Inspection on 01/07/08 for Beech Lodge

This inspection was carried out on 1st July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beech Lodge 21/01/08

Beech Lodge 13/08/07

Beech Lodge 05/03/07

Beech Lodge 27/07/06

Beech Lodge 01/08/05

Beech Lodge 12/04/05

Beech Lodge 13/12/04

Beech Lodge 22/04/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Beech Lodge Beech Lodge 95 Thorkhill Road Thames Ditton Surrey KT7 0UW Lead Inspector Kenneth Dunn Unannounced Inspection 1st July 2008 09:30 Beech Lodge DS0000013564.V366956.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 Beech Lodge DS0000013564.V366956.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. Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Lodge Address Beech Lodge 95 Thorkhill Road Thames Ditton Surrey KT7 0UW 020 8398 5584 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 Kathleen Jeetoo Mr Y Jeetoo Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The bedroom accommodation on the first floor may be used by fully ambulant persons only The age/age range of the persons to be accommodated will be: 18-65 years 21st January 2008 Date of last inspection Brief Description of the Service: Beech Lodge is a detached property set in a residential road. There are three single bedrooms on the ground floor plus an open plan lounge/dining room, a kitchen, shower room, toilet and a laundry room. The property has been extended recently to provide a new room to the back of the building on the ground floor. It has not yet been decided how this room will be used. On the first floor there are six bedrooms, a staff sleep-in room and a small office. There are separate toilets for staff and residents, and a bathroom. The home provides care and accommodation to adults with learning disabilities. Support can be provided for personal care, daily living skills and activities. The fees vary from £812 to £ £1005 per week depending on the needs of the person. Beech Lodge DS0000013564.V366956.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 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced site visit, which forms part of the key inspection to be undertaken by the Commission for Social Care Inspection, (CSCI) was carried out by Mr. Kenneth Dunn on the 1st July 2008. The CSCI Inspecting for Better Lives (IBL) involves an Annual Quality Assurance Assessment (AQAA) to be completed by the service, which includes information from a variety of sources. This initially helps CSCI (us) us to prioritise the order of the inspection and identify areas that require more attention during the inspection process. This document was received by CSCI and is referred to throughout the report. The registered manager post of the service was vacant at the time of the visit, however a person has been appointed to manage the service. The inspector was informed that this person was in the process of making an application to the commission to become the registered manager of the service. The information contained in this report was gathered mainly from observation by the inspector, speaking with residents, and care staff and from information contained within the AQAA. Further information was gathered from records kept at the home. All records sampled were up to date with care plans being signed by the residents and or by their representatives. What the service does well: The people who now use service are provided with appropriate support and encouragement to enable them to develop their independence skills. The support the individuals receive allows them to maximise their opportunities for activities within the service and in the wider community. The people that live in the service remain happy with the support they receive and feel their needs are met. Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 7 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 Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 8 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): Standard 2 was assessed during this visit. People who use the service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. A change in policies and procedures should now ensures that any prospective resident’s will have a full assessment of their needs completed before they are offered a place in the home. EVIDENCE: In line with a requirement from the previous inspection report (21/01/2008) the service has reviewed it policies to ensure that potential people who might use the service will have a full assessment of needs prior to moving in. The service has not admitted any new individuals since the last site visit by the commission. The Annual Quality Assurance Assessment states that a full audit has been completed by the service to ensure that the existing people who use the service have an assessment of needs on file. A random sample of the individual files of the people who use the service was conducted, and a set of full needs assessment had been completed. The assessments were detailed and contained relevant information to enable the service to design a care plan for each individual. However the assessment on file were not the original pre admission assessments. It was stated that Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 9 because of the length of time the residents have lived at Beech Lodge the original assessments are no longer available. It is therefore recommended that a full audit is completed of all archive files in an effort to track down the per admission information for all the current residents. Beech Lodge DS0000013564.V366956.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): Standards 6, 7, 8 & 9 were assessed during this visit. People who use the service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The people who use the service benefit the development of detailed and individual care plans. Individuals living at Beech Lodge know that the decisions they make are supported. A comprehensive set of risk assessments have been developed for each service user. EVIDENCE: The care plans are drawn up with the involvement of the people who use the service and or their representatives. The care plans sets out in detail the action or actions to be taken by staff to ensure that the individual residents needs are fully met and supported. The care plans sampled indicated that there is sufficient information for the staff to follow to ensure that the needs of the individuals are effectively met. The Annual Quality Assurance Assessment states that the individual is at the centre of all action undertaken by the service. A member of staff stated that Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 11 there is an open dialog between the people who use the service and the staff. It was further stated that if an individual ask for a change or changes to there care plan this will be reviewed and actioned. The service is proactive in ensuring that the people who use the service play a role in the day-to-day running of Beech Lodge and in possible future changes to the service. The Annual Quality Assurance Assessment states that the service conducts regular monthly meeting. The inspector was informed by a senior support worker that this is a time when the “residents can raise issues and discuss any problems. The minutes were sampled they demonstrated that the people who use the service are supported to participate to the best of their abilities. One of the people who live at Beech Lodge is an active participant in the whole process and has assumed to role of minute taker. The service has a series of detailed risk assessment on file to ensure that the people who use the service are safe. A random sample of the risk assessments demonstrated that they receive regular reviews and are updated when necessary. Beech Lodge DS0000013564.V366956.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): Standards 12, 13, 15, 16 & 17 were assessed during this visit. People who use the service experience good quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. People who use the service are encouraged and supported by staff to participate in a range of activities both within the service and the general community. The individuals living at the service are provided with a balanced diet. EVIDENCE: A member of staff stated that the people who use the service all have detailed activity plans that out line their daily activities. The member of staff continued “the staff work with and support the individuals to engage in meaningful activities inside of the service and in the community”. The residents “ are encouraged and supported to attend various activities in the community that include visits to the library, local shops, Kingston Upon Thames for shopping and one resident has a membership for a local gym”. The service maintained a basic daily activities chart that provided some information regarding activates undertaken by individuals living at Beech Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 13 Lodge. The information contained on this chart was however minimal and did not provide appropriate details regarding the activities. Further more during a random sample of four of the resident files only one had a fully detailed activities plan in place. During discussions, the person appointed manage the service and staff it was stated that family and friends are always welcome to visit the home, and there are no restrictions on visits. The residents are encouraged and supported by staff to become involved in daily chores that include helping with the cleaning, laundry, weekly shopping and laying and clearing the tables. During the site visit residents were seen participating in activities around the building. During discussions, the staff on duty informed us that they respect residents privacy and dignity through knocking on bedroom doors, calling individuals by their preferred names and providing personal care in the privacy of their bedrooms and bathrooms. Evidence of these practices was observed during this site visit. The residents spoken with during the site visit confirmed that they have a choice of meals and that they are happy with the food. A member of staff stated that they residents “are supported in the kitchen to make the meals” and that “meetings are held to plan the menu and the residents have a choice of meals for the week”. Beech Lodge DS0000013564.V366956.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): Standards 18, 19 & 20 were assessed during this visit. People who use the service experience adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The resident’s physical, emotional and health care needs are monitored and met. Individual’s choice and dignity is promoted. Medication training has remained an issue for the service. EVIDENCE: During discussions, the staff stated that the majority of the residents require some support with their personal care. Personal support is recorded in care plans, and includes information on how the resident likes to be supported. There is information place stating that personal support takes place in the privacy of residents’ bedrooms and/or bathrooms. This was observed during the site visit. A member of staff stated that whenever necessary the service will arrange appointment with relevant health care professional including general practitioners (GP), chiropodist’s dentists and dieticians. The Annual Quality Assurance Assessment provides information that one resident is being supported by the staff and a dietician with a weight loss programme. This was supported by evidence reviewed during the site visit. Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 15 During discussions we were told that only staff that have received the appropriate training administer the medication. However a random review of staff files and training record did not support this. The person appointed to manage the service stated that all staff had received medication training but was unable to locate any supporting evidence during the site visit. This was subject to a requirement from the previous inspection report (21/01/2008). The Annual Quality Assurance Assessment states that one of the resident was being supported by staff to be self-medicating; this was evidenced during the site visit by risk assessments on file and protocols in place for staff to follow. Beech Lodge DS0000013564.V366956.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): Standards 22 & 23 were assessed during this visit. People who use the service experience adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. Some improvements have been made to ensure that the people who use the service can make a complaint and are safeguarded for harm or abuse. EVIDENCE: The service had a complaints policy in place. The policy had been updated since the previous inspection report by the commission (21/01/2008). The updated policy was however only available in a written format and still failed to make the process of making a complaint easy. The contact information for external agencies was not clear and required the complainer to make the complaint in writing to the relevant person or agency. During discussions with the staff there was an agreement that the service would developed in a userfriendly policy, which would be open to all the resident at the service. Records sampled indicated that staff had attended safeguarding vulnerable adults training (05/05/2008) and for newly recruited staff this had been included in the induction programme and ongoing training provided by the service. Both Criminal Record Bureaux checks (CRB) and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. The home has a copy of the Surrey County Council Multi-agency Procedures for the Safeguarding Vulnerable Adults. One safeguarding referral had been have been made since the previous inspection. Action was taken against the service by the Commission for Social Care Inspection in the form of a statutory requirement notice (18/02/08) and a Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 17 multi agency safeguarding meeting held by the local social services team. As a result the resident involved was re assessed and more an appropriate placement was found to meet her needs. Beech Lodge DS0000013564.V366956.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): Standards 24, 25, 28 & 30 were assessed during this visit. People who use the service experience a poor quality outcome in these areas. This judgement has been made using available evidence including a visit to this service. The people who use this service live in a home, which meets their basic needs. However overall the environment, furniture, maintenance, decoration and in some parts cleanliness of this service are not of a good standard. EVIDENCE: Issue identified during previous inspection visits have still not been met. The previous inspection reports (April 2007, August 2007 and February 2008) made requirements regarding the malodour in the service and the poor flooring in one of the service users bedrooms these have not been actioned. The Annual Quality Assurance Assessment stated that a comprehensive refurbishment of the service had been carried out to the building. However, it was apparent during this site visit that the service was in a poor state of repair and very little had been done to meet the requirements made in previous reports regarding the environment. Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 19 The Annual Quality Assurance Assessment provided evidence that the vinyl floor covering in one of the bedrooms, which had been considered a trip hazard had been removed. The tour of the site confirmed that this had been completed. However the carpet in the bedroom that remained was stained and had a very strong smell of urine. In addition the carpets in the public areas were all heavily stained and soiled. This is unpleasant and unhygienic. The furniture in the sitting room was very low and as a consequence difficult to sit in and get up from. This furniture was also institutional to look at and unsuitable for a domestic setting. The downstairs shower room had been poorly converted and was only accessible to people who were physically able and with no visual impairments. The kitchen required a deep clean as every surface was covered in a film of grease. This has implications for the health and well being of the individuals who live and work at Beech Lodge. The protective plastic transport cover on the fridge had been left on and was ripped and could be considered a potential health hazard. The lean-to extension to the rear of the kitchen, which is the main access way to the rear garden, was used as a storage area for unwanted and broken items of furniture. This area contained, a ripped couch and items of bedroom furniture (chest of drawers). This area also contained the COSHH cupboard, which was a tall slim unit that was not secured to the wall and could be easily knocked over. These issues have health and safety implications for both the individuals who live at Beech Lodge and the staff that work there. This access way needs to be cleared and the COSHH cupboard secured. In one bedroom there was considerable areas of water penetration around the chimneybreast and the area around the washbasin outlet pipe was badly damaged. This is not a pleasant environment for anyone to live in and could have health implications. The environment of Beech Lodge has been an area of concern and has been rated poor to adequate over the last four CSCI inspection reports (25/07/2006 poor, 27/04/2007 poor, 13/08/2007 adequate & 21/01/2008 poor). During discussions with the person appointed by the organisation to manage the service it was stated that further refurbishment work was necessary in order to bring the service up to a good standard. A poor environment has a negative impact on care delivery. Steps taken to correct this have been minimal. Enforcement action to address the areas identified is now being considered. Beech Lodge DS0000013564.V366956.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): Standards 32, 34 & 35 were assessed during this visit. People who use the service experience adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The people who use the service have benefited slightly from a review of the numbers of staff on duty and are normally in sufficient numbers to meet their needs. Staff training and development planning requires further development. EVIDENCE: The staff duty rota evidenced that there were normally sufficient staff on duty at any one time to meet the assessed needs of the residents. However on the day of the site visit only one member of staff was on duty, this person had been sleeping in and was now covering the residents getting up, breakfasting and for some out to day services. The rota indicated that a second person should be on duty but they failed to arrive and had not communicated with the service. As a result the person appointed to manage the service was called in early to assist with the site visit. The Annual Quality Assurance Assessment stated that all staff will “receive mandatory training to enable them to work effectively with the residents” and that “training records will be available for inspection”. It was not possible to Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 21 corroborate these statements during the site visit as the training records were in complete or inaccurate. The service must undertake a review of the training needs of the staff and ensure that if any gaps are identified appropriate training must be sourced to meet the needs of the service. In line with a requirement form the previous inspection report (21/01/02008) Staff recruitment files are now held in the home. A random review of staff files indicated that they contained all relevant documentation, however in two files, gaps in the education and employment histories were found. The person appointed to manage the service stated that he would undertake a full audit all staff files, to ensure that any gaps identified would be discussed with the member of staff and alterations made where necessary. Beech Lodge DS0000013564.V366956.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): Standards 37, 38, 39 & 42 were assessed during this visit. People who use the service experience adequate quality outcomes in these areas. This judgement has been made using available evidence including a visit to this service. The organisation has failed to register the person they appointed to manage the home over 10 month ago with the commission. Internal quality assurance takes place and the views of the resident’s are sought. Policies and procedures are in place to protect the health, safety and welfare of service users and staff. EVIDENCE: A person was appointed on the 8th of October 2007 to manage Beech Lodge he has however not made an application to become the registered manager of the service. Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 23 It was stated that quality assurance is undertaken through the regular service meetings when the views of resident’s are listened to and acted upon. The minutes reviewed during the site visit confirmed that meetings are regular and the residents actively participate in the process. The service undertook a full quality audit in January 2008 the outcomes for the residents appeared good. The health, safety, and welfare of the residents and staff are observed and promoted. There is a range of health and safety policies and procedures in place and staff were seen to adhere to these procedures during the inspection. The Annual Quality Assurance Assessment stated that regulation 26 visits by the organisation are now regularly undertaken and that copies of these visits are now kept on file at the service. Control of Substances Hazardous to Health (COSHH) procedures is maintained and risk assessments are in place for all identified risks and safe working practice. However a review of health and safety certificates highlighted gaps in the information essential to safeguard the residents. In addition the COSHH cupboard as was previously mentioned in this report is a potential health and safety risk because of its height, construction and instability due to not being securely fitted to a wall. Beech Lodge DS0000013564.V366956.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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 1 25 1 26 X 27 X 28 1 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 2 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 2 3 X X 2 X Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 25 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. 1. 2. Standard YA12 YA22 Regulation 16(2)(n) 22(2) Requirement All residents must have detailed activity plans on file. The complaints procedure must be user friendly and designed to allow the residents free access to the process. The cause of unpleasant odours identified and eliminated. The chairs in the lounge are to be replaced to make the using of them easier and the look less institutional and more domestic in style. The following action must be undertaken to improve the environment for the individuals living at Beech Lodge All stained carpets in bedrooms and communal living areas are to be cleaned or replaced. The kitchen is to be deep cleaned. Timescale for action 29/08/08 29/08/08 3. YA30 16(2)K 30/09/08 4. YA24 16(2)c 30/09/08 3. YA24 23 30/09/08 Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 26 The plastic transport cover on the fridge is to be removed. The lean-to extension to the rear of the kitchen and access way to the garden is to be cleared and not used to store unwanted items of furniture. The COSHH cupboard is to be secured to ensure it is not a risk to anyone from toppling over. The cause of the water damage in the bedroom is to be identified, eliminated and the decoration made good. In this same bedroom the area around the washbasin pipe is to be repaired and the decoration made good. 4. YA34 18(1)(a) 5. YA35 An audit of staff files must be completed and any gaps in information requires for the safety of the residents must be explored and rectified. 18(1)(c)(i) Evidence of staff training must be held in the home. The registerd provider must ensure that the person appointed to manage the service is registered with the commission. 29/08/08 29/08/08 6. OP38 8(b) 29/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 27 No. 1. 2. Refer to Standard YA2 YA23 Good Practice Recommendations It is recommended that a full audit be completed of all archive files in an effort to track down any pre admission information for all the current residents. It is recommended that an occupational health assessment is undertaken of the converted shower to ensure it meets the needs of the current service user group. Beech Lodge DS0000013564.V366956.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Lodge DS0000013564.V366956.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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