Inspection on 11/04/05 for Beechwood Lodge

This inspection was carried out on 11th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Beechwood Lodge 29/10/09

Beechwood Lodge 03/11/08

Beechwood Lodge 30/06/08

Beechwood Lodge 14/01/08

Beechwood Lodge 29/06/07

Beechwood Lodge 26/04/06

Beechwood Lodge 28/09/05

Beechwood Lodge 30/12/04

Beechwood Lodge 13/08/04

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

CARE HOMES FOR OLDER PEOPLE Beechwood Lodge 148 Barnhorn Road Bexhill on Sea East Sussex TN39 4QL Lead Inspector Kev Whatley Unannnounced 11 April 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. Beechwood Lodge Version 1.10 Page 3 SERVICE INFORMATION Name of service Beechwood Lodge Address 148 Barnhorn Road, Bexhill on Sea, East Sussex TN39 4QL 01424 844989 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) Beechwood Lodge Ltd Mr Robert Jempson Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (OP) 20. of places Beechwood Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is twenty (20). Date of last inspection 30 December 2004 Brief Description of the Service: Beechwood Lodge is a care home which is registered to accommodate a maximum of 20 older people. The home is owned and managed by Mr Robert Jempson. The premises are situated in a residential area of East Sussex near to Little Common and just over a mile from Bexhill-on-sea. The home is close to local shops and amenities and the coast is less than a mile away. Bedroom accommodation is situated on two floors, with a shaft lift to enable residents ease of access to each floor. The home has considerable comunal space and also a well maintained large garden. Beechwood Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Beechwood Lodge will be referred to as ‘residents’. The unannounced inspection took place on a weekday in April between the hours of 10am and 3pm. Eleven residents were accommodated at the home at the time of the inspection. The inspection included a tour of the premises and it’s facilities, with many residents also consenting for their bedrooms to be viewed. Approximately three residents were spoken with individually, whilst several others commented on their care during lunchtime after the Inspector had been invited to join them for the meal. The manager, the deputy manager, a member of care staff, and a visiting District Nurse were spoken with during the visit; whilst care staff were also observed carrying out their duties. Records and documentation inspected included: residents files, residents care plans, fire safety log, the homes complaints book, and various policies and procedures. The Inspector would like to thank residents and staff for the enthusiastic and helpful manner in which they participated in the inspection process. What the service does well: Beechwood Lodge offers residents a good level of personal care, provided by care staff who appear committed and caring. The home’s environment is generally well maintained inside and out and is decorated to a high standard throughout. All bedrooms have been suitably personalised and have en-suite toilet facilities. The home has a commendable amount of communal space that allows residents opportunities to meet with each other or alternatively find quieter areas of the home should they wish. Residents are encouraged to maintain contact with relatives/carers and friends and there is a relaxed approach to visitors and guests. Residents are supported to maintain contact with their local community, and are supported by the home to be make decisions and choices for themselves. Beechwood Lodge has an atmosphere that is homely, relaxed, and caring. Beechwood Lodge Version 1.10 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beechwood Lodge Version 1.10 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 Beechwood Lodge Version 1.10 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, 3, 5, and 6. Beechwood Lodge provides appropriate information about the home and the services it offers. The home ensures they can meet residents needs prior to them being admitted. EVIDENCE: Beechwood Lodge have developed a satisfactory statement of purpose that outlines the layout of the premises, the homes philosophy of care, and the nature of services offered to residents. The home have also developed a guide for residents that offers general information, however this needs to include all relevant information as required by registration, including the contact details of CSCI. Residents files contained pre admission questionnaires and full needs assessments, which had been completed prior to residents being admitted. One resident stated that they had been visited at their home by the deputy manager of Bechwood Lodge prior to moving in. The deputy manager said that all prospective residents are visited and fully assessed before being admitted. The home does not offer intermediate care. Beechwood Lodge Version 1.10 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, 8, and 10. The home must develop a more detailed and comprehensive system of care planning to ensure the assessed needs of residents are fully met. Residents are treated with respect, care, and dignity. EVIDENCE: Requirements to improve the system of care planning were made in the previous inspection, however no action has yet been taken to address these issues. Residents care plans contain basic information in relation to the physical, health, social, and personal care needs of residents, whilst relevant medication information is also evident. However the care plans lack the necessary details of how such needs are to be met and carried out by care staff. Care staff were seen to interact with residents in a relaxed, caring, and respectful manner. Several residents commented on the level of care they received as being: ‘very good’, ‘thoughtful’, and ‘excellent’. Care staff spoken with had positive and respectful views on the residents for whom they care for. Beechwood Lodge Version 1.10 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) 13,14, and 15. Beechwood Lodge has a supportive approach toward encouraging residents to maintain contact with others outside of the home, and exercise choice over their lives. The home meets the dietary needs of residents. EVIDENCE: Many residents at the home maintain regular contact with relatives, carers and friends and have visits throughout the course of the week. The home’s visitors policy was viewed and this indicated that the home encourages residents to invite quests as often as they wish. The visitors book confirmed that visits had taken place recently. Residents are also encouraged to maintain contact with the local community and several residents stated that the home pay for a taxi to take them to and from the nearby shops; whilst care staff shop for small items, such as chocolates and sweets, for residents unable to venture away from the premises. The Inspector was invited to take a meal with residents at lunchtime, this took place in a congenial dining room setting. The meal was well prepared and presented to a satisfactory standard. Previous menu’s indicated that the home provides residents with an appetising, varied, and balanced diet. Residents noted that meals at the home were of a high standard, with one resident stating that generally the food was ‘very good and tasty’. Beechwood Lodge Version 1.10 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 and 18. The home’s poor approach in regard it’s policies and procedures for the protection of vulnerable adults may place residents at risk from harm, neglect, or abuse. EVIDENCE: The previous inspection report made requirements that the home must address it’s polices and procedures in relation to complaints and the protection of vulnerable adults, no action has yet been taken to address these issues. The complaints book was viewed and there was evidence to suggest that previous complaints had been recorded appropriately, though detail of the actual outcome of the subsequent investigation was poor. Beechwood Lodge have a complaints procedure that generally complies with the regulation of the home, however it lacks sufficient details, such as the contact details of CSCI. The complaints procedures are not included in the residents guide, nor are they displayed prominently in a communal area of the home. The home’s Polices and procedures in relation to adult protection were viewed, these included relevant ‘whistle blowing’ advice for staff who suspect harm, neglect, or abuse within the home. Care staff spoken to had a good understanding of basic adult protection procedures. However the home do not have a compulsory training programme for care staff which addresses adult protection. The proprietor/manager said he has yet to implement the requirements made in the previous report, and has therefore not established a suitable system of adult protection training for his staff. Beechwood Lodge Version 1.10 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, 20, 21, 23, 25, and 26. The home’s environment is generally suitable to meet the needs of all residents. However, the home must review it’s health and safety polices and procedures to ensure that residents are kept safe. EVIDENCE: Beechwood Lodge has been maintained to a good structural order both inside and out and has been decorated to a high standard that is both homely and relaxed. A number of residents agreed for their rooms to be viewed and these were seen to be in good order having been personalised with photo’s, pictures and ornaments. All of the bedrooms have en-suite toilets whilst four of these also have showers; there are adequate numbers of communal toilets and bathrooms on both levels of the home, though these must have locks and signs fitted. The home has considerable communal area space including two lounges, both with TV’s and stereo’s, and a large dining area; whilst there is a large well maintained garden to the side and rear of the property with easy access for all Beechwood Lodge Version 1.10 Page 13 residents. The home was found to be clean, tidy, hygienic and free from any odours or smells. However one upstairs bathroom was found to contain a number of stored items, although care staff stated this was no longer used by residents. The Inspector also found an aerosol can of wasp spray in an unlocked chest of drawers, whilst newspapers, due for recycling, were stored under the stairs. Records viewed confirmed that fire safety checks had been carried out though it was unclear how regularly. Records also indicated that the necessary fire safety equipment had been maintained in a suitable condition by a certified engineer. The previous inspection made a requirement that all radiators at the home should be covered to prevent any risk to residents of burns or scalds. However, no action has been taken to address this and the radiators remain unguarded. The proprietor/manager acknowledged that this area of health and safety is now in urgent need of completing, although he could not guarantee a date when the work is expected to begin. Beechwood Lodge Version 1.10 Page 14 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, 29, and 30. The assessed needs of residents are met by the numbers and skills of care staff deployed at the home. The home fails to maintain adequate records or provide suitable training to ensure the protection of vulnerable adults. EVIDENCE: On the day of the inspection the manager was working as a member of care staff and stated that he had had to do so on a number of occasions recently due to staff shortages. The rota indicated that there were three members of care staff on duty during the day, whilst the home operates a system of having one ‘waking night’ and one ‘sleep in’ member of care staff on duty during the night. Residents stated that care staff were ‘thoughtful’ and ‘good’ at their jobs and none spoken to had any complaints as to the level or quality of care they receive at the home. The home are required to keep information relating to care staff on the premises at all times, including details of their previous employment, confirmation of Criminal Records Bureau (CRB) checks, references, and confirmation of training or qualifications. At the time of the previous inspection the proprietor/manager stated that he had this information at his home address. Unfortunately this was also the case at the time of this inspection and consequently no staff files were viewed. The previous inspection made a requirement that an appropriate programme of induction and training, that is approved by the Training Organisation for Personal Social Services (TOPSS), must be implemented for care staff. Beechwood Lodge Version 1.10 Page 15 However, no action has been taken to address this issue. The proprietor/manager stated that as yet he has not been able to implement the required programme since the last inspection. Beechwood Lodge Version 1.10 Page 16 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, 36, 37, and 38. The management of the home encourages an open, relaxed, homely and caring atmosphere. The manager must review the homes ability to offer residents a safe environment, whilst ensuring care staff are suitably supported and guided. EVIDENCE: The home has been managed by the proprietor/manager for a number of years and in general he appears to have fulfilled this role. However the proprietor/manager has no formal qualifications in care or care management and stated he has no intention of gaining any. The proprietor/manager noted that he is considering a number of options at this time including the possibility of employing a care manager. Residents commented that they felt ‘looked after’ and ‘comfortable’ in their environment and able to speak to the proprietor/manager should they have Beechwood Lodge Version 1.10 Page 17 any concerns or complaints. Bechwood Lodge appeared relaxed and homely, whilst residents were seen to be settled and content at the home. The previous inspection recommended that the proprietor/manager should introduce a formal staff supervision programme. However no action has been taken to address this issue and subsequently staff do not receive any formal supervision at the home. Care staff commented that despite having no formal supervision that they felt supported by the proprietor/manager, whilst the deputy manager offers further support and guidance. The proprietor/manager appeared to have a good understanding of legislation in respect of health and safety issues within the home, though he acknowledged that the failure to fit radiator guards continued to place residents at risk. The proprietor/manager also acknowledged that the failure to keep staff files on the premises, as required by legislation, is not acceptable. It was noted that this is the second inspection in a row that this has been the case. Beechwood Lodge Version 1.10 Page 18 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. Where there is no score against a standard it has not been looked at during this inspection. 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 1 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 1 4 3 x 3 x 1 3 STAFFING Standard No Score 27 3 28 2 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 2 3 3 x x 1 1 1 Beechwood Lodge Version 1.10 Page 19 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 OP1 Regulation 5(1)(2) Requirement The service user guide must be reviewed to ensure it contains all necessary information, including the contact details of CSCI (outstanding from the previous two inspections). Residents care plans must set out in detail the action that needs to be taken by care staff to ensure all aspects of residents health, personal, and social care needs are met (outstanding from the previous two inspections). The complaints procedure must be readily available to residents and visitors to the home, and must contain the contact details of CSCI (outstanding from the previous inspection). The home must implement an adult protection training programme, which is compulsary for all staff (outstanding from the previous inspection). That the upstairs bathroom is not not used for the purpose of storage, whilst hazadous chemicals or liquids must be stored securely. That guards must be fitted to all radiators and hot water pipes Version 1.10 Timescale for action 28.02.05 extended to 11.10.05 31.03.05 extended to 11.10.05 2. OP7 15(1) 3. OP16 22 (7) (a)&(b) 31.01.05 extended to 11.10.05 31.03.05 extended to 11.10.05 Immediate 4. OP18 13(6) 5. OP19 13(4)(c) 6. OP25 13(4) 31.03.05 now Page 20 Beechwood Lodge 7. 8. OP29 OP30 17(2) 18(1) (a) & (c) 9. OP36 18(2) 10. OP37 17(3) (a)&(b) 13(4) (a)&(c) 11. OP38 (outstanding from the previous inspection). The home must maintain records on the premises relating to all staff, as required by schedule 4. The home must ensure that there is an adequate induction and training programme for all care staff, that is in line with Training Organisation for Personal Social Services (TOPSS) acreditation (outstanding from the previous inspection). The management of the home must ensure that a suitable programme of formal staff supervision is implemented. The management must ensure that records required by regulation are kept on the premises. The management must ensure that the home complies with all health and safety regulations. Immediate Immediate 31.03.05 extended to 11.10.05 11.10.05 Immediate Immediate 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 OP28 OP31 Good Practice Recommendations That 50 of care staff obtain NVQ level 2 qualifications in care. That the proprietor/manager obtains NVQ level 4 in care management or equivilant, or that a suitably qualified person is employed to manage the home. Beechwood Lodge Version 1.10 Page 21 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Beechwood Lodge Version 1.10 Page 22 - 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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