Inspection on 05/03/07 for Beech Lodge

This inspection was carried out on 5th March 2007.

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 8 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 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

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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 Joseph Croft Unannounced Inspection 5 March 2007 10:00 th Beech Lodge DS0000013564.V329994.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.V329994.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.V329994.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 To be confirmed Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Beech Lodge DS0000013564.V329994.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 27th July 2006 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. The fees vary from £700 to £ £1100 per week. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 5th March 2007 using the new ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspector Mr Joe Croft conducted this visit and the acting manager who was representing the establishment assisted him throughout. The visit took place over a period of six hours commencing at 10:00 and concluding at 16:30. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the staff duty rota, menu, residents’ monies, policies and procedures and records of medication. The Inspector had discussions with the acting manager and two members of staff on duty. The Inspector also had discussions with two residents and he observed staff interaction with residents during the inspection. Feedback from residents was complimentary about the home and the standard of care they receive from the staff. Both residents and staff were complimentary about the acting manager of the home. The pre-inspection questionnaire completed by the home, and comment cards received from residents, their relatives and other associated visiting professionals have been used as a source of evidence in this report. The inspector would like to thank the acting manager, staff and residents for their cooperation during this visit. Feedback was provided to the acting manager at the end of the inspection. What the service does well: Staff in the home encourage residents to participate in a range of activities both within the home and the local community. A healthy and balanced diet is provided for residents. Physical and health care is offered in such a way as to promote residents’ independence. Residents are protected by the home’s storage, administration and recording of medication. The home has a satisfactory complaints system in place to enable residents and their families to raise concerns. Residents are protected by staff having knowledge and understanding of adult protection issues. Residents are supported and protected by the home’s recruitment policy and procedures. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2 and 5 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The policy and procedure for pre-admission assessments ensure prospective residents needs and aspirations are identified and met. EVIDENCE: The home has not had a new admission since the previous inspection. The acting manager explained the admissions procedure that would be followed. This included requesting a full needs assessment from the care manager, from which it would be determined if the home could meet the prospective resident’s needs. Prospective residents would be invited to visit to the home for a meal, and further day visits would be encouraged prior to residents moving into the home. Reviews would be undertaken after three months. The acting manager stated that the registered provider would be involved in the decision making in regard to admitting new residents. The home had a Referral and Admissions Policy and Procedure dated 10th December 2004, which the acting manager stated is due to be reviewed. During the random sampling of care files it was noted that one resident did not have a current written contract or statement of terms and conditions. A requirement in regard to this has been made. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has care plans and risk assessments in place, however, care plans must be reviewed on a regular basis to reflect the changing needs of residents. EVIDENCE: Two care files were sampled as part of the case tracking process. These provided evidence that care plans and risk assessments had been completed, and residents had signed them. Care plans sampled included information in regard to religion, personal care needs, daily living assessments, medical history, nutrition and monthly weights. One care plan did not have evidence that it had been reviewed on a regular basis. The acting manager informed the inspector that it had recently been reviewed, but could not provide an explanation as to why this had not been recorded. It was also observed that one identified resident receives one to one support, however, it was not clear as to how many hours per week this should be, or who was funding it. A requirement has been made that dates of reviews of care plans are clearly Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 10 recorded, and the one to one support for the identified resident must be clarified to detail the hours and funding. The acting manager informed the Inspector that she had only been in her post for six months, but she would be undertaking a full audit of all care plans to ensure the dates of reviews are clearly recorded, and the current needs of residents are being met. The requirement in regard to statutory annual reviews being undertaken had been complied with. The home had began to use Person Centred Plans (PCP) for residents, but on the day of the inspection the PCPs for the two identified residents had not been completed by the key workers. During discussions the acting manager informed the inspector that work is ongoing, and these will be completed for all residents. The residents who were part of the case tracking process did not want to converse with the Inspector. However, two other residents did take part in a discussion with the inspector. Due to their low levels of understanding residents 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. Members of staff were able to give an account of the contents of the care plans for the residents with whom they key work, and were aware of the need to review care plans on a regular basis. Staff informed the Inspector that they encourage residents to make choices about their lives, the activities they like to do and the food they like to eat. Minutes of resident’s monthly meetings show that residents are involved in regard to making decisions that affect the running of the home and their daily lives. Risk assessments were in place and had been signed by residents. Risk assessments had been reviewed in February and March 2007. The acting manager informed the Inspector that there have been difficulties finding advocates for residents, but she is having regular contact with the local advocacy organisation who are currently having a recruitment drive. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 were assessed. 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 residents to participate in a range of activities both within the home and the local community. A healthy and balanced diet is provided for residents. EVIDENCE: Residents continue to be encouraged and supported to be as independent as they are able. Activities included attending clubs, day centres, leisure activities, shopping, restaurants and time for life skills development. During discussions residents informed the Inspector 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. Staff interviewed stated residents are able to make choices in regard to activities they partake in, and are supported when required. Records of activities are maintained in the activity book. Residents had recently enjoyed a week at a popular holiday campus, and they plan to return there later this year for another holiday. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 12 Residents’ family and friends are encouraged to visit the home, and residents can meet with them in their privacy of their bedrooms. During discussions, residents informed the Inspector they had been given keys for their bedrooms, but they choose not to use them. Residents are supported to undertake household chores that include cleaning their bedrooms, sorting their laundry and helping with the cooking of meals. Staff informed the Inspector that they promote residents’ privacy and dignity through treating them as individuals, promoting their independence and knocking on bedroom doors. Two residents follow their religious beliefs and attend church services on a weekly basis. During discussions, staff informed the Inspector they support residents to prepare and cook food from their cultural backgrounds. The acting manager has changed the way the menu operates for the home. At the beginning of each week residents meet to discuss the following weeks menu. Each resident has a day when, with staff support, they cook the evening meal for all residents and staff. The menu was viewed and evidenced that balanced meals are offered, which include meat, fish, pasta, fresh vegetables and fruit. It was noted that the choice for breakfast is not recorded on the menu, or the packed lunched residents take to the day centres. A good practice recommendation has been made that these records should be maintained as a source of evidence of the foods taken by residents. The home had an inspection undertaken by the Environmental Health Officer in January 2007; the registered provider is addressing recommendations made during that inspection. Sampling of staff records provided evidence that staff had received training in food hygiene. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Physical and health care is offered in such a way as to promote residents’ independence. Residents are protected by the home’s storage, administration and recording of 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, and attend Dentist, Optician, and access all National Health Services. Records of appointments and annual check ups are recorded in care files. It was noted the needs of a resident who has been refusing medical treatment is being addressed by the home through the involvement of health care professionals, the care manager and staff of the home. Records of monthly monitoring of weights are maintained. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 14 During discussions, residents informed the Inspector that they see the GP when they need to, and get their medication on time. The home has a Medical Policy and Procedure that is dated December 2004. The home uses the blister packs that are provided by the local pharmacy, and Medical Administration Record sheets (MARs) for the recording of medicines. The home maintains records of medicines received and returned to the Pharmacist. Medicines are appropriately stored in a locked metal medicine cabinet. The MAR records for residents who were part of the case tracking process were accurately maintained. Training records sampled evidenced training in the Safe Administration of Medication for staff who dispenses medication. The acting manager informed the Inspector that refresher training is to be provided for all staff, including herself, during March 2007. The home maintains a copy of specimen signatures of staff administering medication. The acting manager informed the Inspector that no current resident self-medicates, or has been prescribed a controlled drug. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 were assessed. 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 in place 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 has a Complaints Policy and Procedure that includes time scales and the Commission For Social Care Inspection Oxford Area Office details. A copy of this is displayed on the notice board in the entrance to the home, and in each resident’s bedroom. The procedure uses symbols and simple words that enable residents to easily understand. During discussions residents informed the Inspector they would make complaints to the acting manager of the home. The complaints book was viewed and evidenced there had been no complaints since the previous inspection. The home has a Protection of Vulnerable Adults Policy and Procedure. The acting manager and staff were able to give an accurate account of the procedures to be followed in regard to abuse and/or suspected abuse. All stated that the Surrey Multi- Agency procedures would be followed. All staff had received training in regard to Protection of Vulnerable Adults on the 18th October 2006. The home has a copy of the Surrey Multi-Agency Procedures of February 2005 that is available for staff to read. Information provided in the pre-inspection questionnaire informs that the home has a Whistle Blowing Policy. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 16 The home currently has a Protection of Vulnerable Adults issue ongoing, which is due to be concluded on the 21st March 2007. The Inspector had further discussions with the acting manager in regard to the recording and immediate reporting of abuse. The current investigation commenced before the acting manager took up her post, but she informed the Inspector that the correct procedures would be followed in regard the recording and reporting of Protection of Vulnerable Adults issues. Each resident has his or her own bank accounts. The home holds a small amount of money for residents. Monies held by the home balanced with the records maintained. The home has a policy in regard to the management of residents’ money. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 28 and 30 were assessed. 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: A tour of the premises was undertaken. Requirements made at the previous inspection in regard to the environment had been complied with, however, other issues were identified during this site visit. The lounge had recently been decorated, and new curtains and sofas had been provided. It was observed that the doors leading to the garden from the lounge were not secure, and had two holes at the bottom of these doors, which allowed a cold draft to enter the room. During discussions, the acting manager informed the Inspector that she is looking at the general décor of the home, as some of it is now in need of Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 18 attention. This would be included in the annual development plan that is currently being written for the home. Residents have their own bedrooms that are appropriately furnished and personalised. It was noted that a recommendation made during the Regulation 26 visit of December 2006 in regard to the replacement of one resident’s mattress had not been complied with. Bedroom number 8 had an offensive odour that must be attended to. Requirements in regard to these have been made. Residents spoken to informed the Inspector that they like their bedrooms. There are no lockable storage facilities in bedrooms, however, residents stated that this was their choice. The ground floor shower room requires attention to the tiles and loose plaster over the window. The shower does not work and requires repairing and/or replacing. Bedrooms number 6, 8 and the laundry have badly stained sinks that must be repaired/replaced. Vents in the bathrooms and toilets require cleaning, and the vent in the staff toilet requires attention, as it is not fully sealed. The home has a communal garden to the rear of the premises that is accessible by residents. Requirements made at the previous inspection in regard to the garden have been complied with, however, it was noted that the paving slabs outside the back door have become uneven and require attention. The home has a laundry room with a washing machine and tumble drier. It was observed that the covering on the laundry floor requires attention to ensure it is fully sealed and impermeable to prevent the spread of infection. A requirement has been made in regard to this. Staff training files sampled on the day of the inspection evidenced that training in regard to Infection Control had been undertaken. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 and 36 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staff team supports residents to ensure their needs are met. Residents are supported and protected by the home’s recruitment policy and procedures. 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, and there is a sleep in duty each evening. The home employs a domestic cleaner who attends the home three days each week. During discussions staff informed the Inspector that, in their opinion, there are enough staff on duty each shift to cater for the needs of the six residents currently living in the home. The acting manager stated that a third member of staff is used for external activities and at weekends when trips further away from the local community take place. During discussions residents informed the Inspector that there were always staff available, and they liked all the staff as they would always listen and help them. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 20 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. Two members of staff hold the NVQ level 2, one holds the NVQ level 3 and one member of staff is as a qualified nurse. Information provided in the preinspection questionnaire informs that training received by staff during the last twelve months has included dual diagnosis, managing challenging behaviour, epilepsy awareness and basics mental health awareness. The home has a Recruitment Policy and Procedure in place. The home has not recruited any care staff since the previous inspection. Staff recruitment files were sampled at the previous inspection, and provided evidence that the appropriate recruitment process had been followed, which included completed application forms, job descriptions, two references, a satisfactory Criminal Records Bureau, proof of ID and work permits. The acting manager informed the Inspector that the organisation is to seeking the views of residents in regard to being included in the recruitment process. During discussions staff stated they had received training appropriate to their role. Staff training files sampled on the day of the inspection evidenced training courses attended. Staff informed the inspector that formal one to one supervision has not been taking place on a regular basis. This was confirmed during discussions with the acting manager. A requirement in regard to this has been made. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39, and 42 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The arrangements for management and administration ensure the home is run in the best interests of residents, however, the manager must ensure their skills and knowledge are continously updated. EVIDENCE: The home has experienced difficulties in recruiting and maintaining a manager for the home during the last twelve months. The current manager has been in post since August 2006, and to date has not made an application to register. Further discussions took place in regard to this during which the acting manager stated she had completed the application forms and would submit them to the Central Registration Team. The acting manager informed the Inspector that she has ten years experience teaching adults with Learning Disabilities (LD), and had two years experience working as a senior support worker in a care home for adults with LD. She Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 22 holds the NVQ level 3, and is currently undertaking the NVQ Registered Managers’ Award (RMA), which she hopes to complete within the next twelve months. The acting manager informed the Inspector that she has attended training in regard to Protection of Vulnerable Adults; however, she had not received training in Manual Handling, Infection Control or Supervision of staff. A requirement has been made that the registered person must ensure the acting manager undertakes periodic training to maintain her knowledge, skills and competence to ensure the safety, health and wellbeing of residents. During discussions staff informed the Inspector that they have confidence in the acting manager, she has an open door policy in regard to management, and that she works with the residents. Residents informed that they like the new manager and the changes she has made. Quality assurance is undertaken through annual surveys of residents, relatives, friends and associated visiting professionals. The Inspector viewed the summary of the quality assurance during the previous inspection. Minutes of monthly residents meetings were viewed and showed that residents are consulted about the running of the home. Staff training files sampled included training in regard to Fire, Infection Control, Medication, First Aid at Work and Food Hygiene. The pre-inspection questionnaire forwarded to the Commission For Social Care Inspection Surrey Local Office informed that annual health and safety checks are up to date. The acting manager informed the Inspector that she is waiting for the water company to confirm an appointment to visit the home to undertake an assessment in regard to Legionella. The home maintains weekly checks of the water temperatures. On the day of the inspection the records of fire drills, fire risk assessments, fire training, Control of Substances Hazardous to Health (COSHH) risk assessments and the Environmental Health report were viewed. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 2 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 1 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 3 X Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 24 No 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 YA5 Regulation 5 (1) (c) Requirement The Registered Person must ensure the identified resident has a current written contract with the home. The Registered Person must ensure that dates of reviews of care plans are clearly written. The Registered Person must resolve the issues in regard to the one to one support for the identified resident. The Registered Person must forward to the Commission For Social Care Inspection Surrey Local Office, an action plan with timescales of how the identified issues in regard to the environment of the home are to be achieved. The Registered Person must ensure the offensive odour in the identified bedroom is eliminated. The Registered Person must have the laundry floor is sealed to ensure it is readily cleanable to prevent the spread of infection. Timescale for action 05/04/07 2. 3. YA6 YA6 15 (2) (b) 12 (1) (b) 05/04/07 05/04/07 4. YA24 23 (2) (b) (d) 05/05/07 5. 6. YA30 YA30 16 (2) (k) 13(3) 05/04/07 05/04/07 Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 25 7. YA36 18 (2) 8. YA37 9 (2) (b) (i) The Registered Person must 05/04/07 ensure all staff receive a minimum of six one to one supervision sessions per year. The registered person must 05/05/07 ensure the acting manager undertakes periodic training to maintain her knowledge, skills and competence in managing the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA17 Good Practice Recommendations Records of all foods taken by residents should be maintained as a source of evidence. Beech Lodge DS0000013564.V329994.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Oxford Area Office Burgner House 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.V329994.R01.S.doc Version 5.2 Page 27 - 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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