Care Home: Beech Close Care Home

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What the care home does well Pre admission assessments provide sufficient information to inform whether the needs of the person can be met at the home, a full review of the identified needs takes place soon after admission to ensure that needs are being fully met. Within the care plans viewed there was sufficient evidence available to demonstrate that the health, personal, social and emotional needs of people using the service are continually assessed and their changing needs identified. General observations of care practices and interactions between staff and the people using the service indicated that the people using the service are treated with respect and their individuality promoted. People using the service expressed satisfaction with the meals provided, and there was evidence that food choices were made available. Concerns and complaints are taken seriously there were records available of complaints, the outcome of investigation and further action taken. Staff receive training on safeguarding adults, which is provided during the initial staff induction training and in addition the service had obtained a DVD training course. The home is registered to care for people who have a physical disability, the bathrooms viewed had fixed bath hoists available, and other moving and handling equipment was seen to be available to include portable hoists. Outside the home there is access via ramps. Records of staff recruitment and selection evidenced that staff only take up employment at the home once all pre employment checks have taken place. What has improved since the last inspection? Requirements made following the last Key inspection had been met. Further refurbishment work had taken place to improve and upgrade the environment. What the care home could do better: It was apparent from discussion with people using the service who require mental health support that a lack of motivation is a key issue for some and this can directly affect their rights to make choices. This is a training area that could be further explored to enable the staff to support people in making choices. The designated smoking area is within a hallway, which is the only means of accessing the mental health unit; consideration needs to be given as to whether there is a more suitable area within the home that can be used as a smoking area, which will not affect non-smokers. CARE HOMES FOR OLDER PEOPLE Beech Close Care Home Beech Close Desborough Kettering Northamptonshire NN14 2XQ Lead Inspector Irene Miller Unannounced Inspection 8th September 2008 10:00 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 Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Close Care Home Address Beech Close Desborough Kettering Northamptonshire NN14 2XQ 01536 762762 01536 762313 Beech.Close@shaw.co.uk www.shaw.co.uk Shaw Healthcare (de Montfort) Ltd 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) Mrs Rose McClarnon Care Home 42 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (7), Old age, not falling within any other category (42), Physical disability over 65 years of age (6) Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Beech Close care home is registered to provide personal care to male and female service users who fall within the following categories:- Old age, not falling into any other category (OP) 42, Physical disability over the age of 65 years (PD(E)) 6, Dementia - over the age of 65 years (DE(E) 12, Mental Disorder, excluding dementia and/or learning disability - over the age of 65 years (MD(E)) 7 No one falling within the category DE(E) should be admitted into Beech Close when there are 12 persons who fall within this category accommodated in the home. No one falling within the category PD(E) should be admitted into Beech Close when there are already 6 persons who fall within this category accommodated in the home. No one falling within the category MD(E) should be admitted to Beech Close when there are already 7 persons who fall within this category accommodated in the home. No one falling within the category MD(E) should be accommodated in any room outside of the area designated as Flat 1 within the Beech Court care home. To accommodate the persons named in variation application V32420 within the category of DE(E), thereby increasing the number of registered places for DE(E) from 12 to 14. This only applies whilst the persons named in this variation are accommodated at Beech Close care home. To accommodate the person named in variation application V33777 within the category MD. To accommodate the person named in variation application V35095 within the cateogry DE. The maximum number of persons to be accommodated at Beech Close is 42. 20th September 2007 2. 3. 4. 5. 6. 7. 8. 9. Date of last inspection Brief Description of the Service: Beech Close is a home providing personal care to 42 residents in the old age, dementia and physical disability categories. The home is situated within the residential area of Desborough and is close to local facilities and amenities. The premises were purpose built some years ago and provide single rooms and a range of communal areas for the residents. These include small lounge areas within the 6 accommodation areas known in the home as ‘flats’ and ‘the Street’ Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 5 area offering a variety of services including hairdressing, tea bar, library, shop and quiet room. All admissions to the home come through the local authority and the fees are in the region of £420.20 to £445.00 per week. The homes Statement of Purpose and Service User Guide is located within the front entrance of the home together with the most recent CSCI Inspection Report to ensure that information is readily available on the range of services that the home offers. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The focus of all inspections undertaken by the Commission for Social Care Inspection (CSCI) are based upon seeking the outcomes for people using the service and their views of the services provided. This visit was unannounced and focused on the ‘key standards’ under the National Minimum Standards and the Care Standards Act 2000 for homes providing care for older people. The care records of three people using the service were sample checked which involved looking through written information available on their care, such as their individual care plans (a care plan sets out how the home aims to meet the individual service users personal, healthcare, social and spiritual needs). An expert by experience who has experience of both using mental health services and in supporting people with mental disorders was present during part of this inspection visit. This person was introduced to the people using the service and spent time talking with them in order to make an assessment of the level of support provided for people who’s primarily needs are mental health. Time was spent talking with staff to assess their understanding and awareness of mental disorders, the mental capacity act and human rights act, and how staff support and promote people with mental disorders to lead full and productive lives. During the visit people using the service were consulted on how they view the care provided at the home, and discussions with staff gave an insight into the support and training provided at the home. Observations of care practices and discussions with people using the service gave an indication on the quality of the service provided at Beech Close. Records in relation to the homes management and administration systems, quality assurance, staffing and general policies and procedures were viewed. Prior to this visit the Commission for Social Care Inspection sent out to the provider an Annual Quality Assurance Assessment (AQAA) this document allows the provider to supply us with information on how they view their own performance, such as what they do well, what they could do better and plans for future improvements. The AQAA was returned to the Commission for Social Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 7 Care Inspection (CSCI) within the timescale set, and gave an insight into how the home is managed and quality assessed. What the service does well: What has improved since the last inspection? Requirements made following the last Key inspection had been met. Further refurbishment work had taken place to improve and upgrade the environment. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 8 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. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 9 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 Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 (standard 6 is not applicable to this service) Quality in this outcome area is good. Pre assessments are carried out prior to people moving into the home to ensure that the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of three people using the service were viewed, within the plans there was records of pre admission assessments being carried out by a representative from the home and of the placing authority. People spoken with during the visit said that they thought that their care needs were being met at the home. It was confirmed in discussion with the manager and documentation seen that a full review takes place after admission to ensure that the home is suitable to meet the needs of the person. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 11 Details on the services provided at the facility are available within the homes Statement of Purpose and Service User guide, which are generally made available within the front entrance of the home, however on the day of the inspection visit these documents were not on display. The manager confirmed verbally that she would ensure that a copy of the Statement of Purpose would be made available. This is important as the details contained within this document provide important information for people using the service on how the facility aims to meet the needs of people using the service. Work has taken place on producing a new brochure for prospective people wishing to use the service, this was an area that had been identified as an area by the provider with their Annual Quality Assurance Assessment (AQAA). Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 & 10 Quality in this outcome area is good. The assessment and care planning systems in place identify the health and personal care needs of people using the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans of three people using the service were viewed, there was evidence that people using the service had been involved in the development of their care plans and where this had not been possible there was documentation available to evidence that families had been consulted. There was information on the preferred gender of which the person wished to provide their personal care. Records were available of when people had been seen by their General Practitioner, the district nurse, chiropodist, optician and dentist. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 13 There was information available on dietary needs to include nutritional assessments and there were records of people having their weights regularly monitored. Assessments on the mobility needs of people using the service had been carried out and for people identified at risk of developing pressure area ulcers due to immobility pressure are care assessments were in place. The care plans gave instruction on the specific moving and handling equipment needed by the individual, such as the type of hoist, pressure relieving equipment and walking aids. Risk assessments had been carried out which identified risk to the individual, such as falls, and activities of daily living, which balanced people’s rights to take risks to enable independence. There were records of the risk assessments being regularly reviewed and updated. Each of the flats had a safe secure medication storage facility, and on checking the recording and administration records and the storage facilities this was seen to be satisfactory. A new monthly supply of medication had been received on the morning of the inspection; the manager and the senior staff explained that they were experiencing problems with the medications and were having to spend hours rechecking the new medication stocks. The manager explained that this was an ongoing problem and she had shared her concerns with her immediate line manager who had taken her concerns to a higher level within the company. The difficulties with the medication deliveries and the time spent in rechecking the delivery stocks and rectifying these errors creates a major diversion for the manager and the senior staff, taking them away from their daily responsibilities of overseeing the care provision at the service. The team leaders and the manager are responsible for the administration of medication and all had received intensive medication training and as part of the organisations quality assurance systems spot checks are conducted on the medication storage and administration records. Observations made during the visit and discussions with staff and residents evidenced that staff treat the residents with respect and their rights to privacy, dignity and choice are upheld. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 & 15 Quality in this outcome area is good. In general people using the service find that life in the home matches their expectations and personal preferences. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each care plan had a living history profile available, which included information on hobbies, interests, and social, spiritual and cultural lifestyle preferences. An activity co-ordinator is employed at the home, and records were available within the care plans of the person’s involvement and participation in social and individual activities that had taken place. Staff training course had taken place on activities ‘full of beans’ and a training video has been purchased to assist in providing meaningful activities for people living at the home with dementia. In discussion with the manager she confirmed that changes to the activities provided at the home had taken place such as a coffee morning which takes place every two weeks and the provision of a mini bus on Wednesdays which Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 15 has given the opportunity to enable more people to go on outings to places such as the local pub and garden centre. The home has its own chickens that were introduced as a result of seeking information from male residents who had kept their own chickens on allotments. During the visit residents were observed to pursue their own interests such as reading, watching television, listening to music, a small group of residents were observed spending time together in the ‘street’ area of the home. This small group of people were observed to enjoy sitting in this area socialising with visors and staff who were passing through the ‘street’. Time was spent talking with five people using the service who require mental health support below is comments about their experiences of living at the home: 1. This person said that they did not make the decision to live at the home and it was their daughter who had decided they should go there, though they mentioned that they liked the staff. When asked about the elements of choice offered in relation to leisure time and needs they mentioned that ‘they do nothing, but like to sit out when the weather is fine’. They expressed that they cannot go out because they would have to arrange their own transport and felt that life allowed ‘no variety and no freedom’. They said that they do use the library in the home. This person mentioned that the staff ‘laugh and talk in the passage’ and the home offered no feeling of ‘belonging to the people there’. Describing the experience of living at Beech Close as being ‘as flat as flukes’. 2. This person said that they did nothing but then mentioned that sometimes they visit the hairdresser, and that they had ‘no choice’ but did get up at 7.30am most mornings when staff start at 8am. In relation to staff respecting their decisions they mentioned that there was support to go out, but when questioned on rights and freedom they mentioned that ‘the staff have the bigger say’. In relation to respecting their spiritual needs it was mentioned that a priest does visit weekly to give communion. When asked about restrictive rights and freedom they mentioned that ‘when necessary the staff are helpful’ to achieve rights and freedom of choice. In relation to feeling listened to and valued they mentioned that ‘staff do listen to them and respect is given’. 3. This person said that they had stayed at another care home before arriving at Beech Close when asked how they to compared both they said they were very similar, saying that they did not do a lot at Beech close and sleeps a lot. In relation to respect they said that they felt it some of the time and not at others. When asked if the services were better at the home they stated ‘no’. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 16 4. This person mentioned that they do nothing but lie down often, they described the staff as ‘very friendly’ and while ‘the girls look after the food’ this person said that they do use the kitchen to make their own snacks, they said they did not go out. They mentioned they do have choice over the menu and enjoyed the food, saying they mostly stay in their room and smoke. When asked about decision-making they said that they were happy for the staff to make decisions for them. They talked of the homes mini bus that takes people to the day care centre. When asked if staff do attend to their needs in direct relation to their wishes this person stated ‘everything is fine’, and when asked if they felt listened to and respected they said yes that it is ‘the best home so far’. It is acknowledged that some of the people using the home can struggle to answer questions during the inspection visit when asked to give examples because they are ‘put on the spot’ to give detail. Information can only be received in relation to what The people using the service ‘feel they can give’ and they cannot be probed for more information than they can offer. Motivation is an issue for some of the people who require mental health support and this can affects their ‘choice and freedom’. In discussion with the chef it was confirmed that the people using the service had recently been consulted about a change to the menus with the aim to provide more fresh seasonal fruits and vegetables. One person had said that they would like to have Rabbit Stew and the chef said that she was making enquiries with a local butcher to make this available. The chef confirmed that at the moment there are no people using the service who require special diets to meet their cultural needs. Some people using the service have swallowing difficulties and require their foods to be pureed, the chef was aware of the importance of ensuring that pureed foods were presented in a way that still looked appetising. The main kitchen was seen to be clean and tidy although appeared in need of an upgrade / refurbishment, the chef and the manager explained that plans to refurbish this area of the home had been put on hold due to budgetary constraints. Records were available of daily, weekly and monthly food safety checks to ensure that high food safety standards are applied. Lunch on the day of the visit was a choice of Smoked Haddock or Prawn Salad with Apple Charlotte and Custard for afters, there was also a choice of cold desserts such as yoghurt or fresh fruit. People using the service they all expressed satisfaction with the meals provided. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 Quality in this outcome area is good. People living at the home can be assured that any concerns or complaints they may have will be listened to, taken seriously or acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Within the front entrance of the home the complaints procedure was on display, and the procedure is also made available within the service user guides of which a copy is held in each bedroom. Since the last inspection visit on concern had been raised with the Commission for Social Care Inspection, which the provider had been asked to carry out an investigation. Within the information provided through the AQAA the service had received three complaints within the last 12 months. During the visit the complaints log was viewed and records were available on the nature of the complaints and records were available to demonstrate that they had been fully investigated. Records of staff training evidenced that staff receive training on safeguarding adults, which is provided during the initial staff induction training and in addition the service had obtained a DVD training course Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 18 In discussion with staff and observation of care practice during the visit it was demonstrated that the rights of people using the service are upheld, people spoken with said that the staff treat them with respect and said they would know who to speak with if they had any concerns. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 Quality in this outcome area is good. People using the service are provided with a clean, safe and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The architecture of the building from the outside gives the impression of a ‘bungalow’; the front entrance had pot plants and hanging baskets in place that gave a pleasant first impression. There was nice flora and a very pretty sitting area at the rear of the building. The front door to the building is accessible through the use of a keypad that ensures that access to the facility is restricted to those who have a reason to be there. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 20 Improvements have taken place to the environment to include some refurbishment and redecoration work. In general the service is clean and homely, there is space for people to socialise, and have quiet time. Inside, on the ‘street’ there were facilities such as a teashop, bar, library and hairdressers but they weren’t open. There was music and TV there for entertainment and the volume was good, just loud enough for comfort, which created a rather relaxed atmosphere. Each of the six units has single bedrooms a communal lounge/dining room and an open plan kitchen area. The rooms within the area of the home caring for people with mental health needs were brightly decorated (which can only make people feel better). The environment was clean although, there were some unpleasant odours detected within some areas, however generally the environment was a pleasant one. There was a kitchen where people using the service can make their own beverages and snacks although the main meals are brought to each unit by heated trolley from the main kitchen. There is a designated smoking area within a conservatory style hallway, one person was seen to be using this facility, as this hallway is the only means of accessing the mental health unit consideration needs to be given as to whether this is a suitable area to be used as a smoking area. Call alarms are fitted in all rooms so staff know if a person needs help. The home is registered to care for people who have a physical disability, the bathrooms viewed had fixed bath hoists available, and other moving and handling equipment was seen to be available to include portable hoists. Individual bedrooms viewed during the visit were seen to be clean and pleasantly decorated and contained personal possessions such as ornaments, small items of furniture and personal effects. The main kitchen was viewed which was clean and tidy in discussion with the manager and the chef they both confirmed that plans to have this area of the home refurbished had been put on hold due to budgetary constraints. The laundry was viewed which was well managed there was evidence of staff following cross infection good practice, in discussion with a member of staff working in this area of the home they were able to confirm that training had been provided on reducing cross infection. Staff training on the importance of good hand washing techniques had been provided and within the entrance to the home there was a notice requesting Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 21 that all people visiting wash their hands when entering and leaving the building. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 & 30 Quality in this outcome area is good. People using the service receive support from a staff team that are appropriately trained to meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two staff recruitment files were viewed and both had information available to evidence that the employment history had been checked, references obtained and checks carried out with The Protection of Vulnerable Adults register (POVA 1st) and Criminal Records Bureau (CRB) before commencing employment at the home. All new staff undergoes a full induction programme that covers mandatory training in Moving and Handling, health and safety, fire safety, food hygiene and first aid. The annual training plan was viewed which evidenced that the majority of staff have received core training to include training on dementia care and mental health this ensures that the training is appropriate to meet the needs of the people using the service. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 23 In discussion with staff they felt supported and by the company some had worked at the home for many years and said that they still enjoy working at the home. Two members of staff were spoken with one who has been there for a considerable number of years and the other who has been there for a few months. They gave information on the training they had received, which included (some of which took place in previous employment). • Mental health training. • Aggression training. • Dementia training. When asked what they understood by the mental capacity act the response was: • Advocacy for residents when they request it • Individual care plans to respect and meet the needs of individuals • Choice over times to get up and go to bed and activities in general. When asked if the people using the service are enabled to lead full lives there they responded • Yes, they have a choice to go out with an escort • Their dignity is respected by making sure things are done the way the want it to be done. • The approach is ‘open door’ where residents can come for support or a listening ear when they need it. • The home is ‘their home’ • The systems works well through good communication and team work Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,33,35 & 38 Quality in this outcome area is good. Through the effective management of the facility the health, safety and welfare of people using the service is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection visit the registered manager has left the service, the interim manager has submitted an application to be registered with the Commission for Social Care Inspection and is awaiting her ‘fit person’ interview with CSCI. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 25 Observations during the visit indicated that staff treat the people using the service with respect and that they receive appropriate training to ensure they can continue to meet their needs. The company carry out regular quality assurance, health and safety audits and annual surveys to gain the views of people using the service and their representatives to identify areas for improvement to the service delivery. The Commission for Social Care Inspection sent out to the service an Annual Quality Assurance Assessment (AQAA) that was returned to CSCI within the timeframe set. The AQAA provides the opportunity for the service to assess their own performance on how they meet the National Minimum Standards. Regular meetings take place and the minutes are posted on the notice board within the street area of the home. Cash held on behalf of people using the service was sample checked, records of transactions were supported with invoices and receipts for audit purposes, this demonstrated that the financial interests of people using the service are satisfactorily managed. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 26 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 OP25 Good Practice Recommendations The registered provider should consider relocating the designated smoking area (currently located within a hallway) to a more suitable area within the home. This will ensure that those non-smokers are not subjected to the effects of passive smoking. Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 © 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 Beech Close Care Home DS0000060165.V372526.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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