Inspection on 27/07/06 for Beech Lodge

This inspection was carried out on 27th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 9 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 13/08/07

Beech Lodge 05/03/07

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 08/07/2008.

CARE HOME ADULTS 18-65 Beech Lodge Beech Lodge 95 Thorkhill Road Thames Ditton Surrey KT7 0UW Lead Inspector Joseph Croft Key Unannounced Inspection 27th July 2006 10:00 Beech Lodge DS0000013564.V305536.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.V305536.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.V305536.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.V305536.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 1st August 2005 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. A small conservatory adjoins the kitchen, and leads into the garden to the rear of the premises. 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. Beech Lodge DS0000013564.V305536.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key Inspection using the Inspection for Better Lives process for the year 2006/2007. This key inspection ensured that all the core standards of the National Minimum Standards for Younger Adults were considered. This inspection was unannounced therefore staff and residents were not informed in advance of the inspection being carried out. The inspection process included a tour of the premises, sampling of residents’ care plans, risk assessments, staff training records and staff recruitment files; other documents sampled included policies and procedures, staff duty rota, menu, medication and records of medicines. Discussions took place with the deputy manager, manager from another home within the organisation who was overseeing the management of the home, staff, and residents who were present at the time of the inspection. During discussions residents stated they were happy living in the home, that the food was good and they liked the staff and activities offered. Residents’ bedrooms viewed had their personal belongings such as televisions, pictures, and stereo equipment. Residents had been provided with a key for their bedroom doors; however, some residents told the inspector they did not want to have a key to their bedrooms. Residents stated that they like the staff, and they help them to make choices regarding their daily lives. Discussions took place with staff on duty at the time of the inspection. Staff were knowledgeable about residents’ care plans, their likes and dislikes, and how to support residents. Feedback was provided at the end of the inspection to the manager of another home within the organisation who was overseeing and supporting Beech Lodge whilst waiting the new manager to take up her post. The inspector would like to thank the staff and residents for their cooperation during the inspection. What the service does well: The Policies and Procedures continue to be well organised and kept in a lever arch folder that is accessible to staff. The recording of medication was being maintained to a good standard. Beech Lodge DS0000013564.V305536.R01.S.doc Version 5.2 Page 6 Care and health plans had information about the individual residents. The menu evidenced that balanced meals are offered to the residents, which include fresh vegetables and fruit. Food is appropriately stored. Records of fridge/freezer and cooking temperatures are maintained. Residents were encouraged and supported to be as independent as they were able. Residents have access to all National Health Services, and all residents have an annual health check undertaken. The home has a satisfactory complaints system to enable residents and their families to raise concerns. What has improved since the last inspection? What they could do better: The registered person must provide to the Commission For Social Care Inspection Surrey Local Office, evidence of what the main diagnosis is for most recently admitted resident to the home, to ensure the staff of the home are able to meet the identified needs, and the home is working within its categories of registration. The registered person must ensure all residents have a statutory annual review. Comprehensive risk assessments must be written for the use of the garden whilst waiting for the replacement of the fence. The washing line in the garden must be appropriately sited so as not to impose unnecessary risks to residents or staff. An action plan of how the home will address the issues raised under Standard 24 must be forwarded to the Commission For Social Care Inspection Surrey Local Office. A handrail must be fitted to the wall side of the stairs to ensure the needs of identified residents are met. The flat roof must be examined to verify the condition of the roof, and have any damage repaired. The registered provider must submit an action plan of how the home is to achieve the minimum of 50 of the staff to obtain the NVQ level 2 or above. The registered person must advise the Commission For Social Care Inspection Surrey Local Office the date the new manager commences, and the appropriate application forms must be completed and Beech Lodge DS0000013564.V305536.R01.S.doc Version 5.2 Page 7 submitted to the Commission For Social Care Inspection for consideration to be registered. 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 DS0000013564.V305536.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.V305536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has regard for ensuring written needs assessments are undertaken prior to admission to the home, however, the home must ensure the information provided is clear. EVIDENCE: The deputy manager stated the home had recently admitted a new resident to the home. The pre-admission assessment for this person was sampled. This included assessments on communication, personal care, health, medical, social functioning, physical and sensory functioning. The deputy manager stated the previous acting manager had devised a care plan from the care managers’ assessment, which was viewed by the inspector. It was difficult to ascertain from these documents the main diagnosis for this resident. A requirement has been made that the registered person must provide evidence of what the main diagnosis is for this resident, to ensure the home is able to meet the identified needs, and is working within its categories of registration. Beech Lodge DS0000013564.V305536.R01.S.doc Version 5.2 Page 10 Beech Lodge DS0000013564.V305536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has clear care plans and risk assessments in place that ensure the needs of the residents are met, however, statutory annual reviews must be undertaken for all residents. Residents are clearly supported by the staff and have independent and active lives. EVIDENCE: Residents’ files sampled during the inspection evidenced that detailed care plans and risk assessments had been completed, and that residents had signed them. Care plans sampled were detailed and clear for the reader to know how to meet the assessed needs of residents. Information in care plans included health care needs, awareness of safety, behaviour, relationships, daily living and social needs, care support and individual goals. The home also uses Person Centred Plans (PCP) for residents. PCPs sampled were written by key workers, along with the residents, and using the language Beech Lodge DS0000013564.V305536.R01.S.doc Version 5.2 Page 12 as stated by residents. The PCP also used picture symbols to further enable residents to understand what had been written. Discussions took place with residents who were present in the home on the day of the inspection, however, due to their low levels of understanding, their responses were limited. Residents spoken to did not fully understand the concept of what a ‘Care Plan’ was. Residents were able to state they are asked what they would like to do, where they want go, and make decisions about their lives. Evidence was viewed that care plans had been reviewed by the home on a six month basis, however, it was observed in one care plan sampled that the last statutory annual review involving other significant professionals had been undertaken on the 6th May 2004. The deputy manager stated this person is due to have this review in August 2006. A requirement has been made that the registered person must ensure all residents have statutory annual reviews. During discussions, it was evident staff had knowledge of the care plans for residents who they key work, and were aware of the need to update them on a six monthly basis, and as and when necessary. Minutes of resident’s meetings evidence that residents are involved in regard to making decisions that affect the running of the home and their daily lives. These are also recorded in their care plans. During discussions, residents stated they can do what they choose to do, which includes activities they wish to partake in and things they like to achieve. Risk assessments sampled evidenced that they are reviewed annually and as and when required, and clearly dated when the next review is to be undertaken. Beech Lodge DS0000013564.V305536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home encourage and enable residents to participate in a range of activities both within the home and the local community. The home offers a healthy balanced diet. EVIDENCE: Residents were encouraged and supported to be as independent as they were able. Activities included attending clubs, day centre, leisure activities, shopping, discos, restaurants and home time for life skills development. During discussions residents stated they enjoy the activities they do both in the home and at the day centres, and they can choose whether or not to partake in them. One resident was excited at the fact they are to commence attending a local day centre. Staff interviewed stated residents are able to make choices in regard to activities they partake in, and are supported when required by staff. Records of activities are maintained in the activity book. Beech Lodge DS0000013564.V305536.R01.S.doc Version 5.2 Page 14 The deputy manager stated that family, advocates and friends are actively encouraged to visit the home, and residents can meet with them in the privacy of their own bedrooms, and go out if they wished to. During discussions, staff stated one resident is currently in a relationship; evidence in regard to education on relationships was viewed in this persons’ care plan. Staff stated all residents have been offered keys for their bedrooms, however, some residents refused to have them. This was confirmed during discussions with residents. Residents also stated that staff knock on their bedroom doors before entering. Residents also stated that they receive telephone calls and read their own mail. The home uses a four-week rolling menu that includes breakfast, lunch and evening meal. The menu was viewed and evidenced that balanced meals are offered to the residents, which include fresh vegetables and fruit. During discussions, residents stated they like the food, and they can have a snack and drink when they choose to. The deputy manager stated when residents do not like a particular days menu, an alternative meal is offered; evidence of records of these were observed in the daily notes. Food stores were viewed and evidenced that food is appropriately stored. Records of fridge/freezer and cooking temperatures were evidenced during this inspection. Staff at the home are responsible for cooking meals; evidence of training in food hygiene and handling was viewed during the inspection. Beech Lodge DS0000013564.V305536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Physical and emotional health care is offered in such a way as to promote residents independence. The residents are protected by the home’s storage, administering and recording medication policies and procedures. EVIDENCE: During discussions staff stated that residents do not require support with their personal care. Key workers offer advice to residents in regard to personal hygiene. Residents are able to choose the time they go to bed and get up in the morning, the clothes they wish to wear and their hairstyles. This was confirmed during discussions with residents. Care plans sampled evidenced residents are registered with the local GP practice, Dentist, Optician, Audiologist, and have access to all National Health Services. Records of appointments are recorded in care plans. Records of annual health checks undertaken were evidenced. Beech Lodge DS0000013564.V305536.R01.S.doc Version 5.2 Page 16 The home has a Medical Policy and Procedure that is followed by staff. Medical records sampled provided evidence that accurate records of medicines dispensed are clearly maintained. The home maintains records of medicines received and returned to the Pharmacist. Medicines are appropriately stored in a locked metal medicine cabinet. The requirement made at the previous inspection has been complied with. Training records sampled evidenced training in the Safe Administration of Medication for staff who dispense medication. Beech Lodge DS0000013564.V305536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system to enable residents and their families to raise concerns. Residents are protected by staff having knowledge and understanding of adult protection issues. EVIDENCE: The home had a Complaints Policy and Procedure in place. The Policies provide the timescales for responding to complainants, and includes the contact details for the Commission For Social Care Inspection Surrey Local Office. During discussions, residents stated they would talk to staff if they were unhappy or wanted to make a complaint. Staff stated they would ensure complaints are taken to the acting manager, or if necessary, would not hesitate to contact the Commission For Social Care Inspection Surrey Local Office. The complaints book was viewed and evidenced there had been no complaints made since 2004. The home’s Protection of Vulnerable Adults Policy was viewed. This provided information in regard to reporting and responding to abuse. This policy was written in 2004. During discussions staff gave an accurate account of what to do if they witnessed or suspected that a resident is being, or had been abused. Staff reported they would have no hesitation reporting bad practice, and if Beech Lodge DS0000013564.V305536.R01.S.doc Version 5.2 Page 18 necessary, they would report their concerns to the Commission For Social Care Inspection Surrey Local Office. Staff training files sampled evidenced training in the Protection of Vulnerable Adults had been provided. Beech Lodge DS0000013564.V305536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The general standard of the environment requires attention to ensure residents are provided with a safe, secure and homely place to live. EVIDENCE: The home was found to be clean, tidy and free from offensive odour. Bedrooms were appropriately furnished and personalised. Two residents showed the inspector their bedrooms. Residents stated that they like their bedrooms and that they are allowed to have their own things. It was noted that there were no lockable facilities in the bedrooms viewed, however, residents stated this was their choice. During the tour of the environment it was observed that some parts of the home require attention to the décor. The bedroom on the ground floor is in need of redecorating, and holes in the wall where shelves have been removed need to be made good. The first floor bathroom had a light shade missing. A requirement has been made that the registered provider must undertake a review of the home’s décor and submit an action plan with time scales of how this will be addressed. Beech Lodge DS0000013564.V305536.R01.S.doc Version 5.2 Page 20 The home has a garden to the rear of property. At the time of the inspection, a new property, not belonging to the organisation, was in the process of being built to the back of the home. It was observed that the fences around the home’s garden had been damaged, and the fence to the rear of the garden had been removed. The home’s handyman stated the building contractors had caused the damage to the fences, and had stated they would replace all the garden fences at the end of the month. A requirement has been made that until the fences have been replaced, comprehensive risk assessments must be written for the use of the garden to ensure the health and safety of residents and staff are protected. It was also observed that the washing line in the garden was stretched across part of the garden at an inappropriate height, and therefore posing a risk to residents and staff. A requirement has been made that the registered provider must ensure the washing line is appropriately sited and does not pose a risk to residents or staff. The stairway has a banister fitted to the one side of the stairs, and no other handrail on the wall side. In view of the needs of one identified resident, it is important to have a handrail fitted on the wall part of the stairs. A requirement in regard to this has been made. During discussions staff stated the flat roof on top of the home requires attention, as this has produced a leak into one of the resident’s bedrooms. The registered person must have the flat roof examined to verify the condition of the roof, and have any damage repaired. Residents have unrestricted access to all shared facilities of the home, including the kitchen. The home has a Control of Infection Policy in place. Beech Lodge DS0000013564.V305536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff training in regard to NVQ needs improving to ensure residents are in safe hands at all times. Residents are supported and protected by the home’s recruitment procedure. EVIDENCE: The staff team is made up of male and female staff. The duty rota was viewed and evidenced there are a minimum of two staff on each shift. During discussions, staff stated that, in their opinion, there are enough staff on duty each shift to cater for the needs of the seven residents currently living in the home. During discussions residents stated there were always staff available to help them, and that they liked all the staff as they would always listen and help them. During the inspection staff were observed to be interacting in a courteous and respectful manner with the residents, listening and responding appropriately, and offering support where necessary. The deputy manager stated no staff employed to work at the home are under the age of twenty-one. Beech Lodge DS0000013564.V305536.R01.S.doc Version 5.2 Page 22 During discussions the deputy manager stated there are currently two members of staff who hold an NVQ qualification. A requirement has been made that the registered provider submit an action plan of how the home is to achieve the minimum of 50 of the staff to obtain the NVQ level 2 or above. The home has a recruitment policy and procedure in place. Staff files sampled evidenced application forms, job descriptions, two references, a satisfactory Criminal Records Bureau, proof of ID and work permits. Staff stated that when they applied for their posts they had to submit a full employment history, the names of two referees and proof of ID. Staff stated they did not commence employment until a satisfactory Criminal Records Bureau clearance had been received. Evidence was viewed that new staff had attended induction training when they commenced employment. During discussions staff stated they had received training appropriate to their role, which included training in challenging behaviour, Equality and Diversity, Mental Health, and all mandatory training. Staff training files sampled evidenced training courses they had attended, however, it was observed that staff did not have an individual training and development assessment profile; a requirement has been made in regard to this. Beech Lodge DS0000013564.V305536.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home does not have a registered manager and is therefore operating illegally. Residents’ finances are safeguarded and health and safety of staff and residents is considered. EVIDENCE: The home has experienced difficulties in recruiting a suitable manager for the home during the last twelve months, and is currently operating without a qualified manager. The registered provider advised the Commission For Social Care Inspection Surrey Local Office of the circumstances as to why the previous acting manager had left the home. The deputy manager and a manager from another home within the organisation are overseeing the management of Beech Lodge. This manager informed the inspector that a manager had been recruited for the home, and the registered person is waiting Beech Lodge DS0000013564.V305536.R01.S.doc Version 5.2 Page 24 for the outcome of the Criminal Record Bureau check and referees. A requirement has been made that the registered person must advise the Commission For Social Care Inspection Surrey Local Office the date the new manager commences, and an application for Criminal Record Bureau clearance must be made through the Commission For Social Care Inspection Surrey Local Office within seven days of their start date. Evidence of quality assurance surveys were viewed during the inspection, and the home had an annual development and business plan for the year 2005 to 2006. Policies and Procedures sampled evidenced they had been reviewed during 2004. Training files sampled evidenced staff had received the mandatory training as required. The following health and safety checks of the home were evidenced during this inspection; fire drills, testing and maintenance of fire detection and prevention equipment, fire risk assessments, legionalla, gas boiler, electrical certificate, portable electrical appliance testing, COSHH register, fridge/freezer and cooking temperatures, weekly monitoring of the hot water outlets. Other health and safety issues identified under Standard 24 must be addressed. Beech Lodge DS0000013564.V305536.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 X 2 2 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 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 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 3 X 1 X 3 X X 3 X Beech Lodge DS0000013564.V305536.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA2 Regulation 14 (1) (d) Requirement The registered person must provide, to the Commission For Social Care Inspection Surrey Local Office, evidence of what the main diagnosis is for the most recently admitted resident to the home, to ensure the home are able to meet the identified needs, and are working within its categories of registration. The registered person must ensure all residents have a statutory annual review. The registered person must ensure comprehensive risk assessments must be written for the use of the garden by residents and staff to ensure their safety at all times. The registered person must ensure the washing line in the garden is appropriately sited and does not pose a risk to residents or staff. The registered person must forward an action plan to the Commission For Social Care Inspection Surrey Local Office of DS0000013564.V305536.R01.S.doc Timescale for action 31/08/06 2. 3. YA6 14 (2) 13 (4) (a) 28/07/06 11/08/06 YA24 4. YA24 13 (4) (a) 28/07/06 5. YA24 23 (2) (a) (b) (c ) 27/08/06 Beech Lodge Version 5.2 Page 27 6. YA24 7. YA35 8. YA35 9. YA37 how the home will address the issues raised under Standard 24. 23 (1) (b) The registered person must ensure a handrail is fitted to the stairs to ensure the needs of identified residents are met. 18 (1) (a) The registered provider must submit an action plan of how the home is to achieve the minimum of 50 of the staff obtaining the NVQ level 2 or above. 18 The registered person must ensure that all staff have an individual training and development assessment profile. 8 (1) (a) The registered person must Section 11 advise the Commission For of The Social Care Inspection Surrey Local Office the date the new Care Standards manager commences, and an Act 2000 application for Criminal Record Bureau clearance must be made though the Commission For Social Care Inspection Surrey Local Office within seven days of their start date. 14/08/06 27/08/06 27/08/06 31/08/06 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 DS0000013564.V305536.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 DS0000013564.V305536.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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