Care Home: The Beeches Nursing Home

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What the care home does well We asked people what is good about the home and here are some of the comments we received: "The staff excellent" "The staff are lovely, all of them" "It`s a nice little home this". People`s representatives said: "Its lovely here the staff are wonderful" "My mum`s health is so much better since she came here". Health care professionals said: "Staff communicate really well with us, which can only benefit the people in the home" "The Beeches provides a homely environment for residents with excellent care delivered from committed and friendly staff ". People and their representatives said that the home is "a friendly and lively place" this was very evident on the day of our visit. People also said they always enjoy the food and were always offered a choice of meal. The home was clean and free of unpleasant odours when we visited. People and their representatives told us the home is always clean and fresh. Staff, people, health care professionals and relatives spoke very highly of the manager. Comments included: "She is a very good manager; she is always available to help".The Beeches Nursing HomeDS0000029133.V377901.R01.S.docVersion 5.2There is evidence that the ethos of the home is open and transparent. Generally the views of both people who use the service and staff are being listened to, and valued. What has improved since the last inspection? The requirement from last inspection has been dealt with. The home has continued to work on improving the care records since our last visit. The plans contain more detail and are written with the individual much more in mind.This will mean that staff know what care/support each person needs. The overall feedback from people, relatives and health care professionals is that there has been an "all round improvement" in levels of care at The Beeches in the last year. One person`s representative said "twelve months ago things were slipping now its back to normal, if not better". People and their representatives said they thought the amount and type of activities available had improved over the past few months. This will help people to make choices about daily living and be involved in some social activities. Staff and the manager confirmed that staffing levels were adequate and that staffing was more stable and the use of agency staff had reduced. All the staff we spoke with said they felt over the last six months staff moral was much improved. This will help to ensure that people receive consistent care from sufficient numbers of well trained and motivated staff. What the care home could do better: People should be involved in drawing up and reviewing their care plans so that they can have more of a say in how they receive care or support. Some medication practices and storage procedures need to improve so that people`s health and welfare are protected. Key inspection report CARE HOMES FOR OLDER PEOPLE The Beeches Nursing Home 320 Beacon Road Wibsey Bradford BD6 3DP Lead Inspector Mike ONeil Key Unannounced Inspection 5th October 2009 09:45 DS0000029133.V377901.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Nursing Home Address 320 Beacon Road Wibsey Bradford BD6 3DP 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) 01274 608656 01274 608656 beechesch@aol.com Victorguard Care plc Vacant Care Home 64 Category(ies) of Old age, not falling within any other category registration, with number (64) of places The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, maximum number of places 64 The maximum number of service users who can be accommodated is: 64 11th November 2008 2. Date of last inspection Brief Description of the Service: The Beeches Care Home is a purpose built home situated in the Wibsey area of Bradford. It is registered to provide personal care with nursing care for up to 64 older people. The home is located in a residential area that is near to a regular bus route. There are pubs, shops and churches nearby. Adequate parking is available adjacent to the building. Accommodation is provided on two floors. All the rooms have en suite facilities. There is a passenger lift and the home has wide corridors making it good for wheelchair access. Communal lounge and dining rooms are on the ground floor. There are panoramic views over Bradford from one of the lounges. There is an accessible garden and patio Information about the services provided can be obtained from the home in information packs. The home also makes inspection reports available to people who live at the home and their relatives. The current fees range from £388.24-£525.00 per week with additional charges payable for services like hairdressing, chiropody and newspapers. This information was provided at the October 2009 inspection. The home should be contacted directly for up to date information about charges. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2(two) stars. This means the people who use this service experience good quality outcomes. The inspection process included looking at the information we have received about the home since the last key inspection in November 2008. Prior to the visit the service had submitted an Annual Quality Assurance Assessment (AQAA).The AQAA can provide information such as what the service was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Unfortunately this information wasnt made available to the inspector before this report was written despite the service sending us the AQAA on time. Before the visit we sent surveys to the home to distribute to people using the service, visiting health care professionals and staff. 14 surveys were returned to us, 2 from health professionals, 2 from staff, 7 from people and 3 from peoples representatives. The information from the surveys is included within this report We made an unannounced visit to the home. This was carried out by one regulation inspector on 5th October 2009 over six and a half hours. We talked to 8 staff about their work and the training they have completed. We checked some of the records, policies and procedures the home has to keep. We also looked at some parts of the home and observed staff as they carried out their duties. We spoke with 11 people who use the service, a visiting health care professional and 4 relatives during our visit, their views are included within this report. Carol Delaney, manager, was in charge of the home at the time of our visit. At the end of our visit we also provided feedback to Joanne Walkdon, managing director and responsible individual of the home and Jean Ross deputy manager. We were informed by Joanne Walkdon that the previous manager of the home had resigned 3 days ago and that Carol Delaney was to continue to manage the home. Carol Delaney has been acting manager at The Beeches over the past few months. Joanne Walkden confirmed that she would write to us to inform us of these changes and apply for Carol Delaney to be registered as the new manager. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.2 Page 6 We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations - but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: We asked people what is good about the home and here are some of the comments we received: The staff excellent The staff are lovely, all of them Its a nice little home this. Peoples representatives said: Its lovely here the staff are wonderful My mums health is so much better since she came here. Health care professionals said: Staff communicate really well with us, which can only benefit the people in the home The Beeches provides a homely environment for residents with excellent care delivered from committed and friendly staff . People and their representatives said that the home is a friendly and lively place this was very evident on the day of our visit. People also said they always enjoy the food and were always offered a choice of meal. The home was clean and free of unpleasant odours when we visited. People and their representatives told us the home is always clean and fresh. Staff, people, health care professionals and relatives spoke very highly of the manager. Comments included: She is a very good manager; she is always available to help. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.2 Page 7 There is evidence that the ethos of the home is open and transparent. Generally the views of both people who use the service and staff are being listened to, and valued. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Assessments were carried out to ensure that the home could meet peoples needs. This home does not provide intermediate care. EVIDENCE: We checked three peoples files. Records show that pre admission assessments had been undertaken. This told us that prior to the admission taking place, staff from the home carried out an assessment of peoples needs. This confirmed that the service was appropriate for the person and provided staff with information to formulate an individual plan of care. We saw in the files, the home was consulting with, and requesting reviews from professionals when peoples needs were changing. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 10 Peoples representatives all confirmed that the manager had visited the person in hospital or at home to see whether the service could meet their needs. Two representatives added that people were too unwell to visit the service before their admission. However the representatives had visited the home on their behalf and all said they were made to feel very welcome and were very impressed with the helpfulness and friendliness of the staff at The Beeches. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were treated with respect and said they were very happy with the care they received. Peoples health and personal care needs were met and in the main medication procedures ensured that people were protected. Care plans reflected peoples care needs. This will mean that staff know what care/support each person needs. EVIDENCE: We checked three peoples care plans. The care plans contained good detail about the persons biography, personality and their preferences and choices. The care plans were very detailed, all handwritten and they did focus on the individual person. The home has continued to work on improving the care records since our last visit. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 12 Risk assessments were included within the documentation and included moving and handling, skin integrity, nutrition and other risk factors. The care plans identified that a range of health care professionals visited the home to assist in maintaining peoples health care needs. People said they had regular contact with their GP and other health care professionals such as district nurses. We spoke with a GP who confirmed that they made planned visits to the home every morning and twice a week in the afternoon. These good links with the local GP practice will help to ensure people receive specialist intervention and medical attention when they need it. Some people and /or their representative said they were aware of care plans and that they were involved in discussions about their care.This means that most people can have a say in how they receive care or support. However there was no evidence recorded in one care plan to show that the person was involved in drawing up and reviewing their plan. This may mean that this person cannot have a say in how they receive care or support. When we spoke with staff they showed a good knowledge of peoples diagnosis and could verbally describe the health and personal care needs of the people they cared for. People looked well cared for and told us that they are. The overall feedback from people, health professionals and relatives was that the care delivered by staff at The Beeches was very good. Individually: Peoples comments included: The staff excellent The staff are lovely, all of them Its a nice little home this. Peoples representatives said: Its lovely here the staff are wonderful My mums health is so much better since she came here. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 13 Health care professionals were very positive about The Beeches both in their survey comments and during discussions we had with them. Their comments included: Staff communicate really well with us, which can only benefit the people in the home The Beeches provides a homely environment for residents with excellent care delivered from committed and friendly staff . The overall feedback from people, relatives and health care professionals is that there has been an all round improvement in levels of care at The Beeches in the last year. One persons representative said twelve months ago things were slipping now its back to normal, if not better. Medication records were up to date with no gaps. All medication was securely stored in the home. Staff said they had received medication training and records were seen of this training having taken place. However people were not fully protected because not all Medicine Administration Records (MAR) were adequate. Some handwritten MAR sheets checked did not contain General Practitioners or two members of staffs signatures alongside any directions regarding the dosage of the medication or the time the medication was to be given. Controlled drugs under the Misuse of Drugs Act were securely stored.However; there was no evidence to show that there had been a recent audit of all medicines stored in the cabinet. We would suggest that audits of all controlled drugs held be carried out on a frequent basis. Controlled drugs of people no longer at the home should be returned as soon as possible to pharmacy or destroyed. People were treated with respect and dignity and addressed by their preferred name. We observed staff interacting in a friendly and pleasant way. Staff took time to explain what task or support they were about to offer people. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have a choice of lifestyle within the home and are able to maintain contact with family and friends ensuring that they continue to be involved in community life. People are able to make choices about daily living and be involved in some social activities. Meals served at the home are of a good quality and offer choice to ensure people receive a balanced diet. EVIDENCE: People said they are able to get up and go to bed when they chose and generally how they spend their day and evenings. They said they often went out with their families. Relatives said they were able to visit at any time and were made to feel very welcome. People and their representatives said that the home is a friendly and lively place this was very evident on the day of our visit. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 15 Some people said they enjoyed the activities available at the home, whilst other people said that they chose not to join in with the activities arranged. Activities were advertised around the home. The home provides a range of activities including quizzes, arts and crafts and bingo. Singers had recently visited the home to entertain people and some people had just been on a shopping trip to a mill. People and their representatives said they thought the amount and type of activities available had improved over the past few months. A new activities coordinator has been employed at the home and people spoke very highly of her. They were all aware that she was on leave the week of our visit and said they were missing her input. Staff were spending time sitting and talking with people but there was a lack of more structured events. The manager said she was hopeful that another activities coordinator could be recruited which would mean that more people are offered the opportunity to take part in a range of social and leisure activities. We observed the meal service at lunch time. The tables were nicely set, the meal service was well organised and people were given plenty of time to enjoy their food. People told us they had enjoyed their lunch. Staff were supporting people, who needed help with their meal, in a sensitive and discreet way. People also said they always enjoy the food and were always offered a choice of meal. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are appropriate systems in place to make sure that peoples concerns/complaints are taken seriously and acted on and to make sure that people are protected from abuse. EVIDENCE: Information about the complaints procedure is available in the home. People told us they know how to make a complaint if they need to and know who to speak to if they are unhappy. The home told us they have had 2 complaints in the last year, no complaints have been referred directly to us. Although we were contacted by a relative who was unhappy with the response they received from the home to the concerns they had raised. This issue has now been resolved. Records are kept of complaints made and action taken to resolve concerns. There are procedures in place to make sure that people are protected from abuse. There has been 1 referral to the adult protection (safeguarding) unit in the last 12 months. This referral is still ongoing but the service has cooperated fully with the ongoing investigation and has met with families and other professionals when requested. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 17 Staff said they are aware of protection polices and procedures. Records were seen of recent adult safeguarding training staff had undertaken. This ensures people who use the service are safe and protected. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a comfortable, pleasant and safe place for people to live. EVIDENCE: The home was clean and free of unpleasant odours when we visited. People and their representatives told us the home is always clean and fresh. The communal rooms on the ground floor are comfortably furnished and the standard of decor is very good. The home has lovely gardens where people can sit when the weather permits. People said they love sitting in the lounge and looking at the wonderful views across the city. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 19 A passenger lift provides access to the first floor. All the bedrooms are single rooms and some have en-suite facilities. People have lots of their personal belongings in their rooms. People told us they have a lockable cupboard in their rooms to store valuables. There are systems in place to reduce the risk of cross infection and staff have received training on infection control. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are enough staff to meet peoples needs. Staff get the training they need to help them understand and meet the needs of people living in the home. People are protected because all the required checks are done before new staff start work. EVIDENCE: People spoke highly of the staff team and said staff always listened and acted on what they said. People said that staff were always available when needed. Staff and the manager confirmed that staffing levels were adequate and that staffing was more stable and the use of agency staff had reduced. This will help to ensure that people receive consistent care from sufficient numbers of well trained staff. The home told us that all the required checks are carried out before new staff start work. Three staff files were checked. The files contained a range of information including two references and a declaration of health and identification. The staff had undertaken a criminal record bureau check (CRB), at the enhanced The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 21 level. This confirmed thorough recruitment practices were in place, which was sufficient to safeguard people. Staff told us they received induction training when they started work and this covered most of what they needed to know. All staff said they get the training they need to keep them up to date and to help them meet peoples needs. Staff said we get lots of training. Over the past 12 months training has taken place on a variety of subjects including the mental capacity act and dementia care .Training has also been provided on safe working practices for example fire safety, moving and handling and infection control. Staff said that they really enjoyed working at the home and got a lot of job satisfaction. All the staff we spoke with said they felt over the last six months staff moral was much improved. Staff said: I love my job; best one Ive ever had I really think Ive achieved something when I leave to go home a night. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 & 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall the management of the home is good, with policies and procedures in place to protect and safeguard people who use the service. EVIDENCE: On the day we visited we were informed by Joanne Walkdon that the previous manager of the home had resigned 3 days ago and that Carol Delaney was to continue to manage the home. Carol Delaney has been acting manager at The Beeches over the past few months. Joanne Walkden confirmed that she would write to us to inform us of these changes and apply for Carol Delaney to be registered as the new manager. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 23 Carol Delaney is a qualified nurse and has many years experience within the nursing and caring profession. She has completed her Registered Managers Award. Staff, people, health care professionals and relatives spoke very highly of the manager. Comments included: She has made a difference to the home she listens and tries to resolve any problems we have She is a very good manager; she is always available to help. Prior to the visit the service had submitted an Annual Quality Assurance Assessment (AQAA). The AQAA was received on time. This shows that the service works in a cooperative manner with us. Unfortunately the AQAA wasnt made available to the inspector before this report was written so the information contained in it cannot be included in this report. The information in the AQAA, when available, will be used by us over the forthcoming year. The management team of The Beeches have ways in which to check out the quality of the service that they are providing. Regular staff meetings are arranged. Minutes of these meetings were seen. People and their representatives said they saw and spoke with the manager of the home on a regular basis. Her door is always open one person said. Satisfaction surveys are regularly conducted. Results of a recent survey were displayed on the notice board in the home. There is evidence that the ethos of the home is open and transparent. Generally the views of both people who use the service and staff are being listened to, and valued. Staff said they have attended training on the Mental Capacity Act and the Deprivation of Liberty legislation. The manager is aware of procedures to follow in relation to this legislation. She confirmed that the home had previously sought advice from their local social services. This was because staff were unclear and wanted clarification on whether they were inadvertently depriving a person of their liberty in how they were nursing the person in their room. No one in the home was being deprived of their liberty when we visited. These systems and staff knowledge will help to ensure that peoples rights are protected and promoted. The home does not have any involvement with peoples finances. If people are not able to manage their own money and do not have someone to help them with this the home will help them to arrange an independent financial advocate. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 24 We looked at a selection of service records. Servicing of the homes utilities and equipment were, in the main, carried out at the required intervals. This will help protect people. However we did find that the timescale for the servicing of the fire alarm system was overdue. Joanne Walkdon assured us that this servicing will be completed within the next week. The fire risk assessment had been reviewed in March 2009. No issues requiring attention were highlighted in the review. Staff said they had received recent fire safety and other health and safety training .A sample of records showed that staff were receiving this statutory training. These measures will promote the safety and welfare of the people. The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 25 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 2 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 The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 26 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 OP7 Good Practice Recommendations Documentation should show that people and/or their representatives have been involved in drawing up and reviewing the care plans. This will mean that people can have a say in how they receive care or support. To protect people we would suggest that audits of all controlled drugs held be carried out on a frequent basis. Controlled drugs of people no longer at the home should be returned as soon as possible to pharmacy or destroyed. To protect people the Medication Administration Records (MAR) should contain General Practitioners, or two members of staffs signatures, alongside any directions regarding the dosage of the medication or the time the medication is to be dispensed. To protect people fire detecting system should be serviced within recommended timescales. 2. OP9 3. OP9 4. OP38 The Beeches Nursing Home DS0000029133.V377901.R01.S.doc Version 5.3 Page 27 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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