Inspection on 13/08/07 for Beech Lodge

This inspection was carried out on 13th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beech Lodge 01/07/08

Beech Lodge 21/01/08

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

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Beech Lodge Beech Lodge 95 Thorkhill Road Thames Ditton Surrey KT7 0UW Lead Inspector Pauline Long Unannounced Inspection 13th August 2007 09:30 Beech Lodge DS0000013564.V345971.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.V345971.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.V345971.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 Miss Audrey Elaine Cooke Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Beech Lodge DS0000013564.V345971.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 5th March 2007 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. Building work is being undertaken to the back of the home, in order to provide more communal space for the service users. 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 fees vary from £700 to £ £1100 per week. Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 09.30 and was in the service for 5.5 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the services and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. Communication with some of the residents was limited due to their communication difficulties. However their apperance and body language evidenced a sence of wellbeing. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The CSCI would like to thank the residents, and staff for their hospitality, assistance and co-operation during the site visit. What the service does well: The residents benefit from a person centred approach to their care and are included in all aspects of the running of the home. Some of the staff team have worked with the residents for some time, and this was reflected in the level of knowledge and understanding of the needs and preferences of the residents and from the positive interactions and relationships observed. Care plans and daily records are person centred, and comprehensive, providing the reader with a good insight into the service users holistic needs and goals. The home promotes and encourages contact with family/friends and the local community. From the evidence seen by the inspector and comments received, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home must ensure the process for assessing care needs is reviewed in order to ensure that all prospective service users have an upto date care needs assessment and that care needs assessments are kept on service users files. Whilst on the whole the risk assessment process at the home is satisfactory. Risk assessments must be reviewed to ensure that each assessed risk has got a clear action plan in place to manage the risk and that these action plans are implememnted and reviewed on a regular basis. Care plans must be reviewed to ensure that all service users care needs during the night are properly recorded, with clear action plans as to how those needs can be met. A care management review must be held in respect of the service user identified at the site visit. All staff at the home must follow the homes procedures in respect of handling, recording and administering medication in order to ensure the health safety and welfare of the service users. The flooring in one of the service users bedrooms must be replaced in order to provide the service user with a clean and more pleasant place to spend time. A programme of formal staff supervisions must be developed and implemented in order to ensure that staff have the support they need to carry out their roles. The staffing arrangements at the home must be reviewed in order to ensure that in order to ensure that service users are protected and that all of their health and personal care needs are met. Waking night staff must be employed at the home. The quality assurance system must be fully implemented in the home. Service users and other stakeholders views must be sought. Regulation 26 visits must Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 7 be undertaken at the home and subsequent reports must be available for inspection. The organisation must review the management arrangements at the home in order to ensure the health, safety and welfare of the service users is continually promoted and protected. 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.V345971.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Improvements are required to ensure that all prospective residents have an up to date care needs assessment prior to being admitted to the home. EVIDENCE: The homes statement of purpose was sampled, and whilst it was easy for the reader to understand there was no evidence to indicate that it had been developed in pictorial or symbol format, which may make it easier for the residents to understand. The document requires updating to reflect the current details of the Commission’s office address and telephone number. The majority of the residents have lived at the home for some time. One new resident has been admitted to the home since the last inspection. Three residents files were sampled. There was no evidence of the homes care needs assessments in any of the service user’s files. One of the files contained a local authority care management care needs assessment. The lack of care needs assessments were discussed with the acting manager, he stated that two of the residents care needs assessments had been archived. He also commented that the most recently admitted resident had been admitted from one of the organisations other homes and that they were aware of their needs, therefore a further care needs assessment was not carried out. Discussions were had in Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 10 respect of residents not being admitted to the home with out a care needs assessment being carried out. It was noted that the home had two vacant beds, and discussions were had in respect of future prospective residents. The acting manager stated that following a referral and after receiving as much information as possible, from the service user, family, care management and any other agencies. A member of staff qualified to carry out a care needs assessments would meet the individual and carry out an initial assessment. Following this assessment, the potential resident would be invited to the home on several occasions, for example, an afternoon, an overnight stay or weekend stay, in order to test the homes suitability. He also commented that the Responsible Individuals would be involved in the decision making in respect of any new admission. A requirement was made at the previous inspection for the home to ensure that one identified service user was issued with a contract of terms and conditions at the home. This service user no longer resides at the home. A requirement has been made in respect of these areas. Please refer to pages 27 and 28 of this report. Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Despite improvements in the care planning and risk assessment process, service users needs are not being appropriately met. EVIDENCE: Three of the residents care plans were sampled. Two of these documents were very user friendly, had been written by the residents with support and encouragement from the staff. Information was provided in both written, pictorial and symbol format and covered all daily living activities, for example, their personal care needs, dietary needs, health care needs and their likes and dislikes around activities and their particular choices around clothing. The care plans gave clear instructions to the reader as to how the care plan was to be followed. They included guidelines in respect of supporting the resident to achieve their individual choices, aspirations and goals. Both of the care plans had been signed and dated by the resident and by a representative from the home. The daily records in respect of an individual’s care plan were Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 12 sampled and evidenced that staff commented on each aspect of the care plan twice in a 24 hour period. The daily records gave the reader a good holistic insight into a resident’s day. One of the residents stated that they had written their own care plan and was happy to discuss it with the inspector. The third care plan had not been completed in a user-friendly format, however the acting manager stated that work was being done in this respect. On the whole this care plan was informative and had clear guidelines as to how needs and goals were to be met during the day. There was no information however as to how the resident’s considerable health care needs were to be managed at night. Risk assessments had been undertaken in this respect, and indicated that the service user was at high risk in respect of their health care needs, however no action plans had been but in place to ensure these risks were minimised. This was discussed with the acting manager at the time. Discussions were also had with the Registered Individual on the 15/08/07 in this respect. He stated that following the Commissions visit he had requested an urgent social services care management review in order to address this residents needs. There are concerns however, that these health care issues had not been identified by the staff at the home prior to the Commission’s site visit and that this individuals needs were not being appropriately met. It is acknowledged that some work had been undertaken in respect of promoting this residents independence and health care in respect of their mobility. Letters and various health care appointments and care management reviews were sampled in this respect. Other risk assessments and guidelines sampled, were comprehensive and included for example, assessments in respect of community awareness and interaction with the public, use of public transport and challenging behaviours. All of the documents had been recently reviewed, were dated and signed by a representative from the home. Requirements have been made in respect of these areas. Please refer to pages 27 and 28 of the report. Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 13 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): 11,12,13,14,15,16,17 People who use the service experience good quality outcomes in this area. The residents are encouraged and enabled to maintain fulfilling lifestyles and have regular contact with family, friends and the local community. Mealtimes were observed as being a positive and pleasant experience for the residents. EVIDENCE: The majority of the residents at the home are somewhat independent. Some of them go out to work on a daily basis. Others are encouraged to attend various day services, for example clubs, day centres, leisure activities and shopping. On the day of the site visit only three residents were at home. Discussions were had with the residents and they commented that they were encouraged to undertake various activities and household chores during the day. One was observed assisting the food delivery driver to bring in the shopping and to put the shopping away. Residents were also encouraged to help clean the kitchen and vacuum the floors. Residents talked about their recent trip to a holiday camp and commented that everyone from the home went. Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 14 The routines in the home were determined only by the timings of the visits to and from the shops, other activities and health care appointments. Care plans and activity schedules recorded the resident’s likes around activities. Care staff commented that the home is committed to ensuring the residents maintain their relationships with their family and friends and that some families visit regularly, others keep contact by phone. There was evidence in care plans and activities schedules to indicate that two of the residents follow their faith beliefs and that they attend services regularly. The menus at the home are provided on a weekly basis, and again were in easy read format. Daily records evidenced that the service users were involved in choosing and cooking meals. One of the residents enjoys cooking chicken curry and another one stated that it was their favourite meal. The menu was sampled and looked well balanced and appropriate for the resident group. Discussions were had with the staff in respect of the resident’s specialist dietary needs, they commented that any specialist needs would be recorded in the care plan. Care plans sampled evidenced this. A lunch time activity was observed, staff were seen to support the residents in a sensitive and dignified way. One resident commented that he was enjoying his lunch. It was noted that the residents were encouraged to clear their dishes away following their meal. Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s health care needs are not being appropriately met. Staff are not adhering to the homes medication procedures. EVIDENCE: Staff, were observed, and were overheard providing various aspects of personal care support for the service users, this support was offered in a manner that promoted the service users dignity and privacy. As discussed earlier in this report one of the service users has considerable health care needs. Discussions were had with this service user and they commented that they were not receiving all of the support and care they required, they commented that due to the staffing arrangements at night they did not see anyone from when they were put into bed at between 8-10pm and 8am the following morning. They stated that the staff, go to sleep at night. This was discussed with the acting manager and the Registered Manager providing support to the home. They stated that the home does not provide waking night staff, as the service users do not require help at night. Further discussions were undertaken in respect of the considerable needs and dependency levels of one service user and the requirement for an urgent review of the staffing Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 16 arrangements to ensure this service user is given the care required. Following the site visit, discussions were also had with the Registered Individual on 15/08/07. He stated that the service had worked considerably hard in order to promote this individuals independence and to meet their needs, he acknowledged however that further work was required in order to ensure their needs were attended to on a 24 hour basis. He stated that following the Commission’s site visit, he had contacted the local social services care management team and requested an urgent review of the service users care needs, in order that provision could be made for waking night staff. He stated that waking staff would be provided at the home with immediate effect. The registered Individual informed the Commission that a date had been arranged for a care management review of this service users needs. This was further evidenced in an email correspondence. Medication practices, storage and records were sampled. None of the service users are responsible for their own medication. The acting manager commented however, that one of the residents may be able to be responsible for their own medication and that discussions with them were being considered in this respect. The storage of medication was safe. It was noted that the one of the medication record sheets had a gap in signatures, and one member of staff was observed to sign the medication record sheet prior to administering a service users medication. These shortfalls were discussed with the acting manager at the time. Discussions were had with the staff in respect of the medication procedures, they had a good understanding of the procedures. They commented that they had received training in respect of safe handling of medications. Records evidenced that this training was undertaken in September 2006. Requirements have been made in respect of these areas. Please refer to pages 27 and 28 of this report. Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The homes complaints procedure requires updating to reflect the current details of the Commission’s Oxford office. Policies and procedures are in place to protect residents from abuse. EVIDENCE: The commission has not received any complaints about this service since the last inspection. Discussions were had with the acting manager in respect of any complaints received at the home, he could not recall a complaint being made. The homes complaints records were sampled and evidenced that the last complaint documented was in 2004. Discussions were had with the Registered Individual on 15/08/07 in respect of the conflicting information in the Annual Quality Assurance Assessment document. He explained that the complaint referred to in this document was an old complaint that was ongoing. The home must review the process for recording complaints, in order to ensure there is clarity in respect of the records. The complaints procedure was sampled and whilst it was easy to read and understand it must be reviewed, as it is out of date, it must reflect the current details of the Commission’s office and phone number. The procedure is displayed in all of the service users bedrooms and in other areas throughout the home and is available in written and pictorial and symbol format, which makes it easy for the service users to understand. One service user spoken Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 18 with commented that, if they needed to make a complaint they would tell the staff on duty. The home has a safeguarding adults policy and procedure. Discussions were had with the staff in this respect and scenarios put to them about potential safeguarding issues, they demonstrated a good understanding of the procedures to be followed in regard to suspected abuse. The acting manager stated that no safeguarding referrals had been made since the previous inspection. The completed Annual Quality Assurance Assessment document stated that one referral had been made to the local authority in respect of a safeguarding issue. Discussions were had with the Registered Individual on the 15/08/07, he explained the safeguarding issue referred to in the Annual Quality Assurance Assessment document was an ongoing one, which the Commission was aware of and that it has yet to be resolved. The need for clarity in respect of these issues was discussed. Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Improvements have been made in respect of some areas of the environment, however further work is required to ensure the service users live in a clean and hygienic home. EVIDENCE: The environment provides the owners considerable challenges in respect of the upkeep and maintenance of the property, and requirements were made at the previous inspection. Some work has been undertaken in this respect in the last year. The communal areas including the sitting/ dining room have been decorated, new furniture and curtains have been bought. The acting manager stated that they had plans to change the carpets in the sitting/dining rooms in the near future. It was noted that the carpets were soiled in some areas of the room. The laundry room floor has been sealed, repairs have been undertaken in the downstairs shower room. A ground floor extension is being built to the back of the property, the acting manager commented that it would provide more communal space for the service users. Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 20 A requirement was made in respect of malodour in a service users bedroom. The actions taken in this respect were unsatisfactory. A piece of lino had been placed over the carpet in the area of the room where the malodour originated. This lino presented a considerable trip hazard and did nothing to promote a service users dignity and the malodour was still noticeable. A requirement was made in respect of the sinks in two of the service users bedrooms. The subsequent action plan submitted by the owners stated that this requirement would be met in May 2007, the requirement remains unmet. Improvements have been made to the rear garden, the area is now more secure and safer for the service users to use. It was noted that a drain to the front of the property was blocked and overflowing, a member of staff proceeded to unblock it, and commented that it was full of leaves. It was also noted that the disabled access to the front of the property was somewhat steep and may require adjustment to ensure that wheelchairs users and others can enter and exit the home safely. Requirements have been made in respect of these areas. Please refer to pages 27 and 28 of this report. Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34, 35,36 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are protected by the homes staff recruitment and selection procedures and practices. Improvements are required in respect of the staffing arrangements at night. EVIDENCE: There was evidence of a diverse staff group in respect of gender and nationality. Staff files are not kept at the home, they are stored at the organisations head office. There was a form relating to each member of staff in respect of the checks carried out prior to recruitment. The forms evidenced that all the required documentation and checks in respect of service users safety were in place, for example CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks. The completed Annual Quality Assurance Assessment document stated that all of the people who work in the home have had satisfactory employment checks. As discussed earlier in this report, the home has recently admitted a service user with a much higher dependency level than the other service users. The service user commented that because the home does not provide waking night Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 22 staff, they put them to bed between 8 and 10 pm and that they do not check on the service users again until 8am the following morning. Discussions were had with the Acting Registered Manager, who provides support to the home. He stated that he was not aware of this individuals high dependency levels. He was advised that the arrangements in place for staffing the home at night require urgent review, and that staff must be available to ensure that this individuals care needs are met. Care staff commented that the service user has access to a call bell and that it would alert the sleeping in staff if the service user called for help. They also stated that the service user does not use the call bell. It was noted that the service user had a call bell, she commented that she did not use it because staff would be asleep. The completed Annual Quality Assessment document stated that one service user requires the support of two or more staff to help with their care during the day, however nothing was recorded for night care. Following the site visit the Registered Individual stated that he would provide waking night staff with immediate effect, he emailed the commission in this respect. Discussions were had with the staff in respect of the training provided at the home. They commented that they had undertaken training in respect of challenging behaviours and epilepsy awareness earlier in the year. This training was evidenced in the staff training records. There was evidence of POVA training in October 2006. There was no documented evidence that further training had been undertaken since the last inspection. The completed Annual Quality Assurance Assessment document stated that 3 members of staff at the home have achieved an National Vocational Qualification level 2 or above and that 2 staff are working towards a National Vocational Qualification level 2. A requirement was made at the previous inspection in respect of all staff receiving a minimum of six one to one supervision meetings a year. This requirement has not been met. Discussions were had with the acting manager in this respect, he stated that he was aware of the need to undertake staff supervision, however he commented that he works part time and that he had been focusing on developing the service users care plans and did not have the time to carry out staff supervisions. Requirements have been made in respect of these areas. Please refer to pages 27 and 28 of this report. Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39, 41,42 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are not protected by the management arrangements at the home. EVIDENCE: The home does not have a manager in place and has been without stable management for approximately 2 years. The acting manager resigned in April 2007 and the providers have not yet been successful in recruiting a new manager. One of the senior care staff at the home is the acting manager, however he only works part time. The completed Annual Quality Assurance Assessment document stated that the home has good management support from an external consultant and from the head office staff. The senior carer on duty stated that the home was overseen by the Registered Manager from one of the organisations other homes. It should be noted that this manager has Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 24 responsibility for overseeing three homes in the absence of the providers. Care staff spoken with, commented that it was difficult not having a stable manager at the home and whilst the acting manager was good he was not there on a full time basis. They commented that they and the service users needed support and continuity. As discussed earlier in this report there are concerns in respect of the management’s failure to identify the need for more staff input to ensure the needs of one service user was met. It should be noted that issue was not addressed until the commission had highlighted it at the site visit. The completed Annual Quality Assurance Assessment document stated that the home has a quality assurance monitoring system in place, although it has not been fully implemented. Service user surveys are sent out, however the last undertaken in May 2006. There was evidence that some monthly visits had been carried out by the providers, however the last documented one on file had been carried out in November 2006. Discussions were had with the organisations head office in this respect and they confirmed this date of November 2006 was accurate. Health and safety checks are carried out routinely, with clear and accurate records kept. These records were sampled and evidenced that fire equipment, electrical equipment, and the nurse call systems had all been checked in the last two months. Detailed and comprehensive risk assessments were in place for the environment, however it was noted that a risk assessment had not been undertaken in respect of the building work at the home. Requirements have been made in respect of these areas. Please refer to pages 27 and 28 of this report. Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 25 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 2 2 1 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 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 1 34 2 35 2 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 1 2 x 1 1 1 2 X 1 x Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 12(1)(a) 17 Schedule 3 Requirement The home must ensure the process for assessing care needs is reviewed to ensure: (a) Care needs assessments are carried out on all prospective service users. (b) Service users care needs assessments must be kept on their service files. Risk assessments must be reviewed to ensure that each assessed risk has got a clear action plan in place to manage the risk. Care plans must be reviewed to ensure that all service users care needs during the night are properly recorded, with clear action plans as to how those needs can be met. The service must make proper provision for the health and welfare of service users. A care management review must be held in respect of the service user identified at the site visit. All staff at the home must follow the homes procedures in respect of handling, recording and administering medication. DS0000013564.V345971.R01.S.doc Timescale for action 13/09/07 2. YA9 13(4(b(c 13/09/07 3. YA6 15(1) (2)(a(b) 13/09/07 4. YA6 12(1)(a) 13/09/07 5. YA20 13(2) 13/09/07 Beech Lodge Version 5.2 Page 27 6. YA30 23(2)(d) 16(2)( c) 7. YA36 18 (2) 13(6) All areas of the home must be kept clean and free from malodour. The flooring in one of the service users bedrooms must be replaced. A programme of formal staff supervisions must be developed and implemented. All staff must receive supervision meetings with a manager. Previous timescale of 05/04/07 not met. There must be waking night staff working at the home in order to ensure that service users are protected and that all of their health and personal care needs are met. The quality assurance system must be fully implemented in the home. Service users and other stakeholders views must be sought. Regulation 26 visits must be undertaken at the home and subsequent reports must be available for inspection. The organisation must review the management arrangements at the home in order to ensure the health, safety and welfare of the service users is continually promoted and protected. 13/09/07 13/09/07 8. YA33 12(1)(a) 13(4)(c ) 13/09/07 9. YA39 24 13/09/07 10. YA39 26 13/09/07 11. YA37 YA23 8 13/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beech Lodge DS0000013564.V345971.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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.V345971.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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