Inspection on 19/01/06 for Beech Lodge

This inspection was carried out on 19th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beech Lodge 25/09/06

Beech Lodge 14/07/05

Beech Lodge 24/02/05

Beech Lodge 05/08/04

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

CARE HOME ADULTS 18-65 Beech Lodge Guildford Road Broadbridge Heath Horsham West Sussex RH12 3PW Lead Inspector Mrs Jennifer Wright Unannounced Inspection 19th January 2006 09:00 Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 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 DS0000043443.V274069.R01.S.doc Version 5.1 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 DS0000043443.V274069.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beech Lodge Address Guildford Road Broadbridge Heath Horsham West Sussex RH12 3PW 01403 791725 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) Dr Shafik Hussien Sachedina Mr Shiraz Boghani Mrs Corinne Alison Nikolova Care Home 40 Category(ies) of Learning disability (40), Learning disability over registration, with number 65 years of age (1) of places Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users accommodated in Beech Lodge One, Two and Three may also have a physical disability. Service users accommodated in Redwood House are in the category Learning Disability (LD) requiring personal care only. One named service user in Redwood House is in the category Learning Disability over 65 LD(E). 14th July 2005 Date of last inspection Brief Description of the Service: Beech Lodge is situated in a rural area about five miles from the town of Horsham. There are three buildings on the site. There are two single storey purpose built units, Beech Lodge that accommodates twenty people, and a newly built unit, Oak Lodge, that accommodates ten people. In addition there is Redwood House, a detached two storey house that accommodates ten people on the ground and first floor. In Beech Lodge there are four communal areas, plus one double bedroom and eighteen single bedrooms, all of which have en-suite facilities. In Oak Lodge there are ten single en-suite bedrooms. The communal areas are used for activities and there is a separate activities room adjacent to one of the buildings. A spa pool and sensory room are available on the site. The service is privately owned by Sussex Health Care; Dr S Sachedina and Mr S Boghani are the responsible individuals. Mrs Corinne Nikolova is the registered manager reponsible for the day-to-day running of the home. Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second of a minimum of two statutory visits that an inspector must make to each care home during the course of a year. The first inspection, which was announced, was undertaken earlier in the year. At this inspection the Inspector looked at standards that were not looked at during the previous inspection, as well as any outstanding issues from the last report, or concerns raised about the home since the last inspection. Some standards that were assessed at the previous inspection were not assessed on this occasion; the reader is advised therefore to look at the reports of both inspections for a fuller picture of the home. The Manager was present throughout the inspection. During this inspection the Inspector examined records of care being provided to the residents; as well as records of any accidents, issues, or complaints, to make sure that the residents at Beech Lodge were being taken care of. In addition to talking to the Manager, the Inspector spoke with two visitors about how they found the care at Beech Lodge. The Inspector toured all three units during the course of the inspection, observing residents and staff members. At this inspection Beech Lodge was audited against the National Minimum Standards for Younger Adults. All the elements, bar one, in each of the standards assessed were met. A requirement is made in this report for all staff members to receive the necessary fire training. The Inspector would like to thank everyone who cooperated with her on the day of this inspection. What the service does well: The inspector met several residents on the day of inspection, but they were not all able to tell the Inspector what it was like living at Beech Lodge. They were, however, seen to be comfortable, well cared for, and happy. A visitor spoken to on the day of inspection told the Inspector that he had no concerns at all about the care being provided by Beech Lodge. The building is maintained safely, and to a high standard. Records required by the Inspector on the day of inspection, were found to be in order. One visitor to the home told the Inspector that he was made to feel very welcome when he visited the home. The Manager informed the Inspector that Beech Lodge tries not to use agency staff, but if they need to, they try to ensure that the same agency staff members attend in order that the residents know who their carers are, and the carers are aware of the residents’ personalities and needs. Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 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. Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 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 DS0000043443.V274069.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Residents and their families have the information they need to make an informed choice about Beech Lodge. EVIDENCE: Each resident is given a Statement of Purpose and Service Users Guide and a Contract when they enter Beech Lodge. The Manager informed the Inspector that copies of the home’s Inspection Reports are made available for prospective residents’ representatives to read. All of the residents have family, or a solicitor, who act on their behalf. Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion, however these standards were met at the last inspection. EVIDENCE: Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents’ rights are respected and responsibilities recognised in their daily lives. EVIDENCE: The Manager informed the Inspector that residents have their choices recorded at their reviews. Many of the residents are not able to take responsibility for anything, but if a resident is, they are encouraged to do so. Staff members knock before entering residents’ rooms, refer to residents by their preferred choice of name and open residents’ mail with them. Where residents are able to express themselves what they want to do, eg. to go outside or to be left alone, then their wishes are respected. Visitors have unrestricted access during the day. Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 and 21 Residents receive personal support in the way they prefer and require. The residents’ health, personal, physical, emotional and social care needs are well met at Beech Lodge. The ageing, illness and death of a resident are handled with respect, and as the individual would wish. EVIDENCE: The Manager told the Inspector that each resident has a care plan and staff members try and give residents much personal support in whatever they chose to do. This may be with regard to college, shopping, outings, or the spa or the hydra pool. Each resident undertakes a risk assessment, to ensure his or her safety, prior to any activity. Currently there are no residents at Beech Lodge who mange their own medication. Residents choose their own GP, and residents’ relatives are always consulted with regard to the residents’ health. Specialists are consulted where necessary. Staff members assist residents to medical appointments. The Inspector was informed that family or friends are offered a spare bedroom, if available, or a comfortable chair in the residents room, at the end of their life. Following the death of a resident, a memorial service is held at the home at the same time as the funeral, for those residents unable to attend. Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 Page 12 From talking with the Manager, it would appear that Beech Lodge treat residents who are dying, and their family and friends with respect, care and sensitivity. Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Residents feel their views are listened to and acted upon. All complaints are recorded. EVIDENCE: A visitor, spoken to on the day of inspection, stated that they felt their opinions were sought, on behalf of the residents, and that they were listened to. There was one outstanding complaints recorded at the time of the inspection, however the home was seen to be addressing the matter. Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 Residents live in a homely, comfortable and safe environment. EVIDENCE: At the previous inspection it was required that risk assessments with regard to Redwood should be carried out to ensure the safety of the residents who live there. Following that inspection a Fire Officer undertook an inspection and it was seen that following his report Beech Lodge had addressed all the outstanding issues. At this inspection it was seen that there had been some redecoration and refurbishment, including covers on radiators and a new roof on Redwood. In addition much of the grounds have been landscaped, and work is in progress to add a central paved area with raised flowerbeds for residents to work in, and seating, umbrellas etc. During the course of the inspection some of the residents’ bedrooms were visited, and it was noted that many residents had brought personal possessions into the home, including posters and photographs. The bedrooms were seen to be decorated in a way that reflected the personality and needs of the occupant. Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 Residents benefit from clarity of staff roles and responsibilities. Residents’ needs are met by appropriately trained and supervised staff members. EVIDENCE: There were sufficient staff members on duty to reflect the needs of the people living at Beech Lodge. Comments received from the people the Inspector spoke to indicated that relatives of residents feel supported by the home, and would have no hesitation in approaching any member of staff if they had any concerns. Staff members on the day of inspection had a clear picture of the needs and preferences of the residents. Staff members were enthusiastic and were seen to interact well with the residents. The Manager informed the Inspector that each resident has a key worker, and most residents appear aware of the structure of the home. Although it was seen that there is much training for the staff members at the home, there was no evidence that all staff members receive the required fire training. A requirement is made in this report for this matter to be addressed. The Inspector was assured by the Manager that she would look into arranging the training immediately. Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40, 42 and 43 It is apparent that the needs of the residents are uppermost at Beech Lodge, and staff members ensure that residents’, or their representatives’ views are sought and developed by the home. Training, plus external courses and appropriate policies and procedures, tailored to suit the home, ensure that the health, safety and welfare of residents are promoted. Reviews are held at regular intervals and the Inspector noted that these were recorded appropriately. All records are well maintained, in the main. EVIDENCE: A visitor told the Inspector that his views, as to what he felt would be in the person he represents best interest, was always sought. Sussex Health Care has recently introduced the practice of sending monthly computerised accounts of how the residents’ money is spent, to their representative. The Manager informed the Inspector that there are regular staff meetings where minutes are taken. Beech Lodge appears to be run in the best interest of the residents, and staff members are supported by the Manager who is qualified and experienced to run the home. The Manager Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 Page 17 informed the Inspector that Sussex Health Care updates policies and procedures regularly, and that a residents’ questionnaire is produced monthly to seek feedback about the service provided, in addition to a newsletter that Beech Lodge issues monthly. Record keeping, which included care plans, diary notes and daily notes, together with medical and training records were seen to be up to date, and securely kept. The Inspector saw records that showed that not all staff members have received the appropriate fire training, and a requirement is made in this report for this matter to be addressed. Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 Page 18 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 3 2 X 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 3 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 3 32 2 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 X X 3 3 X 2 3 Beech Lodge DS0000043443.V274069.R01.S.doc Version 5.1 Page 19 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 Standard YA42YA32 Regulation 23 Requirement That all staff members receive the necessary fire training. Timescale for action 28/02/06 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 DS0000043443.V274069.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 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 DS0000043443.V274069.R01.S.doc Version 5.1 Page 21 - 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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