1.2.05 not met. The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 26 13.07.05 11. OP7 15(1)(2) 12. OP8 13(4) 10.07.05 13. OP8 12(1)(a) 22.07.05 14. OP8 12(1)(a) The registered provider and manager must ensure that all service users are weighed on admission and monthly thereafter. These weights must be recorded and monitored. Timescale of 10.1.05 not met. Where weight loss is identified this must be brought to the attention of the residents doctor. The registered provider and manager must develop a format for nutritional assessment of service users on admission and thereafter, this must be in accordance with the homes policy ( which must be developed) on nutrition as part of the food safety policy. Timescale of 20.1.05 not met. The registered provider and manager must be able to demonstrate on a daily basis that each residents, full spectrum of personal care needs have been met. This must be fully evidence by appropriate documentation and records for example precise fluid input records where instructions have been made to push fluids Documents/ records to evidence baths, showers, washes, hair, nail, foot and mouthcare, incontinence care and and continence promotion ( and other areas of care that are deemed approproiate). The registered provider and manager must be able to evidence that the full range of healthcare services are accessed for each resident on a regular 22.07.05 15. OP8 12(1)(a) 22.07.05 16. OP8 12(1)(a) 10.07.05 17. OP8 12(1)(a) 22.07.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 27 18. OP8 12(1)(a) 19. OP8 12(1)(a) 13(4) 20. OP9 13(2) 21. OP9 13(2) basis for example, dentist, chiropidist, optician etc. The registered provider and 22.09.05 manager must be able to evidence that each resident has receieved a full health care review from their doctor at least on an annual basis. The registered provider and 12.07.05 manager must ensure that a full risk assessment is carried out in respect of behaviours , for example confusion, wandering etc and that the findings from these are transferred to the residets care plan. The registered provider and 12.07.05 manager must forward to the CSCI a copy of their recent medication audit report undertaken by the pharmacist. The registered provider and 22.06.05 manager must ensure that medication is signed out at the point of administration. 33 signature gaps were identified on medication administration records involving 13 different residents over 4 days. Timescale of 4.1.05 not met The registered provider and manager must : Provide documentary evidence of planned dates of accredited medication training for ALL staff involved in the administration of residents medication. Must arrange adequate medication training from a competent trainer as an interim measure. Documentation to be submitted to the CSCI office. 28.06.05 22. OP9 13(2) The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 28 A serious concern letter which included this requirement was sent to the registered persons following this inspection. 23. OP9 13(2) The registered provider and manager must devise and implement a documented risk assessment process in respect of all service users who self medicate( This to include all routes of administration oral, topical, inhalant). There were no residents self medicating at the time of this inspection. This will be further assessed at future inspections. The registered provider and manager must ensure that a photograph of each resident is attached to their medication records. Timescale of 10.1.05 not met. The registered provider and manager must ensure that no prescribed topical prearations are left in the toilets or bathrooms. Timescale of 4.1.05 not met. 26. 27. OP9 13(2) The registered provider and manager must request that the homes pharmacist assesses the homes medication policy in accordance with Royal Pharmacutical Society of Great Britan guidance and that their view on this policy is documented within the next medication audit report. Timescale of 5.2.05 not met. The registered provider and manager must devise a policy on 01.10.05 As from 22.06.05 on-going. 24. OP9 13(2) 10.07.05 25. OP9 13(2) 22.06.05 28. OP9 13(2) 01.08.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 29 the use of alcohol and substances by service users and visitors. A copy must be forwarded to the CSCI. 29. OP9 13(2) Timescale of 1.2.05 not met The registered provider and manager must ensure that all precribed medications are available within the home at all times. Paracetomol was not available for one resident. The registered provider and manager must ensure that medication during the medication round ( or any other time )are left unattended. The registered provider and manager must ensure that the person administrating medications does not physically touch the tablets. The registered provider and manager must ensure that no staff administrating medication sign the medication administration record before the medication has been given to and taken by any resident. The registered provider and manager must ensure that liquid medication is only given via a measured dosage spoon or medication tot not a domestic teaspoon. The registered provider and manager must ensure that all 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 adminstration records must be confirmed and witnessed by two 23.06.05 30. OP9 13(2) 22.06.05 31. OP9 13(2) 22.06.05 32. OP9 13(2) 22.06.05 33. OP9 13(2) 10.07.05 34. OP9 13(2) 10.07.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 30 35. OP9 13(2) 36. OP9 13(2) 37. OP9 13(2) 38. OP9 13(2) 39. OP9 13(2) 40. OP9 13(2) 41. OP16 22(3) staff whose names must be evidenced at all times. The registered provider and manager must ensure that all medications are administered at the times directed on the medication administration record. The registered provider and manager must ensure that all prescribed topical preperations are detailed on the residents medication administration record and signed for when applied. The registered provider and manager must ensure that when any medication is refused or ommitted for any reason a code must be used to confirm why. The registered provider and manager must ensure that when the medication trolley is put into operation it is appropriatley secured when not in use. The registered provider and manager must ensure that medications are not prescribed as as directed doctors must be asked to prescribe specfic times. All medication administration records must be amended accordingly to comply with this when prescriptions have been altered by the doctor. The registered provider and manager must 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 references purposes. The registered provider and manager must ensure that all staff are trained to what they 22.06.05 22.06.05 22.06.05 22.06.05 22.07.05 01.08.05 22.07.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 31 42. OP16 22(3) 43. OP16 22(2) 44. OP18 13(6) must do if they receive a complaint and what processes they must follow. The registered provider and manager must ensure that all complaints are recorded in the complaints log/ book. Evidence that any complaints made have been invesitigated and the outcome of this must be available at all times. The registered provider and manager must ensure that the complaints procedure is appropriate to the needs of service users. (Large print/ Pictorial formats) The registered provider and manager must revise the homes: Adult abuse policy in line with Department of Health guidance No secrets. Sandwell MBCs Adult Protection guidelines . Physical intervention policy in line with Department of Health guidance. The registered provider and manager 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 CSCIs telephone number). The telephone number of Public Concern at Work was given to the manager during the previous inspection. These requirements were not 22.06.05 22.07.05 22.07.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 32 assessed during this inspection. 45. OP19 23(2)(b) 23(2)(d) The registered provider and 22.07.05 manager must carry out a full documented audit of the home in respect of : Redecoration. Replacement of fabric, furniture, carpets, bed linen, equipument against the assessed needs of the service users. Timescale of 1.2.05 not met. A copy of this document must be forwarded to the CSCI. The registered provider and manager must produce a routine maintenance programme for the home, the findings from this audit ( as mentioned) must be incorporated into this programme with timescales applied to each area. Timescale of 1.2.05 not met. A copy of this document must be forwarded to the CSCI. The registered provider and manager must ensure that all windows are fitted with suitable and safe window catches. Written evidence to confirm that this has been done must be provided to the CSCI. The registered provider and manager must ensure that the toilet door near to the reception area receives the necessary attention to ensure that it closes properly. Timescale of 10.01.05 not met. The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 33 46. OP19 23(2)(b) 23(2)(d) 27.07.05 47. OP19 13(4)(a) 22.07.07 48. OP19 23(2)(d) The registered provider and manager must ensure that all landings and corridors to include skirting boards, walls and doors are redecorated. Carpets are to be replaced where they are thread bare or in a poor state for example the stairs near to the extension. Written evidence to confirm that this has been done must be provided to the CSCI. The registered provider and manager must secure the input of an appropriatley qualified surveyer or engineer to assess the windows/ window frames throughout the home ( with the exeption 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 your intended actions and timescales for action. The registered provider and manager must ensure that the french windows are replaced. A serious concern letter which included this requirement was sent to the registered persons following this inspection. The registered provider and manager 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. Evidence of how you intend to 01.09.05 49. OP19 23(2)(b) 23(2)(d) 01.08.05 50. OP19 13(4)(a) 23(2)(b) 23(2)(d) 20.08.05 51. OP19 13(4)(a) 23(2)(o) 27.07.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 34 52. OP20 23(2)(d) meet this requirement must be forwarded to the CSCI. The registered provider and manager must ensure that the dining room carpet is replaced. An invoice to demonstrate that the purchase and fitting of this carpet must be provided to the CSCI by 1 August 2005. A serious concern letter which included this requirement was sent to the registered persons following this inspection. The registered provider and manager must fully redecorate all communal areas. The registered provider and manager must replace the carpets, following the redecoration, in the two lounges. The registered provider and manager must ensure that curtains in communal areas (and bedrooms if needed) are replaced. That the window in the reception room is provided with curtains or other appropriate window dressings. The registered provider and manager must ensure that all chairs (easy seating) in communal areas are replaced. The registered`provider and manager must ensure that dining room chairs/ tables are fully renovated or replaced. The registered provider and manager must ensure that the carpet in the reception room is stretched. The registered provider and manager must ensure that all toilets and bathrooms throughout the home are 01.08.05 53. 54. OP20 OP20 23(2)(d) 23(2)(b) 23(2)(d) 01.09.05 15.09.05 55. OP20 23(2)(b) 20.09.05 56. OP20 23(2)(b) 25.09.05 57. OP20 23(2)(b) 29.09.05 58. OP20 13(4)(a) 23(2)(b) 23(2)(b) 23(2)(d) 22.07.05 59. OP21 01.08.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 35 60. OP22 13(5) 23(2)(n) redecorated and fixtures and fittings are in a good state of repair/ in good working order at all times. The registered provider and manager must ensure that input from a qualified Occupational Therapist is secured to assess aids and adaptations , moving and handling equipmment( paying particular attention to bath hoisting needs within the home against the present and future needs of the residents. This requirement is similar to one made following the last inspection to which the timescale of 1.2.05 has not been met. A serious concern letter which included this requirement was sent to the registered persons following this inspection. Documentary evidence that this requirement has been met together with a full report detailing outcomes nd requirements from this Occupational Therapist must be provided to the CSCI by the 7 August 2005. In the interim period you must by undertaking robust documented risk assessments in respect of each residents needs in respect of moving and handling / bathing ensure the safety and well-being of all residents. The registered provider and manager must provide authentic documentary evidence to the CSCI that the air bath raiser is LOLER compliant. 07.08.05 61. OP22 Op38 13(4)(a) 23(2)(n) 01.07.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 36 A serious concern letter which included this requirement was sent to the registered persons following this inspection. 62. OP22 13(4)(a) The registered provider and manager must provide valid (within the last six months) certified documentary evidence to demonstrate that the air bath raiser has received a full service. A similar requirement was made following the last inspection the; Timescale of 5.2.05 was not met. If this requirement is not fully met a serious concern letter or other enforcement action may be considered by the CSCI. 63. OP22 23(2)(n) The registered provider and 01.08.05 manager must ensure that the homes call system is extended to the dinning room. Timescale of 1.2.05 not met. The registered provider and manager must carryout an audit in each bedroom against standard 24.2 . This also applies to new residents. Timescale of 21.01.05 not met. All items listed in standard 24.2 must be provided unless written confirmation is obtained from any resident who chooses not to have any item. This must include door keys and lockable storage facilities. The registered provider and 01.08.05 15.07.05 64. OP24 16(2)( c) 65. OP24 23(2)(b) 01.09.05 Page 37 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 23(2)(d) 66. OP24 16(2)( c) manager must ensure that each bedroom and en-suite is included in their 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. The registered provider and 01.08.05 manager must ensure that all bedding and pillows are of a good standard at all times. Particular attention must be paid to (As) bedding room 12. Written evidence must be available at all times to demonstrate that regular audits of bed linen and pillows are being carried out. The registered provider and manager must provide a timescale to the CSCI in which radiators will be guarded. Timescale of 21.01.05 not met. A serious concern letter which included this requirement was sent to the registered persons following this inspection.Stating that the registered provider and manager must ensure that radiators throughout the home are suitably guarded or replaced with a low surface temperture type. In the interim period radiatiors must be reassessed to identify and minimise/ erradicate any risk paying particular attention to radiators that are exposed or are against beds. Evidence of these risk assessments must be 67. OP25 13(4)(a) 01.09.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 38 forwarded to the CSCI by 1 July 2005. 68. OP25 13(4)(a) 23(2)(p) The registered provider and manager must ensure that ventilation extractors throughout the home are checked and cleaned on a regular basis. Timescale of 15.01.05 not met. Documentary evidence to demonstrate that this is being done must be available at all times. The registered provider and manager must ensure that the home is adequatley heated at all times. Timescale of 4.1.05 not met. The registered provider and manager must ensure that the tempertures from each hot water outlet are tested and recorded monthly. Timescale of 10.01.05 not met. The temperatures for the month of June 05 must be forwarded to the CSCI by 15.07.05 and every month thereafter. Failure to do this may result in a serious concern letter being issued or other enforcement action. The registered provider and manager must ensure that water from each hot water outlet remains within the scale of 38oc43oc at all times. This to include en-suite rooms. The registered provider and manager must ensure that LUX readings are taken and recorded for each room.A record of these 22.07.05 69. OP25 23(2)(p) 22.06.05 70. OP25 13(4)(a) 23(2)(j) 22.06.05 71. OP25 13(3) 13(4)(a) 01.09.05 72. OP25 13(4)(a) 23(2)(p) 01.08.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 39 73. OP25 13(4)(a) 23(2)(p) 74. OP25 23(2)(p) 75. OP26 13(3) readings must be forwarded to the CSCI. These recordings must be itemised on an individual room basis, for example big lounge, dining room, bedroom 12 and so on. The registered provider and manager must ensure that lighting throughout the home is in working order at all times for example light bulbs in every room in place and working. Lighting available in all en-suite rooms in good working order at all times. The registered provider and manager must provide adequate mechanical ventilation in all bathrooms and toilets. The registered provider and manager must ensure that hand wash signs are available in all high risk areas. Timescale of 5.2.05 not met. 08.07.05 01.09.05 01.08.05 76. OP26 13(3) This to include toilets, bathrooms, and laundry. The registered provider and 08.07.05 manager must ensure that stocks of clean bed linen / towels are not stored in communal areas. Timescale of 1.2.05 not met. Items were once again seen stored in bathrooms and toilets. The registered provider and 01.09.05 manager must ensure that the laundry is redecorated and the flooring replaced with a type that is impermable. This requirement is similar to ones previously made for example last inspection when a timescale of 5.2.05 was given 77. OP26 13(3) 23(2)(d) The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 40 but has not been met. 78. OP26 13(3) 16(2)(j) The registered provider and manager must request that Sandwell Environmental Health department carry out an assessment and give their view on the suitability and location of the laundry. Timescale of 1.2.05 not met. Written evidence that a request has been made to EHO must be provided to the CSCI by 20.07.05. Their response/ view must also be provided when received. The registered provider must seek the advice of the infection control nurse as to the homes systems for infection control this to include; The need for additional sluicing facilities. Any hazards that may be present in respect of the location of the laundry. Timescale of 1.2.05 not met. Written evidence to demonstrate that this request has been made must be forwarded to the CSCI by 29.07.05. Their views/ response must also be provided when receieved. 80. OP26 13(3) 16(2)(j) The registered provider must consider relocating the laundry. Decisions on this made following the consultation with infection control and Sandwell EHO must be forwarded to the CSCI. If a decision is made not to relocate the laundry alternative 10.08.05 01.08.05 79. OP26 13(3 16(2)(j) 20.07.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 41 suggestions must be forwarded. 81. OP26 13(3) The registered provider and manager 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 consistentley and diligently adhered to. That a stock of red disolvo bags are purchased to minimise staff contact with contaminated or soiled laundry. The registered provider and manager must ensure that a supply of disposable towels are available within the following areas: Laundry. Kitchen. Toilets Bathrooms. 83. OP26 13(3) Timescale of 10.1.05 not met. The registered provider and manager must ensure that all toilets and bathrooms are provided with liquid soap. The registered provider and manager must ensure that incontinence pads are not stored in bathrooms or toilets. They are 08.07.05 08.07.05 82. OP26 13(3) 08.07.05 84. OP26 13(3) 08.07.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 42 85. OP27 18(1)(a) 86. OP27 18(1)(a) 87. OP29 13(6) 19(2) prescribed to the individual resident and should be kept in the individual residents bedrooms. The registered provider and 01.09.05 manager must employ a permanent handyperson to assist in making improvements within the home in respect of decoration and general maintainence and continuing with this in the future. The registered provider and 01.08.05 manager must employ a dedicated laundry hours. A`proposal regarding hours must be submitted to the CSCI. The registered provider and 22.06.05 manager must ensure that all information detailed within Schedule 2 of the Care Home Regulations 2001 must be obtained for all staff working at the care home and prior to employment for prospective staff. Timescale of 1.2.05 not met. Documents required are: A comprehensive application form. Interview details including the name of the interviewer , questions asked and answered. CRB/POVA list check to be satisfactory and obtained before employment commences. This must state the job role they are employed for example a senior carer must state senior carer. Two written references, one from the last employer. The past employer reference must be on The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 43 headed paper if possible and detail their full name and position. A recent photograph. Two sources of identity. Confirmation in document form of their current address. A full health declaration. Risk assessment if applicable. Evidence must be available to demonstrate that they have been issued with a terms and conditions of employment and a job description specific to the role in which they are employed. Evidence must be available to demonstrate that they have been issued with a copy of the GSCC codes of conduct and practice. The registered provider and manager must provide the CSCI with an up to date recruitment policy. 88. OP29 13(6) 19(2) 01.08.05 89. OP30 12(5)(a) 90. OP30 13(6) 18(1)(a) The registered provider and 01.09.05 manager must ensure that a schedule of meetings is produced. Meetings must be held on a regular basis. 01.08.05 The registered provider and manager must ensure that there is : A staff training and development programme. Induction training ( within six weeks of employment ) and foundation training ( within six months of employement) The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 44 91. OP33 24 This standard was not assessed during this inspection evidence must be available ready for the next inspection. The registered provider and manager must implement / continue developing the homes system for improving the quality of care in the home, this to include: Seeking views os serviec users. Measuring the 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 inspector giving realistic timescales when this requirement can be met. Timescale of 1.2.05 not met. 20.08.05 92. OP36 18(2) The registered provider and manager must ensure that all care staff are supervised at least once every two months( six times per year). This requirement was not assessed. Adequate evidence must be available ready for the next inspection. The registered provider and 01.09.05 93. OP37 17(2) 28.08.05 Page 45 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 94. OP37 17(2) manager must ensure that all of the required policies and procedures are in place are up to date and are reviewed annually. The registered provider and manager must ensure that staff read all policies and procedures. Timescale of 1.2.05 not met. The registered provider and manager must ensure that the communication book is not used to write personal details about residents. Records in communication books must be written appropriatey not on loose scraps of paper. All other records must be maintained in an orderly fashion, be easily retrievable and available for inspection. The registered provider and manager must ensure that all doctors visits records are written and retained on the individual residents files. The registered provider and manager must ensure that residents files stored in a lockable cabinet. The registered provider and manager must ensure that all injuries, serious illness , deaths or admissions to hospital or any other untoward incidents are reported to the CSCI without delay. The registered provider and manager must provide evidence to the CSCI to demonstrate that the electrical portable appliances have been tested within the last 12 months. Provide certified evidence to demonstrate the competence of 15.09.05 95. OP37 17(2) 22.06.05 96. OP37 17(2) 22.06.05 97. OP37 17(2) 01.08.05 98. OP38 37(2) 22.06.05 99. OP38 13(4)(a) 23(4)(a) 01.07.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 46 the person carrying out these tests. This requirement was included in a serious concern letter sent to the registered persons following the last inspection. The registered provider and manager must carryout a documented risk assessment of the premises relating to all risks and safe working practices. Timescale of 1.2.05 not met. A copy of this document must be forwarded to the CSCI. The registered provider and manager must forward a valid gas landlords safety certificate to the CSCI. and Forward documentation to detail any asbestos test undertaken in respect of the premises. The registered provider and manager must provide : Evidence that all work identified on the last water testing certificate dated 4/04 has been addressed. A water testing certificate for this year. The registered provider and manager must forward to the CSCI an up to date training matrix deatailing each staff members name the training they have received and the date of this training to ensure the following: That all staff have had: The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 47 100. OP38 13(4) 01.08.05 101. OP38 13(4) 01.08.05 102. OP38 13(4) 01.08.05 103. OP38 18(1)(a) 20.08.05 Food hygiene training. Moving and handling training. First aid training. Infection control training. Fire safety/ Fire drill training twice in any twelve month period. If gaps in training are identified then dates for this training must be booked and forwarded with the matrix to the CSCI. 104. OP38 17(2) The registered provider and manager must ensure that all accident records are completed fully and accuratley. The registered provider and manager must ensure that the health and safety poster is completed with up to date information. 105. 106. OP38 23(4) The registered provider and manager must ensure that : The the weekly fire alarm tests are undertaken consistently. The weekly in-house checks must include the checking of all smoke detectors. The emergency lighting tests must be carried out consistently. 107. OP38 16(2)(j) The registered provider and manager must ensure that : The food probe is collaborated The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 48 22.06.05 20.07.05 01.08.05 regularly and records of these are maintained. Fly screens are provided in the kitchen. That stocks of fresh fruit and vegatables are plentiful at all times. That the kitchen windows are cleaned regularly. That supper is included on the residents food consumption records. The menus are available in pictorial and large print formats. That dry foods are all stored in suitable air tight containers. That all shortlife foods such as jams and sauces are labelled when opened. 108. OP38 13(4) The registered provider and manager must ensure that bed bumpers and bed rails are safe, secure and are checked on a weekly basis. A record of these weekly checks must be made. This includes the bed rails/ bumpers in room 12. The registered provider and manager must ensure that all areas identified in the last fire inspection report dated 1 June 2005 are fully addressed. Evidence must be provided to the CSCI that all work has been completed. The registered provider and manager must ensure that sufficent sysytems are in place regarding all areas of risk; 22.06.05 109. OP38 13(4) 23(4) 01.08.05 110. OP38 13(4) 01.08.05 The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 49 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. The registered provider and manager must ensure that all recommendations made following the Environmental Health inspection carried out in July 2004 are addressed in full. Timescale of 5.2.05 not met. The registered manager must commence on a course to ensure she attains N.V.Q level 4 in care and management by end 2005. The registered manager must ensure that she attends sufficient training and updates her knowledge skill and practice on a regular basis. The manager must ensure that requirements are fully met within the timescales made. That systems and record keeping are improved. 111. OP38 16(2)(j) 01.08.05 112. OP31 9(2)(i) 113. OP31 9(2)(i) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations The Beeches E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 50 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. 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 E55 S4779 The Beeches BlackheathV234362 220605 Stage 4.doc Version 1.30 Page 51 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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