Inspection on 24/01/06 for The Beeches (Rowley Regis)

This inspection was carried out on 24th January 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) 14/06/06

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 24th January 2006 08:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 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 Mrs Anne Jolly Care Home 17 Category(ies) of Dementia (17) registration, with number of places The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22/06/05 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. The Beeches is a traditional Edwardian detached property, which has been adapted and extended for its present purpose- a care home. The grounds have mature gardens and car parking available to the front. The home is sited off a step hill, the drive 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 access between the two floors. The home since the last inspection has been purchased by a new registered person. The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 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 one day between 08.00 and 14.15 hours. The inspection was carried out as the second of the home’s two routine inspections for this inspection year. The inspection focussed on core National Minimum Standards for Older People that were not assessed during the previous inspection and previously made/ outstanding requirements. Records examined included; assessment of need documents, care plans, menus, care delivery documentation and records pertaining to servicing/maintenance and health and safety. Meal times were observed and the medication systems/administration were assessed. Premises were once again randomly assessed to include 5 bedrooms, two toilets, two bathrooms, communal areas, the kitchen and laundry. Six residents and one relative were spoken to during the inspection. The new Registered Person was involved in the inspection process. Not all standards were assessed during this inspection. For a full overview of service delivery this report should be read together with the last inspection report dated 22 June 2006. What the service does well: The home now has a new owner who is committed to improving the overall standards / facilities / care and environment. The home offers a generous size garden. The home provides en-suite facilities in every bedroom. Care staff continue to be kind and caring. A number have been employed at the home for some considerable time offering consistency to the residents’. Residents’ are very much encouraged to and do maintain contact with family and friends. The home has flexible visiting times. The home has a good level of staff attaining N.V.Q. A relative of a new resident to be admitted to the home commented;” I looked at one or two homes, as soon as I walked into this one and spoke to the owner, I knew this was the one. It is homely and my mother likes it here”. The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 6 One resident commented; “ I have no complaints. They do a good job. I have got someone to look after me. The food is nice. I am quite satisfied with the service”. Another resident said;” Oh, I think it is wonderful here. I shouldn’t have come here otherwise. The food is lovely and I am funny about food”. What has improved since the last inspection? What they could do better: The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 7 The new Registered Person purchased the home shortly before Christmas 2005. With the purchase she inherited over 100 requirements a number of which gave great concern to the Commission for Social Care Inspection. A number of these requirements in the short time it has been purchased have been addressed however, a high proportion of these requirements remain which include; care planning, resident documentation, staff training, record keeping, general refurbishment of the premises, health and safety and fire safety, adult protection, complaints processes, activities and stimulation, infection control processes, quality and quality monitoring. Medication systems and administration remain concerning as does the lack of consistency in the monitoring of hot water temperatures. Outstanding requirements and new requirements all need to be addressed. 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.V279716.R01.S.doc Version 5.1 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.V279716.R01.S.doc Version 5.1 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): 4 The home must put in writing a request to vary the certificate of registration to reflect the needs of residents remaining who have needs which fall into the’ ‘older person’ category. EVIDENCE: With the change of ownership the Commission for Social Care Inspection issued a new registration certificate which did not reflect the numbers of residents’ accommodated who only have ‘ older persons’ needs. To rectify this a written request must be made to the Commission for Social Care Inspection by the new owner. Documentation pertaining to a new resident demonstrated that an assessment of need process is in operation to ensure that only those who the home can meet their needs are offered a place. The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9,10. Medication and medication systems continue to be a cause of concern potentially, putting residents at risk. Residents’ feel that they are treated with respect and their right to privacy is upheld. EVIDENCE: Medication and medication systems continue to give concern. A large proportion of the staff team have not received accredited or interim medication training. The homes medication policy has not been updated for some time and does not comply with Royal Pharmaceutical Society of Great Britain guidance. Observation of medication administration revealed a number of shortfalls; the medication trolley at one time was left unattended. The person administering medications physically touched a number of tablets which has hygiene implications. Handwritten medication records did not in all cases detail required information an example being known allergies. There was no evidence to demonstrate that information transferred from medication bottles and packets had been verified as correct by two staff. Instances identified from medication records revealed residents’ had refused medication, yet this was not reflected by an appropriate code used to record. Further, there were over 30 staff initial The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 11 gaps on medication records. Not all incoming medications are being counted and recorded upon receipt. It was not possible to audit a course of antibiotics as the start date and how many days it was prescribed for were lacking. A further concern was the lack of processes in place to ensure medication trolley/cupboard key safety and handovers of the key between shifts. The new owner said; “ Medication has got to now be a priority to address”. She confirmed that she would be having meetings with other pharmacy providers and that she would seek to secure medication training. Apart from the lack of evidence on residents’ files to demonstrate that their preferred form of address had been determined and recorded there was evidence available to suggest that residents’ are treated with respect. During the course of the inspection interactions between staff and residents’ were observed and were positive. Staff spoke to residents politely and gave them choices. One relative said;” The staff are courteous and polite to Mum and other residents’”. Privacy and dignity are enhanced by the rooms all having en-suite facilities. Medical and nursing assessments are carried out in the privacy of the residents’ bedroom. The homes’ terms and conditions document states;” We provide a personal guarantee that residents’ will only wear clothing which belongs to them. The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 12 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): 12,14,15. Further developments are needed to ensure that residents’ find the lifestyle experienced in the home matches their expectations and preferences. Residents’ are helped to exercise choice and control over their lives. Further developments are needed to ensure that residents needs and wants in terms if meal provision are met. EVIDENCE: It is positive that some daily routines examples being; rising and retiring have been determined and recorded on a number of residents’ records. It is also positive that one resident spoken to described her favourite pastime as being reading. She said;” I love to read, I always have”. She proudly showed a number of large print library books she had. Generally it was felt by staff and residents’ that current activity provision is “ad-hoc”. “There is not much offered except to watch television. Residents’ do not go out unless it is with their families”. Staff feel that residents’ would benefit from regular activities and a number would enjoy outings. There was no evidence that residents’ jointly are consulted with by way of meetings. A number of residents’ spoken to were very articulate and could participate/ contribute in a meeting situation. The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 13 It is positive that residents’ are able to and do bring into the home with them various possessions ranging from televisions and radios to pictures and ornaments. The registered provider has recently provided the local council with the required information to ensure that residents’ can vote if they want to. Information pertaining to external advocacy information was available in the front entrance hall. It is clear from discussions that the new registered provider has enhanced the quality of food provision in the home by purchasing from a named supermarket. Items such as shop cakes-chocolate éclairs much to everyone’s surprise- were enjoyed by all as a treat one teatime. One resident who has a long history of being a ‘poor eater’ has been encouraged to try different foods. Her tea for a number of years has been bread with lemon curd. She never ate the bread, just licked the lemon curd. By encouragement she is now having thick yoghurts, which have a better nutritional content, instead. The main meal on the day of the inspection was shepherds pie or steak and onion pie, frozen carrots and sprouts. Bread and butter pudding or jelly was offered as desert. Teatime choices were banana sandwiches or kippers. The cook said; “ if any resident does not like what is offered we always offer something else”. Residents’ commented positively about the food; “ Enjoyed today’s meal”. The food is lovely. “ The food is nice”. The menus at the present time do not include supper. Menus would be enhanced if produced with pictures to aid the understanding of residents who have dementia. Food consumption charts are not being consistently completed as they should, the main shortfalls being tea and supper. The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 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 the following standard(s): 18. More developments in terms of policy, procedures and training is needed to ensure that residents are being fully protected from abuse. EVIDENCE: The homes policies and procedures pertaining to protection are not adequate in their present form. The abuse and whistle blowing policy for example, do not accord with current best practice and Sandwell Council’s abuse procedures. Only a proportion of staff have received abuse awareness training. The new registered person is aware of shortfalls in this area and is committed to rectifying the situation. The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 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 the following standard(s): 19,22,25. Although the new owner has in a short time made improvements to the premises they are not fully safe and cannot yet be described as well maintained. Further improvements in terms of signage, pictures and symbols are needed to aid and enhance orientation. Although improvements have been made the home can not be described as being fully safe or comfortable. EVIDENCE: The new owner in a short space of time has improved parts of the home. The main lounge and entrance hall have been re-decorated and have been fitted with new carpets. Twelve new easy chairs and twelve new beds have been purchased. The owner has a plan of how she is to address the remaining refurbishment needs of the home of which there are many. Examples being; external re-decoration, internal re-decoration replacement of carpets, window The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 16 dressings and the replacement of dining room chairs and tables, windows and window frames. The home is registered to provide care to residents who have a diagnosis of dementia. The general environment is not at present conducive to their needs. Colour schemes, pictures, symbols must be considered when redecorating to aid orientation. Call system activators may confuse residents of their purpose as many look identical to light pull cords. It is positive that the heating system has received attention from an engineer and is in better working order. Unfortunately, radiators remain unguarded with no risk assessments particularly for new residents. The new owner did confirm however, that when the weather gets better the heating system will be reassessed and either new ‘cool touch’ radiators will be installed or guards fitted. The new owner is having ventilation systems in the home assessed as they are not very effective. The lack of hot water temperature checks and recordings of, continue to be a concern in that residents could be placed at risk of burning. An immediate requirement was issued by the Commission during the inspection to rectify this. The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,30. Residents’ are in safe hands. Developments are needed in respect of staff training. EVIDENCE: It is pleasing that at least 50 of the staff have attained N.V.Q in care- well done. The training matrix / individual staff training plans available have not been updated for some time. It is concerning that a number of staff have not received dementia training. The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,35,36,38. The home at the present time does not have a registered manager this must be addressed as a matter of urgency to ensure that the home is well run and that the staff have direction and leadership. Action is being taken to ensure that residents’ financial interests are safeguarded. Further developments are needed to ensure that the health, safety and welfare of staff and residents’ are promoted and protected. EVIDENCE: The former registered manager did not stay long before handing in her notice once the new owner took over the home. The owner has two homes’ and is registered as the care manager for the other home. A decision is being made as to which home has the most urgency in terms of management time and input. A registered manager is required in both homes’. The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 19 The new owner has herself identified concerns in the recording of residents’ money and the fact that a number are not given money regularly by their relative or other managing their finances or personal allowance. The owner is in the processes of establishing new procedures/processes for the recording of residents’ money held in safe keeping which includes for the first time the issuing of receipts. It is positive that the new owner has had a one to one session with 10 staff since she purchased the home. Records reveal that staff supervision sessions are lacking in terms of frequency. Staff are not receiving the required 6 sessions per year. The new owner has inherited substantial work in terms of health and safety/staff mandatory training. It is positive however, that she has already confirmed training dates for moving and handling and refresher food hygiene training for catering staff. Work is needed in all areas from risk assessment, to fire safety. Outstanding requirements remain from previous inspections. The lack of regular bedrail checks is a cause of concern, an immediate requirement has been issued in respect of this by the Commission for the registered person to address this shortfall. Another area which is of concern is the lack of recent staff fire training and fire drills which could place residents at risk. The new registered person commented that she was considering using a consultancy company to improve health and safety systems within the home. The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 20 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 x x 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 1 x x 2 x x 1 x STAFFING Standard No Score 27 x 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 2 2 x 2 The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 21 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 OP3 Regulation 12(3) 14(1)( c) Requirement 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. Timescale of 22/06/05 not fully met. This must be done in respect of all admissions from now on. The registered person must forward to the CSCI in writing a request to confirm required categories /conditions of registration to reflect the ‘older people’ still residing at the home and (ES’s) possible primary diagnosis of Sensory Impairment. Timescale for action 24/01/06 2 OP4 14(1) 24/02/06 3 OP4 14(1)(d) The registered provider must DS0000066557.V279716.R01.S.doc 24/01/06 Page 22 The Beeches(Blackheath) Version 5.1 confirm in writing to prospective residents’ that having regard to the assessment the care home is suitable for the purpose of meeting their needs. Timescale of 22/06/05 not fully met. This must be evidenced at all times with each new admission from now on. 4 OP7 15(1) 15(2) 5 OP7 15(1) 6 OP7 15(1)(2) 7 OP8 12(1)(a) 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 and 13/07/05 not fully met. No evidence (L) care plan updated when she deteriorated. The registered provider must ensure that where weight loss is identified that this is brought to the attention of the resident’s. doctor. Timescales of 10/01/05 and 22/07/05 not fully met. This refers to (FL). The registered provider must be able to demonstrate on a daily DS0000066557.V279716.R01.S.doc 20/02/06 20/02/06 24/01/06 24/01/06 8 OP8 12(1)(a) 24/02/06 Page 23 The Beeches(Blackheath) Version 5.1 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). Timescale of 10/07/05 not fully met. 9 OP8 12(1)(a) The registered provider must be 24/02/06 able to evidence that the full range of healthcare services are accessed for each resident on a regular basis. Timescale of 22/07/05 not fully met. Dentist and optician documentation lacking. 24/01/06 The registered provider must ensure that medication is signed out at the point of administration. 38 initial gaps over 3 weeks for 3 residents were identified during this inspection. Timescales of 04/01/05 and 22/06/05 not met. 10 OP9 13(2) 11 OP9 13(2) The registered provider must; Provide documentary evidence 31/01/06 The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 24 of planned dates of accredited medication training for All staff involved in the administration of residents’ medication. Must arrange medication training from a competent trainer as an interim measure. A serious concern letter was sent to the previous owner by the CSCI regarding these shortfalls. An immediate requirement was issued to this effect during this inspection. 12 OP9 13(2) The registered provider must ensure that a photograph of each resident is attached to their medication records. Timescales of 10/01/05 and 10/07/05 not met. The new owner confirmed that photographs have been taken these need to be obtained and attached to the records. 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 and 01/10/05 not met. 12/02/06 13 OP9 13(2) 01/03/06 14 OP9 13(2) The registered provider must ensure that all prescribed medications are available within the home at all times. DS0000066557.V279716.R01.S.doc 24/01/06 The Beeches(Blackheath) Version 5.1 Page 25 15 OP9 13(2) 16 OP9 13(2) Timescale of 23/06/05 not fully met. (GS) The registered provider must ensure that the person administrating the medications does not physically touch the tablets. Timescale of 22/06/05 not always met. The registered provider must ensure that medication during the medication round (administration) is not left unattended. Timescale of 22/06/05 not fully met. 12/02/06 24/01/06 17 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. Timescale of 10/07/05 not met. 10/02/06 18 OP9 13(2) The registered provider must 10/02/06 ensure that when any medication is refused or omitted for any reason a code must confirm why. Timescale of 22/06/05 not DS0000066557.V279716.R01.S.doc Version 5.1 Page 26 The Beeches(Blackheath) fully met. 19 OP9 13(2) The registered provider must 10/02/06 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 . Timescale of 22/07/05 not fully met. The registered provider must 10/02/06 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. Timescale of 01/08/05 not met. 20 OP9 13(2) 21 OP9 13(2) 22 OP9 13(2) The registered provider must ensure that all incoming medications are counted and recorded, dated and signed by staff. 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. The registered provider must ensure that the balance of all medications is brought forward and recorded to ensure accurate monitoring/auditing of medications. DS0000066557.V279716.R01.S.doc 10/02/06 24/01/06 23 OP9 13(2) 10/02/06 The Beeches(Blackheath) Version 5.1 Page 27 22 OP9 13(2) 23 OP9 13(2) 24 OP9 13(2) The registered provider must ensure that the medication records issued by the pharmacy are correct and accurate. For example one resident’s medication according to the medication record commenced on 28 January 2006. The date this inaccuracy was identified was 24 January 2006. The registered provider must ask the GP to discuss and review resident ( ES) medication regarding her continued refusal of for example; pain relief, laxatives. The registered provider must ensure that all eye drops are date labelled on the day of opening. 12/02/06 10/02/06 10/02/06 25 OP9 13(2) The registered provider must ensure that; Medication keys are kept separate form other keys. Medication keys are kept at all times on the person responsible for the medications per shift. A written policy/ protocol is produced regarding medication key safety and handovers. A recordable system for the handover of medication keys between each shift is established and adhered to. One staff member who is suitably trained and competent is delegated the over all task of managing medication systems. 15/02/06 The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 28 A regular in-house audit of medications is undertaken to identify shortfalls/nonconformance to medication procedures and activated corrective actions. Written instructions on hygiene whilst administering medication ( for example to wash hands before commencing medication administration). Only pen is used to write/record on medication records, the practice of using pencil must cease. The registered provider must 15/02/06 ensure that the preferred form of address for each resident is determined ( at the time of admission for new residents’) and recorded on their personal file. The registered person must 24/02/06 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. 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. 29 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. The registered provider must when revising the menus ensure that supper is added to the DS0000066557.V279716.R01.S.doc 26 OP10 12(4)(a) (b) 27 OP12 12(1)(b) 18(1)(a) 28 OP12 16(2)(n) 24/02/06 24/02/06 30 OP15 17(2) Sched 4 (13) 24/02/06 The Beeches(Blackheath) Version 5.1 Page 29 homes menu. 31 OP15 17(2) Sched 4 (13) The registered provider must ensure that; Residents do not go without food and drink longer than 10 hours throughout the night. All residents are offered on a daily basis a choice of supper options. Residents are offered a cup of tea ( or other preferred beverage) on waking. 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. Timescale of 22/07/05 not met. The registered provider must ensure that all complaints are recorded in the complaints log/book. Evidence that any complaints made have been investigated and the outcome of this must be available at all times. Timescale of 22/06/05 not met. 15/02/06 32 OP16 22(3) 24/02/06 33 OP16 22(3) 15/02/06 34 OP16 22(2) The registered provider must ensure that the complaints procedure is appropriate to the needs of the service users’ ( Large print/pictorial formats). Timescale of 22/07/05 not met. 24/02/06 The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 30 35 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. 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). Timescale of 22/07/05 not met. The registered person must provide to the CSCI an up date on how environmental/ refurbishment issues have progressed. 01/03/06 36 OP19 23(2)(b) 23(2)(d) 01/04/06 37 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. Timescale of 01/09/05 not DS0000066557.V279716.R01.S.doc 01/06/06 The Beeches(Blackheath) Version 5.1 Page 31 met. In the interim written risk assessments must be carried out. 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. Timescale of 01/08/06 not met. 38 OP19 23(2)(b) 23(2)(d) 01/05/06 39 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. Timescale of 27/07/05 not met. Evidence of how you intend to 01/04/06 The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 32 meet this requirement must be forwarded to the CSCI. In the interim period written risk assessments must be carried out. 40 OP20 23(2)(d) The registered provider must fully redecorate all communal areas. Timescale of 01/09/05 not fully met. It is positive that the main lounge and entrance reception area have been redecorated. The registered provider must replace the carpets in the two lounges. Timescale of 15/09/05 not fully met. It is positive that the carpet in the main lounge and the entrance area have been replaced. 01/04/06 41 OP20 23(2)(b) 23(2)(d) 01/04/06 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. Timescale of 01/08/05 not met. The registered provider must ensure that each bedroom and en-suite is included in the DS0000066557.V279716.R01.S.doc 01/05/06 43 OP21 23(2)(d) 01/05/06 The Beeches(Blackheath) Version 5.1 Page 33 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. 44 OP22 23(1)(a) 23(2(a) (n) The registered provider must enhance signage orientation throughout the home; To include colour schemes to aid orientation. Signage/ symbols on doors ( bathroom, toilets etc). The call system must be enhanced by pendants and call point cords ( symbols/pictures), which are easy to understand for people who have poor memory/dementia. 01/03/06 45 OP24 16(2)(c) The registered provider must ensure that all bedding and pillows are of a good standard at all times. Particular attention must be paid to (A’s) 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. 01/05/06 The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 34 46 OP25 13(4)(a) Timescale of 01/08/05 not fully met-work is about to commence. 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. 15/02/06 47 OP25 13(4)(a) 23(4) 13(4)(a) 48 OP25 49 OP25 13(4)(a) 23(2)(p) The registered provider must 12/02/06 ensure that all portable heaters are risk assessed to prevent the risk of burning or fire. The registered provider must risk 12/03/06 assess each bathroom and toilet in respect of hot water pipes. These pipes must be suitably guarded. 12/02/06 The registered provider must 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 and 22/07/05 not met. The registered provider must provide adequate ventilation in all bathrooms and toilets. Timescale of 01/09/05 not met. 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 01/04/06 50 OP25 23(2)(p) 51 OP25 13(4)(a) 23(2)(j) 31/01/06 The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 35 52 OP25 13(3) 13(4)(a) letter was issued to the registered provider in respect of this. 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. Timescale of 01/09/05 not met. 15/02/06 53 OP26 13(3) The registered provider must ensure that ‘hand wash’ signs are available in all high risk areas. Timescale of 01/08/05 not fully met. These signs must be in a format to aid understanding of all. The registered provider must ensure that stocks of clean bed linen/ towels are not stored in communal areas. Timescales of 01/02/05 and 08/07/05 not met. It is intended that cupboards with doors will be provided to house these in. The registered provider must ensure that the laundry is redecorated and that the flooring replaced with a type that is impermeable. Timescale of 01/09/05 not met. New machines are to be installed early 02/06 the decorating will then be done. The registered provider must ensure that ; Policies on infection control. 24/02/06 54 OP26 13(3) 01/03/06 55 OP26 13(3) 23(2)(d) 01/04/06 56 OP26 13(3) 01/03/06 The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 36 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. Timescale of 08/07/05 not met. 57 OP29 13(6) 19(2) 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. 10/02/06 58 OP29 13(6) 19(2) This to include the handyperson . The registered provider must 01/03/06 provide the CSCI with an up to date recruitment policy. 59 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. The registered provider must provide evidence to the CSCI of training dates confirmed for staff in respect of dementia training ( accredited). The registered provider must employ a suitable manager for the home. DS0000066557.V279716.R01.S.doc 01/03/06 60 OP30 18(1)(a) 15/02/06 61 OP31 8,9 01/03/06 The Beeches(Blackheath) Version 5.1 Page 37 62 OP33 24 The registered provider must implement / continue developing the homes system for improving the quality of care in the home, this to include; Seeking views of service users’. 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. 01/03/06 63 OP36 18(2) The registered provider must ensure that all care staff are supervised at least once every two months (six times per year). 01/06/06 64 OP37 17(2) Timescale of 01/09/05 not met. It is positive however, that at least 10 staff have been seen by the new provider on a one to one basis. The registered provider must 01/04/06 ensure that all of the required policies and procedures are in place, are up to date and are reviewed annually. Timescale of 28/08/05 not DS0000066557.V279716.R01.S.doc Version 5.1 Page 38 The Beeches(Blackheath) 65 OP37 17(2) 66 OP37 17(2) 67 OP38 13(4) met. The registered provider must ensure that all staff read all policies and procedures. Timescales of 01/02/05 and 15/09/05 not met. The registered provider must ensure that the communication book is not used to write personal details about residents’. Timescale of 22/06/05 not being consistently met. The registered provider must carryout a documented audit/ risk assessment of the premises relating to all risks and safe working practices. A copy of this must be provided to the CSCI. 15/04/06 03/02/06 01/03/06 68 OP38 13(4) The registered provider must provide the CSCI with evidence of water testing results within last 12 months. 01/03/06 69 OP38 18(1)(a) 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; DS0000066557.V279716.R01.S.doc 01/03/06 The Beeches(Blackheath) Version 5.1 Page 39 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. Timescale of 20/08/06 not met. Where gaps in training are identified then dates for this training must be booked and forwarded to the CSCI. Fire training must be addressed as a matter of urgency. 70 OP38 17(2) 01/03/06 The registered provider must 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. 71 OP38 16(2)(j) The registered provider must ensure that; The food probe is collaborated regularly and records of these are maintained. That supper is included on the 15/02/06 The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 40 residents food consumption records. That menus are available in pictorial and large print formats. That all short life foods such as jams and sauces are labelled when opened. Timescale of 01/08/05 not fully met. 72 OP38 13(4) The registered provider must ensure that bed bumpers and bedrails are safe, secure and are checked on a weekly basis. A record of these weekly checks must be made. This includes bedrails in room 12. Timescale of 22/06/05 not met. An immediate requirement followed by a serious concern letter was issued by the CSCI. The registered provider must ensure that all areas identified in the last fire inspection report DS0000066557.V279716.R01.S.doc 31/01/06 73 OP38 13(4) 23(4) 01/03/06 The Beeches(Blackheath) Version 5.1 Page 41 dated 1 June 2005 are fully addressed. For further information contact West Midlands Fire Service. 74 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. Timescale of 01/08/05 not fully met. This to include the need for key pads on doors, mats to monitor wandering and garden safety. 24/02/06 The Beeches(Blackheath) DS0000066557.V279716.R01.S.doc Version 5.1 Page 42 75 OP38 13(4) 23(4) The registered provider must 24/02/06 provide the CSCI with evidence to confirm that the work highlighted in the fire/emergency lighting service certificates has been completed. 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.V279716.R01.S.doc Version 5.1 Page 43 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.V279716.R01.S.doc Version 5.1 Page 44 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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