Inspection on 26/06/06 for Beech Lodge Nursing & Residential Home

This inspection was carried out on 26th June 2006.

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

The inspector found 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 &... 05/12/05

Beech Lodge Nursing &... 16/08/05

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 Nursing & Residential Home Rakeway Road Cheadle Stoke-on-trent Staffordshire ST10 1RA Lead Inspector Lynne Gammon Unannounced Inspection 26 June 2006 09:30 X10015.doc Version 1.40 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 Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beech Lodge Nursing & Residential Home Address Rakeway Road Cheadle Stoke-on-trent Staffordshire ST10 1RA 01538 753676 F/P 01538 755054 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) Minehome Limited Care Home 31 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (31), of places Physical disability (1), Physical disability over 65 years of age (31) Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD minimum age 60 years Date of last inspection 5th December 2005 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 60 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. Staff organise a programme of activities, trips out and in-house entertainment for the benefit of the service users. 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 has been updated for the attention of prospective service users and their families. Visits to the home are welcome prior to admission. On 12/05/06 information from the care manager identified that the fees for the service ranged from £412 to £466 and additional charges were made for: hairdressing, escort to the hospital and newspapers and toiletries. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was made on the 26th July 2005 at 9.15am. 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 8 hours. Service users spoken to said that they were very happy living at Beech Lodge nursing home and relatives stated ‘we are always greeted very well, manager and staff are always cheerful and helpful and obliging. Any problems which occur are always dealt with immediately and we always go home with peace of mind’. What the service does well: The acting care manager and staff within the home, including the qualified nurses, care and ancillary staff, all contributed to a good standard of service provided within the home. Care plans and associated records were well documented and informative to enable staff to be clear about the needs of the service users and how those needs should be met. Recording within the care plans was thorough and meaningful. Health care needs were met very well and the medication was well managed promoting good health. Visitors were warmly welcomed and staff were friendly and open towards them. There was very good interaction between staff and service users, and service users were supported and encouraged to make their own choices and decisions about their own lives. Service users were treated respectfully and with dignity. Service users were very happy and complimentary about all the staff and the kindness shown to them. There were a range of social, religious and recreational opportunities available to meet the expectations of the service users within the home. A well balanced, nutritious and varied diet was provided for the benefit of the service users. Service users really enjoyed the food and one said ‘‘always very fresh food every day and different - the food is great!’ Staff training had been provided and at least 50 of trained care staff will have achieved NVQ Level 2 this year. All care staff had received supervision. Staffing levels and mix were sufficient to meet the needs of those who lived in the home. Service users were cared for by qualified staff who were competent and trained to carry out their jobs. Recruitment and selection practices were robust for the protection of the service users. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 6 The home was well managed and run in the best interests of the service users. Good robust quality systems were in place that enabled a structured, methodical process for obtaining feedback from both service users and staff. The staff are to be commended for their commitment to providing a very good standard of care. What has improved since the last inspection? What they could do better: The provider had made efforts to improve the environment within the home and this should continue as identified in the maintenance programme. However, a number of requirements were raised as a result of this inspection and almost all of them related to the environment. They were as follows: • • • • • For the lounge carpet to be replaced or professionally cleaned and the lounge and dining room to be redecorated to provide a clean and homely environment for the service users. For the carpet in room 5 to be replaced. To ensure the home is kept free of malodour at all times. In bedroom 27, the carpet should be re-laid for the safety of the service user and staff. The en-suite in room 17 to have a replacement carpet and the room to be redecorated. One further requirement was raised: • for the provider when visiting the home at least monthly to complete an audit of the service and produces a report available for the Commission to inspect at any time. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 7 A few recommendations were also raised as follows: • • For contracts to include the breakdown of charges and payments (if any) from other agencies towards the costs of living in the home. For the provision of maintenance hours to be reviewed and possibly increased to ensure the ongoing improvement of the environment within the home. 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 Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 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 the following standard(s): 1, 2, 3 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users received sufficient information to be clear about the suitability of the home for them. They had full, detailed assessments prior to moving into the home and a letter to confirm that the home could meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide provided all the necessary information to enable them to decide if the home could meet their needs. Assessments were carried out with each service user before moving into the home and each service user received a letter from the home to assure them that their needs could be met. Contracts seen clearly identified what was included within the fees and what additional charges would be made. However it is a recommendation that contracts include the breakdown of charges and payments (if any) from other agencies towards the costs of living in the home. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 10 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 the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning processes in the home were clear and consistent and provided staff with adequate information to meet service user’s needs satisfactorily. Health care needs were met very well and the medication was well managed promoting good health. Service users were treated respectfully and with dignity. EVIDENCE: Four service user’s care plans were examined and all were based on the activities of daily living. Each care plan contained a photograph of the relevant service user and clearly identified their social, personal and health care needs, which were reviewed monthly. Risk assessments were carried out for each individual service user and also reviewed monthly. Service users had access to a range of health care professionals such as the G.P, chiropodist, optician, dietician, tissue viability clinical nurse specialist etc. The documentation and discussions with residents and staff evidenced that health care needs were being met very well. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 11 The medicines within the home, the Medication Administration Records and the Controlled Drug Register were examined and found to be accurate, authorised appropriately and drugs were stored safely. Service users confirmed that they were treated with dignity and respect. One service user commented ‘‘All staff are very helpful and kind’. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were a range of social, religious and recreational opportunities available to meet the expectations of the service users within the home. Visitors were welcomed in an open and friendly manner and service users were supported and encouraged to maintain contact with family and friends and to make their own choices about their day to day lives. A well balanced. nutritious and varied diet was provided for the benefit of the service users. EVIDENCE: A wide range of activities was provided for those living in the home. This included external entertainers visiting the home, trips out to garden centres and other places of interest. In addition to this, the activities coordinator/administrator and other staff made substantial efforts to provide interesting activities within the home to stimulate and provide enjoyment for the service users. Religious needs were also met with regular visits from Church representatives. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 13 During the inspection, staff were observed welcoming relatives and friends of the service users and the acting care manager confirmed that there was open visiting for family and friends. One relative told the inspector that ‘‘this home is excellent, we have not had any problems whatsoever.’ Another relative made comments in a questionnaire sent directly to the Commission, which stated ‘Mother receives excellent care and attention. The level of care was particularly impressive during her recent period of serious illness. Thank you Beech Lodge’. Throughout the inspection service users were observed making their own choices and one service user confirmed that soon they were going on holiday on a cruise ship and another said he went to town and out with his friends when he wanted to. He also stated that he went to bed and got up when he wished to and made his own choices and decisions. During the inspection, a visit to the kitchen took place. A recent environmental health inspection had taken place and the environmental health officer had raised a few requirements which were being put right at the time of this inspection. The kitchen was 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 included the signatures and dates of staff completing the work. The Catering Manager was extremely knowledgeable about the needs of the people who lived in the home and menus showed that a varied and nutritional diet was provided. It was confirmed that fresh fruit and vegetables were provided regularly. Service users were very complimentary about the food, ‘always very fresh every day and different’, ‘the food is great!’ They also confirmed that they were involved in changing the menu and their views were taken into account. The main meal of the day was seen to be well presented, nutritious and of sufficient quantity. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a satisfactory complaints procedure and service users confirmed that their views were listened to and acted upon. Service users were protected from abuse by the home’s Adult Protection procedure but regular training in Adult Protection and Abuse Awareness should be undertaken to ensure a proper response to any suspicion or allegation of abuse if the need arose. EVIDENCE: The Commission had recently received one complaint from a relative regarding the breakdown of the fees charged for her relative’s place at the home. The provider of the service had written to the relative to arrange a meeting to explain the breakdown and a copy of letter had been sent to the Commission. No formal complaints had been received about any other matter since the last inspection. The complaints procedure was observed in each of the service user’s rooms. The home had an Adult Protection procedure which ensured the safety and protection of service users. The acting manager confirmed that abuse awareness training for staff had been booked. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 19, 20, 21, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements had been made to the environment but still needed further maintenance work to be carried out to provide a safe and well maintained environment for the benefit of the service users. Indoor and outdoor communal facilities were provided and were adequate and in some areas needed refurbishment. Suitable lavatories and bathing facilities were available to meet the needs of the service users. Most bedrooms were comfortable and homely and individually personalised. The home was very clean. EVIDENCE: A tour of the home, both inside and out took place. Three new windows had been put in at the front of the home. Externally, the grounds contained a range of lovely baskets and tubs and the lawns had been cut. There were some weeds but overall, the gardens were satisfactory. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 16 The communal areas internally included two lounges and a dining room. The smaller lounge was homely, bright and comfortable. However the main lounge and dining room needed to be refurbished. The décor was tired and needed redecorating. The lounge carpet was heavily stained even though it had been cleaned. The dining room carpet was adequate. It is a requirement of this report that the lounge carpet be replaced and the lounge and dining room be redecorated to provide a similar homely, bright environment as found in the smaller lounge. The patio area accessed from the dining room contained lots of tubs, hanging baskets, a barbeque and raised vegetable beds containing a variety of vegetables tended by a gentleman living in the home. England flags were hung around the lounge during the World Cup competition and the home had a relaxed atmosphere. A number of service users were wheelchair users who were able to propel themselves around the home. Ramps were in place to ensure accessibility throughout the home and garden, although some of the garden was not suitable for wheelchairs. Bathrooms were found to be satisfactory but some boxed in areas need attention. It was observed that oxygen cylinders were secured safely to the wall. Bedrooms were inspected and most were found to be of a satisfactory standard. However in room 5, the carpet was very badly stained and a bad odour was evident. It is a requirement of this report for the carpet to be replaced and another requirement to ensure the home is kept free of malodour at all times. In bedroom 27, the carpet was not flat and therefore unsafe. It is a requirement of this report that this carpet is re-laid for the safety of the service user and staff. Wardrobes were secured and radiators and pipe work were covered to ensure the ongoing safety of the service users. The en-suite in room 17 was seen to have a badly stained carpet and the toilet cistern and walls were discoloured and needed attention. It is a further requirement for this carpet to be replaced and the room to be redecorated. The Provider of the service had replaced carpets in the corridors to comply with previous requirements and other work had been carried out since the last inspection to improve the environment in the home. This included replacement of mixer valves in a number of bedrooms in January 06 and the flat roof was repaired in February/March 06. A number of bedrooms had been redecorated by staff and new bedding and curtains purchased to colour coordinate the room. A copy of the maintenance programme had been provided to the Commission showing that more new windows were to be put in by the end of July 06 and further planned ongoing maintenance throughout the year was seen. One maintenance person provided 20 hours per week and in addition to this, non-maintenance staff carried out a lot of decorating, gardening etc. It is recommended that this situation is reviewed and increased maintenance hours be provided to ensure the ongoing improvement of the environment within the home. The standard of cleaning within the home was very good. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 17 Recently the Fire Officer inspected the home and a Health Protection nurse visited the home and audited infection control procedures and practices. Recommendations made by both professionals had either been completed or were in the process of being completed at the time of the inspection. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 18 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing levels and mix were sufficient to meet the needs of those who lived in the home. Service users were cared for by qualified staff who were competent and trained to carry out their jobs. Recruitment and selection practices were robust for the protection of the service users. Training of care staff does not currently meet the requirements but the home are working towards it. EVIDENCE: Staffing rotas were examined and evidenced that adequate numbers of trained staff were on duty at all times to meet the needs of the service users. Discussion with the acting care manager confirmed that the home currently had 15 carers (plus 2 adaptation nurses) in the home with 2 care staff with NVQ Level 2 and three members of staff having achieved NVQ Level 3. One member of care staff was in the process of completing NVQ Level 2 and another two members of staff were starting NVQ Level 2 next week. Once this training was completed, the home would have achieved the required 50 of trained members of staff with NVQ level 2 or above working in the home. The recruitment and selection processes within the home were examined and found to be robust. Three staff files were examined and each contained the required details to ensure the ongoing protection of service users. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 19 The home offered staff training and supervision and provided a range of topics including fire safety awareness, moving and handling, infection control, etc. The acting care manager was the qualified manual handling assessor for the home. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 20 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The acting care manager has made many improvements and her application to be approved as manager is awaited. The home was run in the best interests of the service users. Good robust quality systems were in place that enabled a structured, methodical process for obtaining feedback from both service users and staff. Staff supervisions were completed on a regular basis to enable staff to have formal, one-to-one sessions with their line manager. EVIDENCE: A registered nurse who had worked at the home for a number of years was promoted to acting care manager in January 2006. She confirmed that she had almost completed her application form to apply to become registered as a care manager with the Commission and would be submitting this shortly. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 21 She provided a 12-hour shift carrying out operational duties once per week and 4 days managing the home. This has led to much improved and systematic processes being set up within the home and her polished management style has provided clarity and direction for the staff. The provider and manager should be complimented for their significant improvements over the last few months, however, it is a requirement of this report that the provider visits the home monthly on an unannounced basis and completes an audit of the service and produces a report available for the Commission to inspect at any time. In January the acting manager wrote to all families introducing herself and asked for feedback about the home and the service. Questionnaires were seen and comments were taken into account. Staff meetings and informal meetings for service users and their relatives took place. Minutes of the relatives meetings were seen and evidenced the range of topics raised and action to be taken. Completed staff supervision records were seen. The format and recording of these were excellent. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 3 X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 3 X X Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP19 Regulation 23(2)(b) Requirement For the lounge carpet to be replaced or professionally cleaned and the lounge and dining room to be redecorated to provide a clean and homely environment for the service users. For the carpet in room 5 to be replaced. To ensure the home is kept free of malodour at all times. In bedroom 27, the carpet should be re-laid for the safety of the service user and staff. The en-suite in room 17 to have a replacement carpet and the room to be redecorated. For the provider to visiting the home at least monthly unannounced to complete an audit of the service and produces a report available for the Commission to inspect at any time. The Provider to ensure that at least 50 of staff NVQ L2 (or equivalent) are working in the home so that service users are in safe hands at all times. (Previous Requirement not met) DS0000026939.V291558.R01.S.doc Timescale for action 30/09/06 2. 3. 4. 5. 6. OP24 OP26 OP24 OP24 OP33 23(2)(b) 16(2)(k) 23(2)(b) 23(2)(b) 26 30/09/06 31/08/06 30/09/06 30/09/06 31/08/06 7. OP28 18 (1) (a) 30/09/06 Beech Lodge Nursing & Residential Home Version 5.1 Page 24 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. 2. Refer to Standard OP2 OP19 Good Practice Recommendations For contracts to include the breakdown of charges and payments (if any) from other agencies towards the costs of living in the home. For the provision of maintenance hours to be reviewed and if possible increased to ensure the ongoing improvement of the environment within the home. Beech Lodge Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Stafford Office 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 Nursing & Residential Home DS0000026939.V291558.R01.S.doc Version 5.1 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. 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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