Inspection on 05/12/05 for Beech Lodge Nursing & Residential Home

This inspection was carried out on 5th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 &... 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 5th December 2005 10:00 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.V270617.R01.S.doc Version 5.0 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.V270617.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beech Lodge Nursing & Residential Home Address Rakeway Road Cheadle Stoke-on-trent Staffordshire ST10 1RA 01538 753676 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.V270617.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD minimum age 60 years Date of last inspection 16th August 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 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. Staff organise a programme of activities, trips out and in-house entertainment for the benefit of ther 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 requires updating for the attention of prospective service users and their families. Visits to the home are welcome prior to admission. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors carried out this unannounced inspection on 5th December 2005 at 10.00am using 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 7 hours. The inspection included a tour of the home, inspection of records, observation and discussions with service users, relatives and staff. Since the last inspection on 16th August 2005, no complaints nor any incidents or reports of abuse of any kind had been received. One requirement against the regulations was outstanding from the last inspection report i.e. formal staff supervision and one further requirement was partly outstanding i.e. not all mandatory training had been completed. What the service does well: What has improved since the last inspection? As stated previously, a significant amount of work had taken place to improve the care planning processes to enable staff to be clear about the current needs of the service users and how to meet those needs. Risk assessments had also been reviewed regularly and signed and dated accordingly. Health care needs were identified well and each individual staff file had been reviewed and updated to include all required elements for the protection of service users. Pipe work in bedrooms had been lagged, wardrobes restricted and oxygen cylinders secured for the safety of service users and staff. A new washing machine, dishwasher and laminator had been purchased for the home. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 Page 6 What they could do better: A number of requirements were raised as a result of this report as follows: • • • • • • • • • For written confirmation to be provided to all new service users prior to moving into the home that having regard to the initial assessment that the home is able to meet their needs. To replace/repair windows, particularly at the front of the building that require urgent attention. For carpet strips to be used instead of black tape on carpet in the corridor to ensure the safety of staff and service users. For a maintenance programme to be provided to CSCI detailing the timescales in which the maintenance work/redecorating will be completed. The provider to ensure that at least 50 of trained members of care staff (NVQ Level 2 or equivalent) are working in the home so that service users are in safe hands at all times. All staff to receive mandatory training. To obtain regular feedback from service users to inform service delivery. Financial processes to be reviewed to provide a more ordered and accountable system. Formal supervision sessions for care staff to take place at least 6 times per annum. Also a few recommendations were raised as follows: • • • • • • For copies of the complaints procedure to be made available to service users for their information. Where the working shifts for a member of staff are split between homes and is a permanent arrangement, a copy of the relevant staff file is available for inspection at both homes. For the Health Protection Nurse for the area to visit the home to provide advice to staff on infection control measures and practice. For staff and relatives/service users to sign and date receipts for the transfer of monies and/or valuables and a copy to be held by both parties. That a certificate from the approved electrical contractor be obtained as evidence of compliance to all required standards. For the maintenance person to record action taken to rectify any discrepancies in the accepted water temperature range. 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.V270617.R01.S.doc Version 5.0 Page 7 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.V270617.R01.S.doc Version 5.0 Page 8 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): 2 and 4. Each service user had a written contract/statement of terms and conditions with the home but did not receive written confirmation that the home could meet their needs prior to moving into the home. EVIDENCE: The care manager confirmed that each service user file had been reviewed and the inspector was shown up-to-date contracts/statement of terms and conditions that had been provided for each individual service user, both for Social Services funded and privately funded people. These included overall care and services covered by the fee, a breakdown of fees payable and by whom, additional services to be paid for over and above those included in the fees and terms and conditions of occupancy including period of notice. The inspector saw a contract that had been signed by an individual service user, dated 13th September 2005. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 Page 9 Records showed that new service users had received pre-admission assessments prior to moving into the home. However, no written confirmation was provided to the service user that having regard to the assessment, the home was able to meet the needs. It is, therefore, a requirement of this report that this takes place for all new service users prior to moving into the home. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 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 and 8. Care planning processes had been improved substantially but still required more stringent recording to enable staff to have a thorough understanding of service user needs and how to meet those needs. Service users had access to a range of other health care professionals and health needs were met well. EVIDENCE: Individual care plans were examined and seen to include all aspects of daily living which were reviewed regularly. It was apparent that a significant amount of work had taken place by the manager of the home in the review of service user’s health needs and in the development of nutritional assessment documentation in order to access expert advice for the service user from a dietician or other health professionals. The care manager also confirmed that parts of the initial nutritional assessment were copied to the Catering Manager to ensure that needs would be met. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 Page 11 The inspector was also shown examples of improved formats for Waterlow assessment and a discussion took place regarding the link to fluid intake/output, nutritional supplements and weight recording that were recorded as required depending upon the outcome of the monthly Waterlow assessment. Examination of other health related records evidenced that health care needs were generally met very well, however, more stringent recording was required in terms of turn chart records and, following discussion with the care manager, the need for a risk assessment to be in place regarding the consumption of alcohol for a particular service user. The care manager confirmed that this would be done and the inspector will monitor this at the next inspection. The risk assessment for falls had also been updated and it was clear that a lot of work had taken place to implement the requirements from the last inspection and staff were to be commended for their efforts. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 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 and 14. A variety of activities were available to meet the needs of the service users and should continue to be developed. Service users were supported and enabled to make their own choices and decisions about their day-to-day lives. EVIDENCE: The inspector noted that the pre-admission assessment documentation had been revised to strengthen the section regarding the hobbies and interests to ensure that all aspects of service user’s social needs could be met. Staff continued to work hard to provide as many activities as possible for the service users but these had not been recorded until recently, when the home’s administrator had started to record all activities/trips/entertainment etc in an activities log. Discussions with service users provided a mixed response to the activity provision. One service user stated ‘It is fantastic here; there’s not much to do though. There used to be songs and dances’. Another service user said ‘Staff look after my health needs. They help me have a bath - they are good with me - sometimes they help me dress but sometimes I can do it myself. They always close the bathroom door. I can go to bed when I want but they tend to get me up when I sometimes want a lie in. I cant remember any activities taking place and I haven’t been out because I don’t want to go out’. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 Page 13 Other service users confirmed that they were supported and enabled to exercise choice and control over their lives and relatives, when asked, endorsed this. One service user told one of the inspectors ‘the food is very good, with lots of choice, a different choice everyday. I came here from hospital and I couldnt walk when I arrived but I can walk now. There are some activities, we are having a pantomime, going to The Potters for Xmas lunch and I grow vegetables in the garden’. A relative made the following comments ‘We can visit when we want to. Staff are always helpful. If we need to know something, staff will try to find out’. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 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, 17 and 18. Service users were confident that their concerns were listened to, taken seriously, and acted upon. Service users were enabled to exercise their legal rights and participate in the electoral process. Service users were also protected from abuse by the home’s Adult Protection policy and staff knowledge on abuse awareness and the protection of vulnerable adults. EVIDENCE: No complaints or allegations of abuse had been reported since the last inspection. Service users and relatives confirmed their overall satisfaction with the staff and the service provided within the home and that staff listened to their views and acted upon them. However service users were unclear about the complaints procedure. One said ‘ I havent seen anything about complaints but I never want to complain’ and another said she was not sure about the complaints procedure and it is therefore, recommended that copies of the complaints procedure are made available to service users for their information. Discussions with staff highlighted that service users were supported to take part in the political process and enabled to vote in elections. Updated information regarding the service users at the home was sent to the Local Authority in order for them to participate in the postal voting system or to attend the local polling station if required. Service users were protected from abuse by the Home’s Adult Protection Policy, which the inspector noted that staff had signed as read and understood since the last inspection. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 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, 21, 23 and 25. Some areas of the home needed maintenance/redecorating work to be completed to ensure a safe, well-maintained environment for the service users and staff. There were adequate toilets and bathrooms to meet the needs of those living in the home, and service users rooms were of adequate size. Service users accommodation met the needs of the individuals, but attention to the water temperature in one of the bathrooms was required to prevent risk of harm to service users and/or staff. EVIDENCE: The location and layout of the home was suitable for its stated purpose, however the home required some attention to provide a safe and well maintained environment for the service users and staff. In particular, it was noted that some windows needed to be replaced/repaired, particularly at the front of the building. It is a requirement of this report that these are replaced/repaired as soon as possible. Also in one of the corridors, black tape had been used to hold down carpet that was lifting and it is a requirement of this report that carpet strips are used to replace the black tape and ensure the safety of staff and service users. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 Page 16 Other areas within the home needed some attention, such as paintwork and some bedrooms required redecorating. No redecorating or replacement of windows had taken place since the last inspection but the care manager confirmed that an audit of the building had been completed in October 2005, identifying the maintenance work/redecorating that was required within the home. It is a requirement of this report that a maintenance programme is provided to CSCI detailing the timescales in which the maintenance work/redecorating will be completed. Other than bathroom 3 (see below), the toilets and bathrooms within the home were suitable to meet the needs of the service users and were very clean. Service user’s rooms were sufficient of size and layout to meet their needs and in shared rooms, no more than 2 service users occupied them and each had made a positive choice to share. In bathroom 3, the water was excessively hot and the care manager explained that work was needed to the heating element, as there was no thermostat, but that arrangements had been made for a plumber to carry out the work the week following the inspection. The inspector will monitor this. A discussion took place regarding the need for risk assessments to be put in place for those service users using bathroom 3. The care manager stated that the bathroom would be closed off until the work had been completed. Pipe work and radiators were guarded and lighting in service user’s bedrooms was of domestic in character. One relative commented ‘The home always feels warm, there are never any unpleasant smells’. New purchases that had been made for the home included a washing machine, a dishwasher and a laminator. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 Page 17 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. Staffing numbers and skill mix were appropriate to meet the needs of the service users. More trained care staff were required to ensure that service users were in safe hands at all times. Staff files and recruitment procedures were generally robust 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 27 service users, of which 23 were nursing clients and 4 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, 2 housekeepers, a laundry assistant and a maintenance man. It was agreed that the shift cover was adequate for the existing service user’s needs. At the time of the inspection, there were 18 care staff of which 3 had achieved NVQ Level 3 and 3 had achieved NVQ Level 2. Therefore, the minimum requirement to have at least 50 of trained members of care staff (NVQ Level 2 or equivalent) will not be achieved by the end of 2005. It is a requirement of this report that the provider improves this level of qualified care staff in the home so that service users are in safe hands at all times. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 Page 18 Further to the requirements following the last inspection, a review of all staff files had taken place and records showed that significant efforts had been made to ensure that information within all staff files complied with Schedule 2 of the Care Homes Regulations 2001. 3 staff files were examined and all had been subjected to CRB clearances and contained application forms, job descriptions, proofs of identity and some evidence of training completed. 2 of the files contained relevant references, however there was some confusion regarding the references on one of the files. The manager and administrator said they would address this and overall, they were to be commended for their prompt attention to these files and their commitment to the ongoing protection of the service users. The care manager confirmed that no new starters had commenced work at Beech Lodge since the last inspection and therefore, no evidence of recent induction training was seen, although the inspector was shown evidence of the induction training forms. However, the care manager stated that a qualified nurse, who had completed her induction at the sister home, was new, but no documentation was available at Beech Lodge. It is a recommendation that in cases like this, where the working shifts for a member of staff are split between homes and is a permanent arrangement, a copy of the relevant staff file is available for inspection at both homes. Some training had taken place such as one staff file identified that she had undertaken fire safety training in April 2005 and the inspector was shown certificates of Food Hygiene training having taken place for all staff in February 2005. However, the training matrix did not identify which year the matrix related to or when the training took place for the individual member of staff. During the inspection, the administrator was observed making these changes to the matrix but the inspector remained concerned regarding the completion of the mandatory training for all staff. The administrator confirmed that some staff had completed First Aid training and manual handling training would take place at the start of the New Year, which as a qualified trainer, would be carried out by herself. Other mandatory training, such as health and safety also needs to take place and therefore, it is a requirement of this report that all staff who have not done so, receive mandatory training as a matter of urgency, and records to be provided to the inspector at the next inspection of those staff who have completed the training and the date of completion. It is also recommended the Health Protection Nurse for the area, visits the home to provide advice to staff on infection control measures and practice. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 Page 19 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, 35, 36, 37 and 38. The care manager was fit to be in charge but was about to go to a new post. Another long-term member of staff was anticipated to take over but even so, a period of instability within the management structure of the home would be created. Service users and staff did not formally contribute to the delivery of the service via group meetings. Financial accounting and recording needed to be more robust to safeguard service users financial interests. Formal supervision for care staff had not taken place. Records held were accurate and secure. The health, safety and welfare of service users were protected at all times. EVIDENCE: An application for registered manager had been sent to the care manager by the Commission, however, he informed the inspector that he would be leaving to take up a new post in a different service area in a couple of months. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 Page 20 A few days after the inspection, the administrator informed the inspector that it was anticipated that an existing long-term member of staff would be taking over the care manager’s post and when this had been agreed, CSCI would be informed. The proprietor will be reminded by this report that it is a condition of registration that a home has a Registered Care Manager. Feedback from service users about service provision had not been obtained for some time. Comments from group meetings and satisfaction questionnaires had been used in the past to determine the quality of the service and it is a requirement of this report that these be resurrected to provide a regular review of the quality of care. Discussion with the administrator and examination of financial records confirmed that reasonable accounting and financial procedures were in place. However, the system for storing and recording amounts of service users pocket monies was not robust enough to protect staff or service users financial interests and therefore, it is a requirement of this report that financial processes are reviewed to provide a more ordered and accountable system. It is also recommended that staff and relatives/service users sign and date receipts for the transfer of monies and/or valuables and a copy to be held by both parties. It was observed that insurance cover was in place to a minimum of £5 million and all records for the protection of service users were kept secure, up to date and in good order. The inspector was shown a new template which had been developed for staff supervision sessions which was very good and contained appropriate sections. However, formal staff supervision sessions for care staff had not taken place and it is a requirement that this is commenced as a matter of urgency, particularly in regard to the forthcoming changes to the management of the home and this requirement was raised before at the last inspection. Observation of individual records and home records evidenced that they were secure, up-to-date and in good order. The inspector examined a variety of records and documentation, to establish if the health, safety and welfare of service users and staff were protected. Fire safety records showed that fire alarm testing took place weekly and the home had had a fire systems check (of fire alarms, emergency lighting, and smoke detectors) on 08/03/05. Records showed that Stafford Fire and Safety had been called out to a faulty siren, which they repaired on 25/07/05, and Staffordshire Fire and Rescue checked the nurse call alarm and fire alarm system in August 04. However no record of any visit from the Fire Officer could be found for 2005 and the inspector recommended a visit from the Fire Officer should take place as soon as possible. (A few days after the inspection, the Fire Officer did carry out an inspection at the home). Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 Page 21 Records evidenced that a Gas safety inspection was carried out on 20/09/04 and the care manager confirmed that this had been booked again to take place the week following the inspection. The mains installation test and inspection was conducted in May 2004 and a record showed electrical repair work was completed at that time. This is not due again until May 2009. However, a new certificate should have been given to the provider following the repair work and it is recommended that a certificate from the approved electrical contractor be obtained as evidence of compliance to all required standards. The home’s maintenance person who, the care manager confirmed is a qualified electrician, last carried out the PAT testing in the home in June/July 2005. The maintenance person undertook checks on the water temperatures within the home each week and any discrepancies in the accepted temperature range were attended to immediately but details of the action taken were not identified. It is a recommendation of this report that the maintenance person details action taken to address the problem on each occasion. The inspector also examined records showing that the water in the tanks had been tested on 21/06/05 and the certificate of analysis evidenced satisfactory, safe readings. Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 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 X 3 X 2 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X 3 X 3 X 2 x STAFFING Standard No Score 27 3 28 2 29 4 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 2 3 3 Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 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 OP4 Regulation 14(1)(d) Requirement For written confirmation to be provided to all new service users prior to moving into the home that having regard to the initial assessment that the home is able to meet their needs. To replace/repair windows, particularly at the front of the building that require urgent attention. For carpet strips to be used instead of black tape on carpet in the corridor to ensure the safety of staff and service users. For a maintenance programme to be provided to CSCI detailing the timescales in which the maintenance work/redecorating will be completed. The provider to ensure that at least 50 of trained members of care staff (NVQ Level 2 or equivalent) are working in the home so that service users are in safe hands at all times. All staff to receive mandatory training as a matter of urgency. To obtain regular feedback from service users to inform service DS0000026939.V270617.R01.S.doc Timescale for action 05/12/05 2. OP19 23(2)(b) 31/03/06 3. OP19 23(2)(b) 05/12/05 4. OP19 23(2)(b) 31/03/06 5. OP28 18(1)(a) 31/03/05 6. 7. OP30 OP33 18(1)I (i) 24 (1) 31/01/06 31/03/06 Beech Lodge Nursing & Residential Home Version 5.0 Page 24 8. 9. OP35 OP36 17(2) 18(2) delivery. Financial processes to be 31/03/06 reviewed to provide a more ordered and accountable system. Formal supervision sessions for 31/03/06 care staff to take place at least 6 times per annum. 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 OP16 OP30 Good Practice Recommendations For copies of the complaints procedure to be made available to service users for their information. Where the working shifts for a member of staff are split between homes and is a permanent arrangement, a copy of the relevant staff file is available for inspection at both homes. For the Health Protection Nurse for the area to visit the home to provide advice to staff on infection control measures and practice. For staff and relatives/service users to sign and date receipts for the transfer of monies and/or valuables and a copy to be held by both parties. That a certificate from the approved electrical contractor be obtained as evidence of compliance to all required standards. For the maintenance person to record action taken to rectify any discrepancies in the accepted water temperature range. 3. 4. 5. 6. OP30 OP35 OP38 OP38 Beech Lodge Nursing & Residential Home DS0000026939.V270617.R01.S.doc Version 5.0 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.V270617.R01.S.doc Version 5.0 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!