CARE HOMES FOR OLDER PEOPLE
Beech Lodge Residential Home Frogs Abbeygate Holbeach St Johns Holbeach PE12 8QJ Lead Inspector
Julie Western Unannounced 25 August 2005 10:00 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 Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Beech Lodge Residential Home Address Frogs Abbeygate Holbeach St Johns Holbeach Lincolnshire PE12 8QJ 01406 423396 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) Mr Abdul Kachra Karen Davies Care Home 22 Category(ies) of Dementia - over 65 (DE(E)) - 1 registration, with number Old Age (OP) - 21 of places Beech Lodge Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Service users can only be admitted to the home with the written permission of the named representatives of the Commission for Social Care Inspection. Date of last inspection 26/11/04 Brief Description of the Service: Beech Lodge Residential Home is a large two storey former farmhouse with a purpose built extension. It is situated in farming land in Holbeach Fen approximately three miles from the town centre of Holbeach. There are gardens to the rear and front with a car park at the front. The accommodation has 16 single rooms with 12 providing en-suite facilities and 3 double rooms with en-suite facilities. The home is registered to give care and accommodation for up to 22 residents, one of those having a mental health problem associated with old age. Beech Lodge Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 6 hours. On the day of the inspection 11 residents were being accommodated. A partial tour of the building took place and care records were inspected. The main method of inspection used was called ‘case-tracking’; this involved selecting three residents and tracking the care they received through the checking of their records, discussion with the residents and care staff and observation of practices. Some policies and procedures were examined and records concerning the safety of the home were also seen. Three of the fourteen residents and two of the care staff were spoken with. The owner, the Manager who has been in post since July and the newly appointed training co-ordinator were present throughout the inspection. What the service does well: What has improved since the last inspection?
The registered Manager has worked very hard to collate the home’s records including policies and procedures, with the result that most records are now well organised and easily accessible. Care plans are in the process of being reviewed. The Manager has introduced a key worker system and staff supervision has now commenced. Environmental improvements have included the provision of a new walk-in shower, the redecoration of the outside of the building and the cutting down of the hedges to allow more light into the home. Ongoing maintenance has included the redecoration of two bedrooms and the replacement of carpets in two rooms. The home is now benefiting from having a stable staff group. Beech Lodge Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 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 Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 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 Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 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) 1-6 The home clearly sets out what it intends to do for its residents and this information is freely available, although it does need some updating. Prospective residents are encouraged to take time before making the decision to move into the home on a permanent basis. EVIDENCE: There is a comprehensive statement of purpose that tells the service user and their relatives what they can expect from the service; this needs to be updated as there is a reference to the NCSC and a previous Manager. The service user guide is available in a clear and easily understood format. The Manager said that she usually carried out pre-admission assessments, visiting them in their own homes or in a hospital or care setting; she demonstrated a knowledge and awareness of the needs of older people including those with a dementia. The statement of terms and conditions was in the service user guide. Residents spoken with confirmed that they had visited the home for a coffee or a day before permanent placement and the Manager confirmed that there was a sixweek trial period. Beech Lodge Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 Page 9 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) 7-10 The home’s records give a clear picture of the needs of residents and enable staff to meet their needs with sensitivity and regard for their privacy and dignity; the Manager is in the process of updating these records. Staff members are trained in the safe handling of medication, ensuring that residents are safely cared for. EVIDENCE: The Manager was still in the process of reviewing all care plans; consequently some care plans contained duplication. The three care plans looked at in depth contained initial assessments including risk assessments and care plans and were reviewed regularly. There was a clear medication policy and the pharmacist visited regularly, the most recent report being on 21/6/05 and from which there were no issues of concern. The Manager and staff spoken with confirmed that only trained staff members were able to administer medication. Residents said they felt safe and well looked after; one said ‘they’re all good to you here’ and another compared the home favourably to another home he had been to. The staff team were observed carrying out their duties with kindness and sensitivity towards the residents, especially when attending to their personal needs. Beech Lodge Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 14,15 Events and activities, which residents are informed about, are available. The home would benefit from having a designated member of staff responsible for the co-ordination of activities and the production of a Newsletter to inform residents and visitors of events. The residents exercise choice about which activities, if any, they wish to participate in and what meals they want to eat. EVIDENCE: Current activities provided by the home include film shows, music and outside entertainment. Recent events included a ‘sing-a-long’ and trip to a local shopping and garden centre was planned for next month. Two residents spoken with said they did not want to have any organised activities and preferred to be quiet; they often stayed in their own rooms and this was their choice. It was noted that there was no one responsible for organising a programme of activities; the training co-ordinator said that this had already been identified as a lack of resources and there were plans to appoint someone to this post. Residents were seen eating the mid-day meal and all spoken with said they enjoyed the food served at the home; one said ‘the cooking is what you’d get at home’. All said they had a choice for both the main meal and for tea. The mid-day meal was seen to be balanced and nutritious. One resident had a pureed diet and was being assisted to eat it. Beech Lodge Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 Page 11 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 The home’s complaints procedure is clear and gives residents and their relatives the confidence that comments and concerns will be listened to; there is a robust adult protection procedure. EVIDENCE: Residents said they did not wish to complain but knew how to make a complaint. The home had received one complaint in the last twelve months. There was a clear adult protection policy, which was linked to the Local Authority Adult Protection Procedures and a whistle blowing policy. Staff members spoken with had received training on adult protection issues on 14/12/04. Beech Lodge Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 Page 12 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) 19-22, 25,26 The residents live in a comfortable, pleasant and safe environment with both private and communal space being on the whole suitable for their needs. EVIDENCE: Overall, the standard of decoration internally is high and affords residents a great degree of comfort. The handyman, who visits on a weekly basis, is responsible for the rolling maintenance programme and has a notebook into which matters needing attention are entered; he also inspects water and room temperatures and fire records. Environmental improvements have included the provision of a new walk-in shower, the redecoration of the outside of the building and the cutting down of the hedges to allow more light into the home. Ongoing maintenance has included the redecoration of two bedrooms and the replacement of carpets in two rooms. The building was light and warm and one resident said ‘my room’s lovely – it looks onto the fields and I like that’. Records for the maintenance of the home were up to date. The home was free from odours throughout. Beech Lodge Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 Page 13 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) 27-30 Staff numbers are in sufficient quantity for them to be able to care for the residents. Staff members are suitably trained, qualified and competent; they undergo an induction programme before commencing their duties. EVIDENCE: The residents were positive about the care they received from the staff. Two said ‘they are good to me and they’ll help you when you need it’. The most recent staff member to be appointed confirmed that she had given two references, which were followed up, a CRB check and undertaken an induction programme before commencing work. Training records showed that statutory training was completed with recent specialist training being First Aid. There was some confusion about the training programme and the training coordinator said that she would be developing a full programme of training across all the homes owned by the organisation. Three staff members were working towards National Vocational Qualification at Level 2. The staff rota showed that there were enough staff numbers according to the staffing matrix and shifts were staggered to accommodate the needs of residents; due to staff annual leave, there were two staff members from the organisation’s sister home present. Residents spoken with thought there were enough staff and staff confirmed this. Beech Lodge Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 Page 14 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) 31,32,36,37 The home is managed competently and the staff are supported and supervised in carrying out their respective roles. EVIDENCE: The home now has a Registered Manager; she has been working in the care profession for eighteen years and has been in post since July. She is currently working towards the National Vocational Qualification Manager’s Award. Staff interviewed said they felt supported by the management of the home and they were approachable and accessible. Supervision has commenced and all staff have received appraisals. Staff records and the home’s records were partly examined Beech Lodge Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 x x 3 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 Standard No 16 17 18 Score 3 3 3 3 3 x x x 3 3 x Beech Lodge Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 Page 16 None 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 OP1 Regulation 4(1) Requirement The registered person must update the statement of purpose to reflect current management structure in the home and the altered name of the Commission The registered person must review all care plans to ensure that there is no duplication. The registered person must consult residents about the programme of activities arranged by or on behalf of the care home and provide facilities for recreation, social, cultural and religious activities appropriate to the circumstances of residents. Timescale for action 27th October 2005 27th October 2005 27th October 2005 2. 3. OP7 OP12 15 16(2m&n) 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 OP12 Good Practice Recommendations It is a recommendation that the home produces a monthly newsletter where forthcoming activities are listed and where residents, staff and visitors can contribute articles. Beech Lodge Residential Home C53 C04 S2671 Beech Lodge V246712 250805 Stage 4.doc Version 1.40 Page 17 Commission for Social Care Inspection Unity House, The Point Weaver Road Lincoln LN6 3QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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