CARE HOME ADULTS 18-65
Walsall Road, 804 Great Barr Birmingham West Midlands B42 1EU Lead Inspector
Nancy Johnson Key Unannounced Inspection 23rd August 2007 10:30 Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 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 Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. 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. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Walsall Road, 804 Address Great Barr Birmingham West Midlands B42 1EU 0121 358 0412 F/P 0121 358 0412 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) londonroad@tiscali.co.uk Milbury Care Services Ltd Mrs Veronica Christopher Follows Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The registered person may provide personal care and accommodation for service users of both sexes whose primary care needs ona dmission to the home are within the following categories: - Learning Disability (LD 3). The maximum number of service users to be accommodated is: 3. 2. Date of last inspection 15th November 2006 Brief Description of the Service: 804 Walsall Rd is registered to provide accommodation, care and support for three people with learning disabilities. The property is a detached bungalow, located on the main Birmingham to Walsall road in the Great Barr area of Birmingham. The Scott Arms Shopping Centre is within walking distance, and the home is well situated for local amenities including public transport and local shops. The accommodation includes a through lounge and dining area, a domestic scale kitchen, and separate laundry. The bathroom offers assisted bathing facilities, and there is a separate toilet available also. One of the three bedrooms has en-suite facilities. There is also a small office. To the rear of the property is an attractive private garden, which is accessible for wheelchair users via a ramp. The home is comfortably furnished and well maintained. There is off-road parking for several vehicles on the drive at the front of the house. The Registered Manager also has responsibility for another small home situated about a hundred yards further along the road. Both houses are run by Milbury Care Services. The weekly cost is £1437.17 and does not include aromatherapy, music therapy, hairdressing, visits to the barbers, beautician. The fee also include one holiday a year; any additional holidays requested are paid for by the residents. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This key inspection involved one inspector and took place over a day; the fieldwork visit was unannounced and took place between 10.30am and 6.30pm. Information was gathered from records seen during the inspection which included, the completed Annual Quality Assurance and Assessment(AQAA) the previous inspection report, service history, care records, staff files, training records, activity records, staff duty rotas, health and safety records and medication records. Two residents’ files were examined, including care plans, risk assessments, activities, daily reports, health plans and reviews as part of the case tracking process. This process involves establishing an individual’s experience of living within the home by observing them, talking to the carers and relatives (where possible) about their experiences, looking at the resident’s care files and focusing on outcomes. The inspection process also consisted of a review of policies and procedures, discussions with the registered manager, operational manager, staff and residents (where possible) and a detailed tour of the building. During this tour the inspector looked at the garden, all bathrooms, toilets, kitchen, laundry facilities, communal areas and all three residents’ bedrooms. Some observations of care practices were undertaken. The building was clean and tidy and pleasantly decorated. What the service does well:
The features of home are similar in design to that of neighbouring properties so it fits in well and does not stand out as a ‘ care home’. The home has a welcoming atmosphere and provides a homely environment. The communal areas have recently been redecorated to a good standard. All areas seen were clean and free from any offensive odours. People have the chance to visit and see what the service can offer, prior to making a decision to move in. Residents’ care needs are properly assessed and detailed care plans developed so that staff know how residents liked to be treated and supported. Residents are supported to go to appointments with their doctor or other professionals involved in their care. They are encouraged by staff to do as much for themselves as possible in order to promote their independence. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 6 Residents rights are recognised and respected and staff deal with residents in a warm and caring manner. They are encouraged and supported to maintain family contacts both in and away from the home. The home’s recruitment policies and procedures ensure that people who work in the home are fit to do so, by interviewing them properly, and carrying out checks on them before offering them the job. There was a pleasant and happy environment and the staff and residents appear to share a warm relationship. Due to the stable and long established staff team the staff are very knowledgeable about the residents care needs. We were able to speak to one resident who took great pride in sharing plans for their forthcoming birthday party and was observed inviting a regular visitor to the home. The resident also stated “I like the staff and I like it here”. Relatives of residents spoken with were complementary of the manager and staff and commented that they were all very pleased with the care that their relatives received. What has improved since the last inspection?
The home is better run, residents and relatives’ views are sought and taken into account. As commented by one relative “ the manager listens, I was able to advise on the refurbishing of my relative’s room. After all, the resident is not able to say but we have come to know their likes and dislikes”. Areas for improvement highlighted in the last inspection report have been addressed. The home has been redecorated throughout with specialist advice on colour schemes to improve the environment for the resident who has a sensory impairment. The organisation SENSE, were commissioned by the home and has carried out a comprehensive assessment on the environment, the needs of residents and staff and has assisted the home with advice, guidance and training on how to best meet the complex needs of resident with sensory impairment. This has included changing the colour scheme of communal areas and providing training for their keyworker. We are informed by the manager that training for all staff is being planned. The home has further developed communication passport, which provides a clear ‘pen picture’ how the resident will communicate their choices and preferences in a non-verbal manner. This communication tool is developed by acquiring the residents’ history from family members and long term support staff. This information will assist new staff in quickly gaining an understanding of residents assessed needs and will be better able to support them. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 7 Care plans now feature assessed measurable goals which are reviewed and evaluated regularly. Each resident has had a ‘Health Action Plan’ where all health care needs are assessed. For example, looking at the resident’s last appointment. The Learning Disability Nurse working in conjunction with the Practice Nurse annually develops plans for identified needs.. ‘ Health Action plans’ have also been reviewed in conjunction with staff, residents and their doctors. 87.5 of permanent care staff are now qualified to National Vocational Qualification (NVQ) Level 2 or above. A new training toolbox is now in place where the home can provide in-house training. The manager has also completed a course on Dementia Training for Trainers and is therefore able to roll out training where needed. We were informed by the manager that this dementia training is scheduled for 4th and 7th September 2007 to include all staff. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 5. Quality in this outcome area is good. Prospective residents are given the opportunity to visit the home, meet with Residents (where appropriate) and have tea in order to ensure that the home is able to meet their needs and aspirations. Each resident has an individual contract. The home provides this in a variety of formats, which makes them easier to understand. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We saw that a statement of purpose and service user guide were available. These documents have been made in audio, pictorial and large print formats to meet the varying needs of the residents and increase their understanding. There have been no new admissions since the last inspection. However, all potential new residents are able to visit the home and have tea to ensure that the home will be able to meet their needs and aspirations. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. Care plans contain detailed information as to assessed needs, how they will be met and clearly show each resident’s personal goals. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A requirement was made in the last inspection report for care plans to be developed to improve the way in which goals are measured so that they can be evaluated and reviewed. A date has been set 26/09/07 to evaluate care plans. Care plans are very detailed and identify needs, management plans, risk assessments and goal setting. Goals are identified in terms of short, medium and long term in conjunction with the resident where possible. All goals
Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 11 are then given timescales and are evaluated. Records indicate that not only are residents’ participation and satisfaction closely monitored but staff ability and expectations form part of their supervision, staff meeting and identification of their training needs. As commented by a staff member “The introduction of residents’ communication passports (clear ‘pen picture’ of how the resident will communicate choice and preference in a non-verbal manner) is an excellent communication tool and will ensure better outcomes for residents”. Direct observation of staff and residents showed that residents were supported to make decisions, for example, what they wanted to eat or drink. Due to needs connected with, for example; their learning disability residents are only able to make limited choices. To improve this, pictorial aides, for example, depicting certain food, fruits, toilets and communication passports are in use. Observations and records indicate that residents are supported to develop social skills where applicable. One resident enjoys polishing his bedroom furniture, making his bed and vacuuming his carpet and is supported to do so. The home works closely with relatives in developing the use of person centred approach, for example, object reference (car keys) in the case of sensory impairment to indicate preference of activity. This will be further developed in implementing the outcome of specialist assessment undertaken by SENSE. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17. Quality in this outcome area is good. Residents’ enjoy a variety of appropriate and enjoyable leisure activities. They are supported to maintain contact with their family. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents’ engage in a wide variety of activities including; visits to the library, going out for meals and weekly music session. The music therapist comes into the home and residents are encouraged to play different types of instruments and to sign along. One resident has purchased a tambourine and enjoys playing it. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 13 Since the last inspection a range of leisure opportunities have been reviewed and further developed and made available to the residents. It was also a requirement that activities should be properly recorded and evaluated. There has been marked improvement in the way in which activities are recorded. Each resident has their own monthly activity planner that details his or her choice of indoor and outdoor activity. The manager has also devised a new activity-recording sheet that indicates the choice of activity offered and how it was offered, the choice of activity made and how the choice was made. Details are also written as to the duration of activity. These records are evaluated as to the resident’s level of participation and outcome of activity represented by a rating given by staff in conjunction with the resident. Residents are supported to maintain contacts with relatives by telephone and visits. Relatives spoken to were very appreciative of the support the home provides in ensuring that their relatives visit them at home as failing health prevent them visiting the home regularly. We were able to observe the lunchtime meal. The residents were seen to enjoy their food. Meals were well balanced with individual choice of meal, fruits, yoghurts, choice of hot and cold drinks. Fresh fruit were available and cupboards were well stocked. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. Appropriate supportive staff, access to primary and specialist health and the homes policies and procedures meet residents’ emotional and physical needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents are well cared for and have access to primary health care professionals. Appointment records are well organised and up to date. These include referrals to Doctors, Psychiatrist, Occupational Therapist, Speech and Language therapist and Chiropodist. It was a requirement from the last inspection that the home produced a protocol in respect of Lactulose prescribed on an “as required” basis. This is now in place.
Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 15 It was also required that a note be placed in the accident book to remind staff that all incidents must be reported to the commission. We saw that this has been done. We also saw that recommendation made following the last inspection for counterfoils of accident records to be dated has been addressed. Residents Health Plans have been reviewed in conjunction with the learning disabilities nurse, practice nurse and the residents’ doctor. We saw evidence to confirm that one resident has been referred to a Speech and Language Therapist and an assessment has been undertaken. Assessment on resident’s aids and adaptations has also been carried out by the Occupational Therapist who has confirmed that no additional equipment is required. Interactions between staff and residents were warm, supportive and friendly. All residents presented as clean, were appropriately dressed and it showed that care was taken with personal hygiene. No-one living at the home is able to administer their own medication. The Medical Administration Record (MAR) was examined and was found to be completed appropriately. As previously reported, there is a system in place for a second member of staff to check and sign that medication has been appropriately administered and recorded. Staff spoken to were fully knowledgeable of medication policies, procedures, storage and recording and were confident in explaining processes. As part of the case tracking process, administration of medication at lunchtime was observed and the appropriate guidelines were followed. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. A consistent staff group who have an understanding of the residents’ complex support and communication needs protect residents from abuse, neglect and harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints or allegations have been received since the last inspection. Since the last inspection audio and pictorial versions of the complaints policy have been developed in conjunction with staff and residents’. However, it is of no relevance to one resident due to the extent of their disability. Relatives interviewed were aware of the policy and how to complain. One relative commented “I have no complaints, only compliments on the way we have been kept informed on matters concerning our loved one. We are content in the knowledge that our relative is well cared for and protected”. The staff team are well established and have good knowledge of the residents’. They are therefore able to understand when they are unhappy or require assistance. This has been implemented into the development of the communication passports as measurable outcomes.
Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 17 All staff have now completed training in adult protection. Examination of staff records showed good recruitment practice including Criminal Records Bureau disclosure and Protection of Vulnerable Adults checks have been complied with. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26 & 30 Quality in this outcome area is good. Residents’ benefit from living in a well-maintained, clean and homely environment. Bedrooms are personalised and their personal space helps to promote their limited independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is a specially adapted bungalow, which is well maintained. It provides a homely environment to live in. Residents’ rooms are personalised to reflect their tastes and interests. A tour of building showed that the home was clean, hygienic and free from any unpleasant odours. The garden area is well cared for and one of the residents expressed that they enjoyed sitting in the garden. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 19 The majority of the premises has been redecorated including; the communal hallways. This was originally placed on ‘hold’ while advice was sought from specialist organisation commissioned to undertake a comprehensive ‘ functional assessment’ of resident with dual sensory impairment; in order to ensure that the appropriate colour schemes, contrast and textures designed to improve the overall environment were used. Also assessment of staff and training needed to meet resident growing complex needs. It was identified that a three-seater settee needs replacing. This is used by resident who, we were informed and observed had sensory impairment and complex support needs, necessitating undue wear and tear on the settee. This settee is part of a three piece suite and the other chairs are in good condition. The home is in the process of replacing this settee, however we have been informed that decision has been reached not to replace the dining table and chairs as they are sturdy and in good condition and fits in with the rest of the furniture. A relative commented “the chairs are sturdy but become uncomfortable after sitting for a while.” During the last inspection concern was expressed by a relative about the temperature in the resident’s bedroom. This has since been appropriately assessed and the bedroom was fitted with a large radiator providing the required temperature. There was also a requirement that the bath with the broken hoist be replaced and the bathroom to be refurbished. We have seen evidence that this work is in progress. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35. Quality in this outcome area is adequate. Residents are supported by a competent and qualified staff team and are protected by the home’s recruitment policy and practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has eight permanent staff and shares a manager with another care home close by. A full time deputy manager supports the manager. 87.5 of staff are trained to NVQ Level 2 or above. The home benefits from a very stable staff team. As a result of a recent staffing review a 20 hour support worker post has become available. The home is now in the process of recruiting for this post. Staff, are very understanding of the residents’ needs and it was observed that they interacted in a warm and friendly manner. Key working sessions are appropriately recorded, signed and dated by the key worker.
Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 21 Staff files were reviewed and were found to contain all necessary documentation including identification, application forms, references, Criminal Records Bureau disclosure and Protection of Vulnerable Adults checks and confirmation that induction had taken place. Sampled files showed that staff are now receiving regular supervision sessions and details of the sessions were documented. Regular staff meetings are held and the agendas reflect a range of issues including; equality and diversity, both in terms of residents and staff. It was pleasing to note that the Inspection Report was consistently on the agenda with key targets. The organisation SENSE, a specialist advice and facilitator for people with sensory impairment assessed the home and staff through direct observation over an eight month period. Following the assessment all staff will receive training in working with resident with sensory impairment. The comprehensive assessment and training will enable staff to better understand resident’s needs. The use of objects (feel) will assist one resident in developing an awareness of the environment and improve their quality of life. Deaf and Blind Awareness Training is schedule for 3 days in September 2007. The previous inspection highlighted that the Training Officer’s post was vacant. We have been informed by the operational manager that a training manager is being recruited. The organisation has piloted a number of courses including Health and Safety, Food Hygiene, Manual Handling, Infection Control referred to as ‘The Health Box’. This training is linked to Accreditation and will be delivered on site and available to all members of staff. During the inspection, discussion with staff showed that they were knowledgeable about their residents and the homes policies and procedures. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41 & 42. Quality in this outcome area is good. Residents benefit from a well run home. Their health, safety and welfare are promoted and protected by the home’s policies and procedures. The home works closely with residents, their relatives and related professionals in developing person centred approach in their efforts to ensure that staff are enabled to understand and provide appropriate care for residents’ irrespective of their complex support needs. This judgement has been made using available evidence including a visit to this service. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 23 EVIDENCE: As highlighted in the last inspection report, the current manager has worked with the organisation for several years. She currently manages another home, situated in close proximity. An experienced deputy who has been with the organisation for several years, as well as a committed staff team supports her. The Manager is a qualified Registered Nurse in Mental Health (RNMH) and holds the Registered Managers’ Award and National Vocational Qualification Level 4. Relatives spoken to were very complementary of the Manager and stated “she works closely with relatives, she is a good listener, often take on board suggestions in her endeavours to improve the service. We are confident in the knowledge that our relative is being well cared for”. A requirement was that a completed application to register the Manager be submitted to CSCI. This requirement has been complied with and fully met. The home continues to develop its Quality Assurance systems as recommended by the last inspection, illustrating how judgements have been made in relation to residents’ views and opinions. An Annual Service Review is undertaken and involves residents, relatives, external professionals and staff with keyworking meetings forming part of the Annual Service Review. Regulation 26 Visits are undertaken within timescale, clearly setting targets in a number of areas including meeting CSCI requirements (weekly update from the manager), identifying how requirements are being met and improved. The fire alarm and emergency lighting systems have been serviced, weekly tests were undertaken as required with written record completed. Fire drills have been carried out at regular intervals and appropriately recorded. Temperatures at all water outlets have been tested and records maintained. Control of Substance Hazardous to Health (COSHH) stores were secured with manufacturers’ data information in place. Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 3 3 3 X Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 25 No 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. Standard Regulation Requirement Timescale for action 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 YA6 Good Practice Recommendations Continue to develop care plans, to expand communication guidelines, to set goals with measurable outcomes and evaluate them at review. Develop risk assessments so that hazards are correctly identified and control measures are included in individual care plans. Replace the bath and refurbish the bathroom Further develop quality assurance reporting to show more clearly how residents’ views have been obtained and judgements made. 2. 3. 4. YA9 YA27 YA39 Beeches (The) (Seven Kings) DS0000016937.V352499.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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