Inspection on 05/04/06 for Beech Lodge Residential Home

This inspection was carried out on 5th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beech Lodge Residential Home 25/03/09

Beech Lodge Residential Home 03/04/07

Beech Lodge Residential Home 06/12/05

Beech Lodge Residential Home 25/08/05

Beech Lodge Residential Home 26/11/04

Beech Lodge Residential Home 05/05/04

Beech Lodge Residential Home 11/02/04

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 Residential Home Frogs Abbeygate Holbeach St Johns Holbeach Lincolnshire PE12 8QJ Lead Inspector Kima Sutherland-Dee Key Unannounced Inspection 5th April 2006 10:15 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 Residential Home DS0000002671.V288321.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 Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 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 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) Mr Abdul Kachra Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22) of places Beech Lodge Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary need falls within the following categories: Old Age not falling within any other category (OP) 22 Dementia over 65 years (DE (E)) 22 The maximum number of service users to be accommodated is 22. Date of last inspection 8th December 2005 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 personal care and accommodation for up to 22 residents who require support due to old age or associated dementia. Beech Lodge Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was carried out over 4.5 hours and took any previous information held by CSCI, about beech lodge into account. The site inspection consisted of case tracking a sample of the resident’s records and assessing their care. The inspector spoke with three residents, the acting manager, three members of staff and one visiting relative. A partial tour of the home and a review of a sample of the records was also included. What the service does well: What has improved since the last inspection? The acting manager has made improvements to the care planning and the care that is delivered. The medication is now stored, administered and recorded safely. There has been an increase in the social activities, in January, and February. The staff numbers have increased in line with the increase in the number of residents, and this has improved the level of service for all the residents. The staff working in the home are able to communicate well with the residents and the residents made positive comments about the care they receive. The staff are now receiving supervision and annual appraisals. Beech Lodge Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 Page 6 The acting manager has applied to be registered with the commission and they are undertaking their manager’s award and N.V.Q level 4. This manager is managing the staff team and the staff now feel confident to raise issues of concern. The residents and a visitor said they would feel able to approach the manager with any complaints or concerns. The providers have improved the environment, by fencing the rear garden and employing a full time cleaner. The laundry has been repaired and the resident’s clothes can now be washed and dried effectively. 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 DS0000002671.V288321.R01.S.doc Version 5.1 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 Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 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): 1,2,3,4,5 Prospective residents are given the information they need, but there is a long delay in them receiving confirmation letters before admission or contracts after admission. EVIDENCE: The providers have produced a new version of the statement of purpose and the service users guide. Copies of these were made available to the inspector and copies of the guide were in the resident’s rooms. Three residents files were seen and two of them did not have contracts. The provider later explained that they have to wait until social services forward their contracts. The need to provide the contract between the home and the resident remains the responsibility of the provider and they may need to discuss this issue with Social Services contracting department. The manager stated that they had recently spoken to the relatives of a resident to confirm that the home could offer a place and meet this persons needs. This should be followed up in writing before every admission. Beech Lodge Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 Page 9 Pre admission assessments were in the files and they were detailed enough to allow the manager to make an assessment of the prospective residents needs, and to form the basis of the care planning process. Beech Lodge Residential Home DS0000002671.V288321.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 The manager has improved the care plans and the administration of medication. Not all the care plans are completed within two weeks of a resident being admitted. The home is able to meet the health care needs of the residents. EVIDENCE: The care plans have improved and the staff and manager said they are much easier to use. Two residents had been in the home for more than two weeks and the information from the assessment had not been transferred onto a care plan, although the daily records were being maintained. The daily records were detailed and the standard of written information had improved since the last inspection. More information was available that showed that the care plans were being implemented and where the residents required help with their food and drink this had been noted. The manager stated that they were training senior staff to be able to complete the care plans, and staff on duty complete the daily records. Beech Lodge Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 Page 11 The manager and the staff demonstrated their knowledge about the residents needs and health care had been provided appropriately. The G.P visited two residents during the inspection, and their advice was followed through. The staffing level has increased incrementally with an increase in resident numbers, this has meant that there are 3 carers on each daytime shift and two waking night staff. The staff said they have time to care for the residents and the residents were complementary about the staff. The residents appeared to be wearing clean clothes, and they had had all their personal needs attended to. The senior staff on duty was observed administering medication. This was carried out safely and there have been improvements to the storage and administration of medication since the previous inspection. A secure storage cupboard has been provided and the medicines are given at the prescribed times. Beech Lodge Residential Home DS0000002671.V288321.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): 12,13,14,15 The home has improved the level of activities, however the range and frequency of activities and the opportunity to consult the residents about this could be increased. A suitable diet is provided. Visitors are welcomed at the home. EVIDENCE: There had been an improvement in the level of stimulation and activity in January and February during the employment of an activities co-ordinator, this had stopped but the staff said they do carry out the activities that are advertised on the notice board. The residents said that the home did not provide activities, however evidence showed that events had taken place and residents had participated. It was observed that on arrival at the home the staff were playing a C.D of wartime songs and a number of the residents were singing along. Two residents said they enjoyed the music. Individual interests were recorded in the care plans and the manager said they were attempting to facilitate these whenever possible, they were able to give examples. The residents are able to choose how they spend their time within the limits of the care they need to be provided by the staff. The majority of the residents have some form of dementia and they are dependent on the staff to provide all Beech Lodge Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 Page 13 care. The staff were observed chatting to the residents and reassuring them during the day. The statement of purpose states that visitors are welcome at any reasonable time. Visitors were at the home during the inspection and one relative spoke with the inspector. They said they were always made to feel welcome and offered a drink, and they felt that the staff offered good care. The statement of purpose also sates that residents and relatives meetings are held regularly. The manager said these meetings had not happened although the residents are consulted about their choices daily. The manager made a commitment to re start meetings by May 2006. A member of staff said that they are skilled at asking the residents about their food choices. An example was given where an individual choice had been provided. The menu is advertised and the staff were observed reminding the residents about the meals. The food is home cooked and the residents were complimentary about the food. Most of the residents eat in the dining room but they can choose to have meals in the lounge or their rooms. The staff were observed helping a resident to have their meal, this was done in a dignified way. Beech Lodge Residential Home DS0000002671.V288321.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): 16,18 The home has the procedures in place to effectively deal with complaints and abuse allegations. EVIDENCE: The home’s statement of purpose states how complaints can be made. A visiting relative said they would be happy to approach the manager with any concerns. There is a book in the reception hall where relatives can write their comments. Staff said they can bring any concerns to the manager or the area manager and they are confident they would be taken seriously. There have not been any complaints since the last inspection. The home has the procedures in place for dealing with allegations of abuse. The staff last received training in Abuse awareness in August 2004 and new staff have started their employment since this date, so although one member of staff said they knew what to do, an updated course would increase the staff’s skills. Beech Lodge Residential Home DS0000002671.V288321.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): 19,21,23,26 There have been improvements to the cleanliness of the home and the security. EVIDENCE: The residents said they like their rooms and a sample of these showed them to be well decorated and furnished. During a tour of the home, the water from the bath and sink taps was run, and this felt a comfortable temperature to the touch. The temperature is tested on a weekly basis. The home felt comfortably warm and the boiler is working at all times. The dryer that had previously broken down has been repaired and clothes are cleaned and provided daily to the residents. The back garden has been fully fenced and the provider stated plans to fence the front of the home. A full time cleaner is employed and the home was clean, tidy and odour free. Beech Lodge Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 Page 16 Beech Lodge Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 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): 27,28,29,30 The home has improved the level of service by increasing the staff numbers, and the training opportunities. EVIDENCE: The staffing levels have increased incrementally with the increase in residents. The staff said they had enough time to meet all of the residents needs, this included spending time talking to the residents and doing activities. The staff have received appropriate training opportunities, and the manager said that the range of courses had improved. Recent courses have included, Palliative care, challenging behaviour, Fire safety and Dementia awareness. The staff on duty were able to communicate effectively with the residents and one member of the team said this had also improved, with new staff now having competent communication skills. One member of staff said that the staff work well together as a team and they feel supported by the acting manager. A sample of the staff files were seen and they did contain information that was available during the recruitment process. 1 File did not contain a job description, although this member of staff was clear about their role. Staff do receive an induction to the home but the records have not been completed. Beech Lodge Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 Page 18 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): 31,33,36,38 The manager is making improvements to the service, but they need to increase the consultation with the residents and their representatives. Staff are supervised and the residents health and safety are protected. EVIDENCE: The acting manager has started their registered managers award and N.V.Q level 4 and is able to lead the care team. The commission has received an application to consider registration of the acting manager. The manager has introduced regular supervision and annual appraisals. The providers have previously met with a number of the resident’s relatives and discussed the quality of the service. The home have not conducted any recent quality reviews, but the manager stated that they plan to carry this out over the next month and that the forms are prepared. Beech Lodge Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 Page 19 The manager informed the inspector that the Environmental Health Officer had inspected the home in February 2006 and a certificate had been received, no requirements had been made. The manager and staff have been completing regulation 37 notifications and the accident book corresponded to the information that the commission had received. Beech Lodge Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 Page 20 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 2 3 2 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 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 X 3 X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X 3 X 3 Beech Lodge Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO 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 OP2 Regulation 5(1)(c)(3) Requirement The provider must give each service user a contract between the home and the service user. They must also supply a copy of the service agreement from the funding authority. The provider must confirm in writing that the home can meet the needs of each service user, prior to their admission. The provider must complete a care plan (service user’s plan) in consultation with every service user or their representative and this must be kept under review. This must be completed as soon after admission as possible for both respite and long-term service users. The provider must consult the service users and use the results to improve the level of choice of each service user, and to make continuous improvements to the home. The provider must consult the service users and use the results to improve the level of choice of each service user, and to make DS0000002671.V288321.R01.S.doc Timescale for action 30/05/06 2 OP4 14(1)(d) 30/05/06 3 OP7 15 30/05/06 4 OP33 24(1)(2) (3) 30/05/06 4 OP14 24(1)(2) (3) 30/05/06 Beech Lodge Residential Home Version 5.1 Page 22 5 OP18 18(c)(i) 13(6) continuous improvements to the home. The provider must ensure that the service users are protected from abuse by providing training for all staff. 30/07/06 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 OP30 Good Practice Recommendations It is recommended that any induction that new staff undertake is recorded. Beech Lodge Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Residential Home DS0000002671.V288321.R01.S.doc Version 5.1 Page 24 - 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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