Inspection on 23/05/05 for Beech Lodge Residential Care Home

This inspection was carried out on 23rd May 2005.

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 Residential Care Home 11/09/07

Beech Lodge Residential Care Home 05/06/06

Beech Lodge Residential Care Home 16/11/05

Beech Lodge Residential Care Home 15/12/04

Beech Lodge Residential Care Home 09/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Beech Lodge 418 Burton Road Derby DE23 6AJ Lead Inspector Vanessa Davies 23rd May 2005 9:30am 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 C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Beech Lodge Address 418 Burton Road, Derby, DE23 6AJ 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) 01332 348118 01332 370890 care@goldenkeyhomes.co.uk Golden Keys Homes Ltd Mrs J Glover CRH 15 Category(ies) of Older People registration, with number of places Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 15.12.04 Brief Description of the Service: Beech Lodge is a 15 bedded home that provides personal care for people aged 65 years and over. The home is located in a residential area, on a main route into Derby City Centre. Service users accommodation is located over two floors, with access to the first floor via stairs or a stair lift. The home has 11 single occupancy rooms and two shared rooms. Bathing and toilet facilities are located on each floor. Beech Lodge has separate lounge and dining areas located on the ground floor. Service users may smhoke in the enclosed porch area at the front of the building. Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was unannounced and took place over 4 hours. The inspector examined 3 residents files, spoke with 4 residents, 2 staff and a relative. In addition to residents files a number of policies and procedures were examined, Health and Safety information and complaints information was also examined. What the service does well: What has improved since the last inspection? The Responsible person now completes regular monitoring visits to the home. The manager is now involving residents and/or relatives with their care. There are currently 14 staff employed at the home, 7 have NVQ 2, 1 is completing it, 1 staff has NVQ 3 and 1 staff is completing NVQ 3. This is a big improvement on the last inspection and the home have exceeded the National Minimum Standard of 50 by 2005. Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 6 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 C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,5 There is sufficient information for potential service users and representatives to make an informed choice of home. Assessments of need were not fully completed and valuable information was missing, leaving the potential for service users needs not being fully met. EVIDENCE: There was a detailed Statement of Purpose in place providing potential residents and relatives with plenty of information about the home. A relative spoken with confirmed that they had visited the home prior to their relative moving in. Each file examined had a copy of a contract of terms and conditions agreed between the home and the resident, all had been signed by the relevant people. There was evidence of an assessment completed by the home in the 3 files examined, however there were a number of areas not completed in 2 of the 3 files. Each file also had a community care assessment. The manager has Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 9 developed detailed care plans from the information within the assessments of need. There was evidence of residents/relatives involvement within 1 file examined. It was clear on the day of inspection that residents and relatives are encouraged to become as involved as possible with their care, however the manager and staff do not document this. Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10 All residents are treated with respect and their health needs are clearly being met. Some medication practices need addressing to prevent the occurrence of a serious incident. EVIDENCE: As stated previously, areas within the assessment of need were not completed, therefore all needs of residents were not highlighted and could not be fully met. It was evident that the home has a good relationship with the GP and district nurses, both visiting as necessary. There was evidence of falls risk assessments being completed and a tissue viability risk trigger tool in all files examined. Staff were witnessed knocking on doors and closing toilet doors when they were in use. The residents spoken with stated that “the staff are lovely, they look after us very well” The area of privacy and dignity is also detailed within the care plans. The inspector did not fully assess medication. There was no agreement with residents for administration of medication by staff. Within the daily records of 1 file it was documented on 2 separate occasions that a Warfarin tablet had Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 11 been found under a table. The Registered Person must ensure that all staff receive training in administration of medication. Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 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 standard(s) 13,15 This home welcomes visitors and relatives are encouraged to maintain contact ensuring service users retain links with their community. The chef provides a high standard of food and the kitchen is kept very well organised, ensuring a varied and well balanced diet for the service users. EVIDENCE: A relative spoken with in the day of inspection stated that they were always made to feel welcome and could visit at a time, which suited their relative without restrictions. The files examined evidenced close family involvement. The kitchen is very organised, the chef has a 4 week rolling menu with choices provided. He asks residents daily what they would like to eat from the menu. Fridge and freezer temperatures are kept, along with food temperatures. It was evident on the day of inspection that residents are able to eat where they choose; 1 resident eating in the bedroom and another eating in the lounge. Residents spoken with said that the food was “very nice”. Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 13 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) 16,18 Adult protection matters are not addressed sufficiently in this home leaving service users potentially vulnerable to abuse. EVIDENCE: The Registered Person keeps a clear record of any complaints and the resolutions, there have been no complaints since the last inspection. There is a detailed procedure for the protection of vulnerable people, however this does need amending as some of the information is incorrect. NCSC needs to be changed to CSCI. The manager stated that training in Adult Protection is offered, she must ensure that all staff complete this training and that it is updated for others. Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 14 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) 19,20,21,23,24,25,26 The home provides a safe pleasant environment, ensuring the comfort and safety of service users. EVIDENCE: Beech Lodge is a very clean pleasant home. It consists of a very nice oak panelled dining room, a lounge and a small seating area off the hall, with a payphone available. There are large surrounding well kept gardens easily accessible to residents. On the day of inspection the home was being measured for carpets highlighted as needing replacing. Resident’s rooms were very personal and individual. The home has 2 double rooms, as single rooms become available residents in double rooms are offered the opportunity of moving. There is a stair lift to the first floor and residents are assessed prior to admission to ensure they are able to use this safely. There is a shower room on the ground floor and a bathroom on the first floor. 1 room which used to be used as a bathroom on the first floor is now not used and the manager is considering the option of changing its use to a hairdressing/chiropody room. Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 15 Residents are asked if they would like a lock on their bedroom door, as they move in. Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 16 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) 27,28,30 The staffing numbers in this home are good and priority is given to induction and training ensuring staff have the experience, skills and competence to provide appropriate and safe care for service users. EVIDENCE: The Registered Person has 2 members of staff on duty throughout the day, 1 cook and 1 domestic/laundry assistant. Residents spoken with stated that they felt safe within the home. The inspector spoke with a new member of staff who stated that she had received a full induction, including working supernumerary (in addition to 2 experienced staff) for 2 weeks. She had completed First Aid and Health & Safety training. Whilst reading through 1 residents file, a member of staff had used inappropriate language, this was discussed with the manager, who will address in supervision. The manager evidenced a rolling training programme to cover mandatory training and additional courses to meet the needs of the residents. 7 staff have completed NVQ 2 and 1 is doing it. 1 staff has completed NVQ 3 and 1 is doing it. The manager has met the 50 minimum staff training to level 2 by 2005. Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 17 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) 31,32,33,37,38 The home is well managed by an experienced and competent person, who has policies and systems in place to ensure service users needs are met. EVIDENCE: The Registered Person is a Registered Nurse and is currently completing the Registered Managers Award. She clearly has an excellent relationship with the residents and the staff team. The residents spoken with felt she was approachable and were confident that any concerns raised with her would be addressed. The manager has implemented clear policies and procedures in order to protect the residents, however as stated earlier within this report the policy for Adult Protection must be amended. She monitors the records on a monthly basis. Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 18 She has recently appointed a new maintenance man, who has a relative living at the home and is therefore known to the residents. On the day of inspection he was assessing the property with a view to prioritising work. Fire records were examined and found to be up to date, with all staff due to attend a fire training session the following day. The Certificate of Registration was displayed in the hall, along with the liability insurance. The manager regularly monitors records, she stated that the responsible person visits the home regularly to undertake monitoring visits, however there was no documentary evidence to support this, as he does not complete a report. This has been highlighted previously and must now be addressed. Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 19 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 3 3 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 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 3 3 2 x x x 2 3 Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 20 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 33 Regulation 26 Requirement Timescale for action 31.07.05 2. 3, 7 3. 9 4. 13, 30,37 The Responsible person must undertake monitoring visits to the home and provide witten reports to the home and CSCI. THIS HAS BEEN OUTSTANDING SINCE JULY 2003. 14 The Registered Person must obtain a completed assessment for all service users invovling the service user and reviewing regularly. 13.2, 18.1 The Registered Person must (C,i) ensure that staff receive training appropriate to the work they undertake. 13.6, 18.1 The Registered Person must (ci) ensure that arrangements are made to prevent service users being harmed from abuse. 31.07.05 31.08.05 15.07.05 5. 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 3 Good Practice Recommendations The registered person should start to document service C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 21 Beech Lodge 2. 3. 19 30 users invovlement with their care. The manager should ensure that the carpets highlighted for replacement are replaced. The manager should ensure that she addresses report writing with the member of staff highlighted on the day of inspection. Beech Lodge C52 C02 S1963 Beech Lodge V229979 230505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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. 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