Inspection on 16/08/05 for Beech Lodge Nursing & Residential Home

This inspection was carried out on 16th August 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beech Lodge Nursing &... 26/06/06

Beech Lodge Nursing &... 05/12/05

Beech Lodge Nursing &... 28/02/05

Beech Lodge Nursing &... 05/10/04

Beech Lodge Nursing &... 22/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Beech Lodge Rakeway Cheadle Stoke-on-Trent Staffordshire Lead Inspector Lynne Gammon ST10 1RA Announced 16 August 2005 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 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 Older People. 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 E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Beech Lodge Address Rakeway Road Cheadle Stoke-on-Trent Staffordshire ST10 1RA 01538 753676 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Minehouse Ltd CRH 31 Category(ies) of DE(E) - 6 registration, with number OP - 31 of places PD - 1 PD(E) - 31 Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1) PD minimum age 60 years Date of last inspection Brief Description of the Service: Beech Lodge Nursing Home is situated in a rural location close to the market town of Cheadle in the Leek Moorlands area. The home is a 31-bedded establishment providing personal and nursing care to frail elderly persons over the age of 65 years and younger physically disabled persons over the age of 50 years. There is an adequate skill mix of staff including first level trained nurses and trained care staff, ancillary staff, administrative support and a handyman. The home provides links with specialist health care professionals including General Practitioners, district nurses, dentist, chiropodist, optician etc. Service users are accommodated in ground floor rooms (mainly single). A limited number of double rooms and en suite rooms are available. The establishment offers two lounges and a dining room for the benefit of service users. There are designated areas for smokers away from the main communal areas. The home can be accessed via private transport and has car-parking facilities at the front and another car park located next to the laundry building. It can also be accessed by bus and the train station is located in the nearby town of Cheadle. The home employs a part time activities co-ordinator who organises a programme of activities, trips out and in-house entertainment. Links with the community are encouraged and service users participate in local events. The home has a Statement of Purpose and Service User Guide which requires updating for the attention of prospective service users and their families. Visits to the home are welcome prior to admission. Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced visit was made on the 16th August 2005 at 10.00 a.m. The inspection was carried out by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. The total time spent for the inspection, including pre and fieldwork, amounted to 12hrs. The manager, Mr Tim Mellors, was in charge of the home on the day of the inspection plus 1 trained staff and 5 care assistants in the morning, 1 trained staff and 3 care assistants in the afternoon and 1 trained staff and 2 care assistants on night duty. Other ancillary staff on duty that day included: an office administrator/activities co-ordinator, a catering manager, a kitchen assistant, 3 housekeepers, a laundry assistant and a handyman. (A private gardener mowed the lawns as and when required). The numbers, skills and experience of staff on duty were adequate to meet the needs of those service users living in the home that day. The inspection included a tour of the building, inspection of records, observation, and discussions with service users, relatives and staff. Since the last inspection on 28th February 2005, one complaint had been received by the home and had been dealt with in accordance with the complaints procedure. No incidents or reports of abuse of any kind had been received by the home or the Commission for Social Care Inspection. Three requirements and two recommendations, against the regulations or the minimum standards, were outstanding from the last inspection report. The Statement of Purpose and Service User Guide needed updating to provide prospective service users with sufficient information to make a choice about where to live. The manager or a designated registered nurse carried out preadmission assessments and generally identified a broad range of needs, but more information was needed in terms of social interests, hobbies and dietary preferences in order to ensure all aspects of care needs could be met. Trial visits were offered to all prospective service users who were welcome to look around the home with their relatives and/or stay for lunch. It was clear that efforts had been made to improve the care planning processes in the home, however, changing health care needs should be reviewed regularly to ensure needs were consistently being met. Good standards of care were being delivered and service users confirmed that they were treated with respect, privacy and dignity. There was a safe system for the receipt, storage, and administration of medicines. Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 6 The home was generally maintained to a satisfactory level, but some attention was required to improve the standard of decorating in some areas. The heating in particular needed urgent attention and although the radiators were guarded, some of the pipe-work was not and required urgent lagging to protect service users and staff from harm. Indoor and outdoor communal facilities were available for service users and there was, overall, good access for wheelchairs throughout the home and grounds. A range of specialist equipment was available to meet the needs of the service users, bedrooms were individually personalised, the laundry was well organised and the home was very clean. Menus were balanced and nutritious, with choices available to meet a range of needs. The home had been without a registered manager for some time and certain areas had suffered because of this e.g. mandatory training, induction training and formal staff supervision had not taken place. Service users who were able, could make their own choices and decisions about the day-to-day activities within the home. What the service does well: What has improved since the last inspection? A lot of effort had taken place to improve the care planning processes within the home and systems had been updated. Some bedrooms had been redecorated to a reasonable standard. Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 7 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 E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 5 More detailed and up-to-date information was required to enable prospective service users to make a decision about the suitability of the home. Preadmission assessments were carried out for service users prior to moving into the home and they were welcomed to visit the home beforehand before making a decision to stay. EVIDENCE: The Statement of Purpose and Service User Guide were examined and did not contain all of the required elements to provide prospective service users with the information they needed to make a choice about where to live. It is, therefore, a requirement of this report that the Statement of Purpose and the Service User Guide is reviewed and updated to include all of the necessary information as set out in the National Minimum Standards for Older People and the Care Homes Regulations 2001. The manager or a designated registered nurse carried out pre-admission assessments. These were seen to include most aspects of daily living and were, overall, comprehensive and informative. However, it is recommended that more information be obtained in terms of social interests, hobbies and Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 10 dietary preferences in order that all aspects of care needs can be identified and met. Trial visits were offered to all prospective service users where individuals were welcomed to have a look around the home with their relatives and/or have lunch with other service users in the home before making a decision to stay. Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The care planning processes had been improved but needed to continue to develop in order to provide adequate information for staff to meet the needs of the service users. Changing health care needs were not reviewed consistently to ensure needs were being met at all times. Good standards of care were being delivered. There was a safe system for the receipt, storage, and administration of medicines. Service users were treated with respect, privacy and dignity. EVIDENCE: Each resident had a documented care plan and two care plans, one nursing client and one residential client were examined in detail. It was evident that staff had carried out a considerable amount of work to improve the care planning processes within the home. Both care plans contained meaningful recordings by staff and were, overall, organised and well laid out. Care plans were reviewed monthly but risk assessments seen to be reviewed regularly were not always signed by the reviewer, signed but not dated, and one risk assessment had not been reviewed since March 2004. Staff confirmed that this particular risk assessment was no longer appropriate and a discussion took place about the need to close and remove non-relevant documentation. Activities were recorded on the care plans but it was not clear when these took place for the individuals. Staff confirmed that they were current records. Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 12 Also, identified health care needs recorded well in the care plans, were not always followed through. For example, one resident’s care plan stated that she needed three monthly chiropody appointments but no records were found to evidence that these had taken place, or if the needs had changed which would influence the frequency of the chiropody visits. One of the care plans identified the need for nutritional supplements, and although staff confirmed that these were given to the service user, they were not recorded on the MAR sheets or on fluid intake/output sheets. Other health care needs were not assessed such as oral hygiene for a very frail resident, however, the same resident’s care plan evidenced the development and treatment of a pressure sore which was recorded in detail and successfully healed with excellent nursing care. It is a requirement of this report that risk assessments are reviewed regularly and signed and dated accordingly. A further requirement is for health care needs, including nutritional assessments, to be reviewed in line with service user’s changing health needs and all nutritional supplements to be recorded when given. The administration, storage and disposal of all drugs were in order. Medication Administration Record charts were examined and had been completed in line with NMC requirements. However, it is a requirement of this report that nutritional supplements are recorded on the MAR sheets when given. The storage and administration of controlled medication was examined and stocks were checked and tallied with the register stock levels. All service users had a current photograph in place on the MAR sheets and a list of staff specimen signatures and initials was up to date and kept in the front of the charts. Trained nurses administered medication to all service users. There were no service users self-medicating at the time of the inspection. However, a requirement was made to secure oxygen cylinders on trolleys in the designated storage area. Service users, who were spoken to, confirmed that staff were respectful and the inspector observed staff knocking on bedroom doors before entering. One relative said ‘the care here is very good; the staff are very friendly and helpful. There is a lot of banter between the service users and the staff – it’s nice to hear. They also make sure that service users wear their own clothes that match, it’s those little things that staff do that make all the difference as well as the good care’. The inspector overhead staff talking to service users who were bed bound and they were also respectful and caring in their comments to service users. Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 The home provided a range of activities and events to satisfy the needs of the service users and family and friends were welcomed and encouraged to maintain contact with the service users in the home. Dietary needs of service users were well catered for with a balanced and nutritional selection of food available that met service user’s tastes and choices. EVIDENCE: The Administrator in the home was also the Activities Co-ordinator who arranged a wide selection of activities for the benefit of the service users. This included a monthly visit to the home by an entertainer who sang and played the keyboard, large sized garden games such as noughts and crosses, draughts, darts, archery, barbeques, books and tapes from the library service, hairdressing, manicures, visits to the local public house, Uttoxeter racecourse and celebrating key events such as Valentine’s Day (where service user’s partners were invited for lunch), Easter egg hunt, England football matches, the Grand National, a large bonfire with fireworks on Bonfire Night etc. The weekend prior to the inspection, service users and staff had participated in a local community event to raise money for the Resident’s Fund, where the Catering Manager had made a significant number of cakes which were sold on a stall in a large marquee. The inspector was shown photographs of service users having a good time on that day. Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 14 The Administrator/Activities Co-ordinator and other staff within the home worked hard to provide a range of activities for the majority of service users. To support this, it is recommended that more specialist ‘activities’ be researched to provide stimulation for those service users who have dementia and/or communication/mobility difficulties. The Administrator/Activities Coordinator confirmed that she would be prepared to undertake a relevant activities training course if a suitable course was available. Enquires were to be made to access an appropriate course. Religious needs were also accommodated and included a monthly Holy Communion service for those service users who wished to attend. In addition to this, a local Roman Catholic priest visited the home weekly and one service user had a weekly visit from representatives and friends of her local Church. During the inspection, it was observed that family and friends were openly welcomed and service users were encouraged to maintain contact with them. Some service users spoken to confirmed that they could choose to stay in their rooms for meals if they so wished. The kitchen was inspected and found to be very clean and all temperature recordings for fridges, freezers and food probes were within the required ranges and completed correctly. A cleaning schedule was in place and it is recommended that it be updated to show the signatures and dates of staff completing the work. The Catering Manager confirmed that this would be done. The Catering Manager knew the service users well and provided a varied and nutritional diet. There was a choice of main meal, and seen by the inspector to be well presented, nutritionally balanced and of sufficient quantity. Help was observed being given to people unable to cut up their own food, and encouragement to service users who were not able to feed themselves. Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home had a satisfactory complaints procedure and service users confirmed that their views were listened to and acted upon. Adult Protection training should take place for all staff to ensure the continued protection of the service users. EVIDENCE: The Commission had received no formal complaints since the last inspection and one complaint received by the home during the last twelve months had been dealt with in accordance with the complaints procedure. Service users confirmed that they did not have any complaints but felt able to approach staff with any issues at any time. No incidents of neglect or alleged abuse of any kind had been reported to the home or the Commission. However, it is a requirement of this report that all staff who have not already received Adult Protection training, do so as a matter of urgency to ensure service users are protected from all forms of abuse at all times. The home had been without a registered care manager for a considerable amount of time and training was one area that had suffered because of this. The new manager confirmed that this would be rectified as a priority. Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20, 22, 24 and 26 Indoor and outdoor communal facilities were available for service users and there was, overall, good access for wheelchairs throughout the home and grounds. A range of specialist equipment was available to meet the needs of the service users, bedrooms were individually personalised, the laundry was well organised and the home was very clean. Some attention was required to improve the standard of decorating within the home in some areas and the heating needed urgent attention. EVIDENCE: The home provided two lounges and a dining room which led from the largest of the lounges. These communal areas, particularly the small lounge, were clean, bright and homely. Both lounges had a TV, although the smaller lounge had been considered to be a quieter area for service users if required. The dining room was a good size with a hatch directly from the kitchen where food was served to the service users. Furnishings within the communal areas were satisfactory and of good quality. Outdoor communal areas included a grassed area where there were three raised beds containing vegetables and a Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 17 greenhouse. This area was not accessible for service users with wheelchairs; however, there were three patio areas which were accessible for wheelchairs that had a variety of hanging baskets, flowerbeds, seating facilities and a water feature. Some of the external areas needed attention, in particular some of the windows at the front of the property. The replacement of windows in this area had already commenced and would continue for the foreseeable future. It was also noted that environmental adaptations and equipment had been provided to meet the assessed need of the service users. These included handrails fitted along the corridor and grab handles in the toilets. There were also hoists, pressure mattresses, a significant number of variable height beds and assisted bathrooms for the benefit of the service users. Some bedrooms had recently been redecorated and others had been designated for redecorating over the next few months. There was clear evidence that bedrooms had been personalised by the service users and were generally well appointed and very clean. The cleanliness of the environment was a credit to the domestic staff. Each bedroom was of a good size and it was observed that radiators were protected, adequate numbers of sockets were available and smoke detectors were fitted. Overall, a satisfactory standard of furnishings and fittings were witnessed. However, in a number of bedrooms, the heat was overpowering and on inspection, pipes attached to the radiators were found to be excessively hot. The manager confirmed that the heating controls were causing problems and a plumber was due to visit the home to try to rectify the problem. In the meantime, it is a requirement of this report that pipe work is checked in each room and lagged to protect service users and staff from risk of burns. Also on inspection, it was observed that a number of wardrobes were not secured to the wall and a further requirement is for all wardrobes to be restricted for the protection of service users and staff. Two bedrooms were noted to have malodour on inspection, and the registered person confirmed that he had ordered a new product which had been known to be successful in removing bad odours from carpets which even regular cleaning by the dedicated domestics had not managed to remove completely. It is a requirement of this report that the home is kept free from offensive odours at all times. The laundry was inspected and found to be well organised and all washing was undertaken at the correct temperatures including soiled linen in the appropriate red bags for easy identification. The home had two sluice facilities; one with a sluicing disinfector, and it is recommended that a lock be put on both sluice doors for the protection of service users. Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 18 Proposals had been made to extend the property and to increase the total number of beds by 15 and the Commission for Social Care Inspection will be involved at each stage of the planning and building stages. Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Staffing numbers and skill mix were appropriate to the needs of the service users. Staff files and recruitment procedures needed to be audited to ensure the continued protection of service users. Some training had taken place but mandatory training was not up-to-date for all staff. EVIDENCE: On the day of the inspection, there were 28 service users, of which 25 were nursing clients and 3 were residential clients. The Home Manager was on duty all day with 1 trained staff and 5 care assistants in the morning, 1 trained staff and 3 care assistants in the afternoon and 1 trained staff and 2 care assistants on night duty. Other ancillary staff on duty that day included: an office administrator/activities co-ordinator, a catering manager, a kitchen assistant, 3 housekeepers, a laundry assistant and a handyman. (A private gardener mowed the lawns as and when required). It was agreed that the shift cover was adequate for the existing service user’s needs. Three staff files were examined and two of the files had one or two of the required elements missing as set out in Schedule 2 of the Care Homes Regulations 2001). Discussions with the registered provider highlighted that some of the information was held at the company’s central office, but the home must have written confirmation held on file about POVA first checks and CRB clearances for all staff to ensure the continued protection of the service users. The inspector was pleased to see all sampled files contained current photographs of staff members and proofs of identity with in-depth information Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 20 provided for staff from overseas. It is a requirement of this report that all existing staff files are audited and any gaps identified and corrected. As stated previously, the home had been without a registered manager in post for a considerable time and this had contributed to the reduction in training opportunities provided for staff. One main concern for the inspector was the lack of induction training for new staff with no recorded evidence of staff being supervised although discussions with the home manager confirmed that on the job supervision had been given to new staff. The inspector was shown a training matrix, which detailed that staff had received some mandatory training but this was not dated and so was unclear about the time period of the training. It is a requirement of this report that all staff receive mandatory training as a matter of urgency and a recommendation that induction training is recommenced and provided within 6 weeks of appointment for all new staff. Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 The home had not had a registered care manager for a considerable time and formal supervision for staff had not taken place for some time. EVIDENCE: The current home manager, an experienced RMN, had been in post for approximately 3 months. He appeared to have settled in well, and had a good understanding of the key priorities and issues that needed to be addressed. Both the registered provider and the home manager confirmed their commitment for the home manager to apply for registered manager status and the inspector agreed to forward an application pack to the home manager for completion within the next few days. In addition to training, supervision of staff had not taken place for some time and it is a requirement of this report that staff receive appropriate supervision and a recommendation that formal supervision sessions for staff take place 6 times per annum. Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 x 15 3 COMPLAINTS AND PROTECTION x 3 x 4 x 2 x 2 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x 2 x x Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP 1 Regulation 4, 5 and 6 Requirement To review and update the Statement of Purpose and Service User Guide to provide sufficient information for prospective residents to make a choice about where to live. For risk assessments to be reviewed regularly and signed and dated accordingly. For health care needs, including nutritional assessments, to be reviewed in line with service user’s changing health needs For all nutritional supplements to be recorded when given. To secure oxygen cylinders on trolleys in the designated storage area. For all staff to receive Adult Protection training to ensure residents are protected from all forms of abuse at all times. For all pipe work to be audited in each room and lagged to protect service users and staff from risk of burns. For all wardrobes to be restricted for the protection of residents and staff. For the home to be kept free from offensive odours at all Timescale for action 30/11/05 2. 3. OP 7 OP 8 13 (4)(c) 14(2)(a)( b) Sched. 3 3 (m) 13 (2) 13 (6) Immediate Immediate 4. 5. 6. OP 9 OP 9 OP 18 Immediate Immediate 30/11/05 7. OP 25 13 (4) Immediate 8. 9. OP 38.1 OP 26 13 (4) (a)(c) 16 (2) (k) Immediate Immediate Page 24 Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 times. 10. 11. 12. OP 29 OP 30 OP 36 Sched. 2 19 (b) 18 (1) (c)(i) 18 (2) For all existing staff files to be 30/11/05 audited and any gaps identified and corrected. For all staff to receive mandatory Immediate training as a matter of urgency. For all staff to be appropriately Immediate supervised. 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 OP 3 Good Practice Recommendations To include more information in terms of social interests, hobbies and dietary preferences in the pre-admission assessment in order that all aspects of care needs can be identified and met. To research more specialist ‘activities’ to provide stimulation for those service users who have dementia and/or communication/mobility difficulties. To sign and date the cleaning schedule as completed. For a lock be put on both sluice doors for the protection of residents. For induction training to be recommenced and provided within 6 weeks of appointment for all new staff. For formal supervision sessions to take place 6 times per annum for staff. 2. 3. 4. 5. 6. OP 12.3 OP 26.1 OP 26.1 OP 30.2 OP 36.2 Beech Lodge E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 E51-E09 S26939 Beech Lodge V240057 16.08.05 Stage 4.doc Version 1.40 Page 26 - 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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