Inspection on 26/04/06 for Beechwood Lodge

This inspection was carried out on 26th April 2006.

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 28/09/05

Beechwood Lodge 11/04/05

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 Liz Daniels Unannounced Inspection 26th April 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beechwood Lodge DS0000021046.V288488.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. Beechwood Lodge DS0000021046.V288488.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beechwood Lodge Address 148 Barnhorn Road Bexhill-on-Sea East Sussex TN39 4QL 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) 01424 844989 Beechwood Lodge Limited Mr Robert Jempson Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Beechwood Lodge DS0000021046.V288488.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty (20). Service users must be older people aged sixty-five (65) years or over on admission. 28th September 2005 Date of last inspection Brief Description of the Service: Beechwood Lodge is a care home registered to accommodate a maximum of 20 older people. 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. There are twelve single rooms and four double rooms, all of which have en-suite facilities. In addition there are two bathrooms and six toilets. The Home has two lounges, a billiard room and a dining room to provide communal space and there is also a large garden. The Home welcomes prospective residents or their representatives to view the premises and discuss their needs with the Manager. Weekly fees, as at 19/04/06, range from £395 - £550. The fee includes hairdressing, chiropody and manicures, standard toiletries, newspapers/magazines, transport for medical appointments and residents’ telephone calls: there are no additional charges. Information about the service, including the Commission’s inspection report, is available from the Manager on request. Beechwood Lodge DS0000021046.V288488.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 unannounced. It included a visit to the Home by an Inspector, which began at 10am and lasted for a period of just over eight hours. The visit was facilitated by the Owner/Manager and it provided the opportunity to meet with three members of staff and talk with one in more detail before spending time with the residents, both within the privacy of their own room and as they sat together in the lounge. No visitors were available to meet with the Inspector during the site visit and no surveys had been returned, for their feedback to be included in this report. The Inspector also toured the premises and examined records that included resident’s files, the medication records, accident log, complaints log, kitchen records including the menus and CRB disclosures. Evidence contributing to this inspection has also been gathered from data provided by the owner of Beechwood Lodge and from previous inspections. All of the key standards, together with those where concerns had been raised at the last inspection, were inspected. There are currently 12 residents at Beechwood Lodge. What the service does well: What has improved since the last inspection? What they could do better: Six Requirements are outstanding from the last inspection: one relates to the Home’s information, one to the health and safety of residents, three to the recruitment and development of staff and one to future management arrangements. As recommended at the last inspection, the Statement of Purpose and Resident’s Guide must be updated to reflect the level of service provided and therefore give clearer information for prospective residents. The Home must also confirm that they can meet the needs of prospective residents Beechwood Lodge DS0000021046.V288488.R01.S.doc Version 5.1 Page 6 and once admitted, an individual plan of care must be developed, enabling staff to deliver appropriate care. Residents would benefit from a structured activity programme and their individual choice as to how they feel respected should be considered. Residents would be better protected if the outstanding health and safety concerns were addressed: these include fire safety measures, risk assessments for self-medication, inappropriate storage and the provision of radiator guards and window restrictors. Robust recruitment procedures must be implemented to protect residents: induction and foundation programmes, as well as a formal programme of staff supervision, must be introduced to enable staff development. The Home needs to introduce formal quality assurance systems, including gaining feedback from residents and relatives, to ensure the Home is run in the best interest of residents. 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. Beechwood Lodge DS0000021046.V288488.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 Beechwood Lodge DS0000021046.V288488.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, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The information available for residents does not reflect the service available at Beechwood Lodge and the limited assessment process of prospective residents is only suitable for those with low care needs. EVIDENCE: It was recommended at the last inspection that the Home’s Statement of Purpose & Residents Guide should provide information about its service provision for respite care and details of the services it does not offer. Resident’s comments regarding the level of service offered at Beechwood Lodge should also be included. Neither document has been amended. The records for four residents were reviewed. All had evidence that they had been assessed and the Proprietor/Manager explained that this is done prior to admission. Two ‘pre-admission assessments’ had not been signed or dated, one was dated two days after admission and one on the day of admission. One file contained an Occupational Therapy report dated two months prior to a resident’s admission and two files contained old Risk Assessments by Social Services. The Proprietor/Manager confirmed that he asks for information from Beechwood Lodge DS0000021046.V288488.R01.S.doc Version 5.1 Page 9 nursing and medical staff before accepting residents from hospital, but written information is not usually available. Following the assessment the resident is informed verbally whether or not the Home can meet their needs. The last inspection found that a new format for care planning, which included an assessment and a plan of how the assessed needs could be met, had been introduced. Three of the four files seen had evidence of assessments undertaken last August. There were then Care Plans that identified several needs but did not reflect some of the areas of support that had been identified in the assessment. There was no evidence that a resident admitted three weeks previously had had any assessment other than pre-admission and the Care Plan had not been started. One resident said ‘no one came and talked with me when I arrived, to find out about me. I didn’t know there’s a plan for me’. They recalled the owner coming to see them in their home, but did not realise why he had come. Overall the Inspector found that the assessment documentation is limited as it does not contain all the areas of personal, social and health care needs required. The resident’s records seen did not demonstrate a comprehensive pre-admission assessment to underpin the development of a care plan. Beechwood Lodge does not provide Intermediate Care. Beechwood Lodge DS0000021046.V288488.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 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Each resident must have a detailed plan of care that sets out the action needed to meet all his or her needs. EVIDENCE: The assessments and care plans for four residents were reviewed. General assessments had been competed last August, for three of those residents. There was no evidence that the Care Plans had been drawn up with the resident and the information in them does not reflect the changing needs of the residents, nor have they been reviewed. The fourth file for a resident, who has been at the Home for over three weeks, did not have a Care Plan. Two residents had Risk Assessments that had been completed prior to their admission, but none were seen that had been completed after any of the four residents had come into the Home. Although one resident had been noted in their assessment last year as becoming more forgetful and becoming increasingly unsteady, there was no record of a Risk Assessment and the support needed for her mobility was not explained in the Care Plan. The Proprietor/ Manager confirmed that health professionals are accessed as needed and gave several examples of situations that had arisen with residents, Beechwood Lodge DS0000021046.V288488.R01.S.doc Version 5.1 Page 11 but it is unclear as to whether this information is recorded. The Home supports residents in caring for themselves as far as they are able: many of the residents at Beechwood Lodge need minimal help with their personal care apart from with their weekly bath. One resident self-medicates and keeps a month’s supply in her room. There is no lockable cupboard, although the Proprietor/Manager explained that he has bought safes for the rooms, which have not yet been installed: currently this resident’s medication is kept in a drawer. It is recorded that she self-medicates on the Medication Administration Record (MAR chart) and the resident said she would tell the staff if she was worried that she couldn’t do it anymore. There was no evidence to suggest Risk Assessments are completed to ensure residents are able to self-medicate. The MAR charts were seen and were correctly completed and medication stored safely: the majority of medication is dispensed in blister packs and all the care staff have had recent training with Boots pharmacy. The Proprietor/Manager confirmed that training records were not available to be seen on the day of the visit to the Home. The pharmacist undertakes a medication audit every 3 months. During the visit, staff were observed to be attentive and considerate. Residents have a telephone in their room and staff confirmed the importance of promoting privacy and respect when residents are undergoing examinations or personal care. The preferred term of address for residents is recorded in the Care Plan. One gentleman confirmed that he would far rather be known by his first name but that it is usual to be addressed formally: during the visit both the staff and other residents were noted to be referring to him by his surname. Beechwood Lodge DS0000021046.V288488.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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The lifestyle experienced by residents does not always match their expectations and preferences, and does not satisfy their social, cultural, religious and recreational interests or needs. However, they benefit from a wholesome nutritious menu. EVIDENCE: There are different lounge areas at Beechwood Lodge, providing space for residents to meet together, watch television or sit quietly to read or listen to music. There is a library of videos and a selection of records available. There is also a room with a billiard table for the residents to use and large gardens that are accessible for the residents, surround the Home. Friends and relatives can visit anytime and the staff re-arrange meals for residents who wish to go out. There was no record in any of the Care Plans seen, of residents joining with community activities and no resident who spoke with the Inspector had developed links with the local community. Several residents, who were sitting together in one of the lounges during the visit, commented that ‘it’s a lovely place’ where they are free to stay in their rooms or can go downstairs as they wish. They then all agreed that ‘they would like to go out more’ as ‘there’s not much to do’. One resident, who was spending time in his room, commented that there is little opportunity for everyone to get together as they only meet Beechwood Lodge DS0000021046.V288488.R01.S.doc Version 5.1 Page 13 at mealtimes and ‘there is the risk of becoming insular’. Another said she had no complaints but if activities were organised she thought she would join in. There is not a pre-planned Activity Programme at the Home and residents’ meetings are not currently held. Possible activities were therefore discussed with the Proprietor/Manager during the visit and it was agreed that he would explore possibilities for the residents. As stated earlier many of the residents remain active and do not need high levels of personal care. They have personal possessions in their rooms and they either manage their own financial affairs or a relative or solicitor acts on their behalf. The Home does not act as the appointee for any resident or handle any personal monies. A new cook has recently joined the home following a considerable period when there has not been a permanent person in post. There had therefore not been a choice of foods written on the menu although the Proprietor/Manager confirmed that despite what is on the menu, residents can ask for alternatives they may prefer. Fresh fruit and vegetables were evident and overall the menu appeared varied and nutritious. Meals can be eaten in a pleasant dining room or in the resident’s own rooms if they prefer. The residents who met with the Inspector gave a mixed response to the food, which varied from it being ‘run of the mill’ and ‘not bad’ to ‘very good’. Beechwood Lodge DS0000021046.V288488.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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The Home has a satisfactory complaints procedure, with some evidence that resident’s views are listened to and acted upon, although the investigation, outcome and any action taken is not recorded in full. Good measures are now in place to ensure residents are protected from abuse. EVIDENCE: Previous inspections have found a comprehensive complaints procedure in place, which is readily available for residents and their relatives. Residents seen during this site visit expressed great confidence in the Proprietor/Manager and confirmed that they can raise anything with him and feel reassured that he will listen to them and follow through their concerns. The Commission has received one complaint about Beechwood Lodge since the last inspection, which, when investigated, was not upheld. This was not recorded in the Complaints Log: the last recorded complaint was in April 04. The Proprietor/Manager commented that he had not realised the need to record minor concerns that he ‘sorts out’ nor complaints about the service that have not been raised directly with him by an individual using the service. There continues to be adult protection policies and procedures in place that include clear guidance on whistle blowing. Staff were trained about Adult Protection in October 05. The Proprietor/Manager explained that as the fees are all inclusive and there are no extra services provided, there is therefore no need for the home to handle residents’ monies: the home does not therefore have an account for resident’s monies. Beechwood Lodge DS0000021046.V288488.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, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The standard of furniture and décor is good, providing residents with an attractive and homely place to live: however residents are at risk until a number of health and safety issues are addressed. EVIDENCE: Beechwood Lodge is accessed from one of the main roads leading out of Little Common. It is a detached property with accommodation over two floors and it has a large gravel frontage providing parking space for several cars and level access to the front door. The main entrance hall is spacious and there are several lounge areas and a dining room all on the ground floor. One room has a billiard table for residents to use, with a quiet area at one end and the Home has its own hairdressing room. There is a large garden that can be accessed from two of the lounge areas. A shaft lift provides access for both the ground and first floor. The Home is nicely furnished and, as with past inspections it was again found to be clean and tidy, free from any odours. Resident’s bedrooms that were seen are furnished and equipped to assure comfort and Beechwood Lodge DS0000021046.V288488.R01.S.doc Version 5.1 Page 16 privacy. Most of the residents who met with the Inspector commented that they liked their bedrooms: they described Beechwood Lodge as ‘a lovely place’ and that ‘the surroundings are more like a hotel’. The last inspection highlighted that radiator guards had been fitted in most bedrooms. The Proprietor/Manager explained that residents have found the guards prevent the radiators heating their rooms sufficiently. He has therefore ordered low surface temperature radiators to be fitted throughout and anticipates these will be installed within three months. In the meantime, the communal areas continue to have unguarded radiators. A tour of the premises again found that windows do not have restrictors and the area of the Home up some stairs, which is being used for storage, has not been cordoned off to prevent residents accessing it in error. The Proprietor/Manager confirmed that although he does not have a written maintenance plan or programme, he plans to address these hazards. There are not locks on the bedroom doors whereby residents can have their own key, and no lockable space within the rooms. Beechwood Lodge DS0000021046.V288488.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 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. There is not a planned approach to staff training and development, to ensure that the staff who care for residents are skilled and competent. Robust recruitment procedures must be implemented to ensure the residents are protected. EVIDENCE: As found at previous inspections, there are two carers rostered to work during the day at Beechwood Lodge and one waking carer at night, which appeared adequate for the number of residents currently in the home. The Proprietor/Manager often assists with the daytime care of the residents and, as he lives nearby, is accessible at night if needed. This is an informal arrangement as there is not a written rota of staff ‘on call’. Agency staff are employed if required: the Proprietor/Manager identified six nights over the past eight weeks when an agency care assistant had worked. Of the eight care staff at Beechwood Lodge, one has achieved NVQ Level 3 and one has NVQ Level 2. There are also two carers currently studying for Level 3 and one undertaking Level 2. It is not known whether the agency staff who work at the home have any NVQ training. The Proprietor/Manager stated that staff files were unavailable to view, during the visit. He explained that although he has information about staff, it is not organised and filed. Criminal Record Bureau (CRB) disclosures were available and three were seen. However the Proprietor/Manager confirmed that he has not yet received either the CRB disclosure nor written references for an Beechwood Lodge DS0000021046.V288488.R01.S.doc Version 5.1 Page 18 ancillary member of staff who had started nine days previously. This practise has been evident at past inspections. The value of applying for a Protection of Vulnerable Adults First (POVA first), to enable staff to start employment and work under direct supervision until the CRB is received, was discussed. The new member of staff has not had a formal induction programme arranged but confirmed she was shown around and the whereabouts of the fire exits, fire procedure and equipment were explained. The Proprietor/Manager explained that training records were also unavailable but he confirmed that whilst incidental training is arranged as necessary to ensure staff receive their mandatory updates, there is still no programme of induction or foundation training that is approved by ‘Skills for Care’. However as with past inspections, care staff were seen to be courteous, caring and knowledgeable in the way they approached the residents and as many of them have been at the Home for some time they have gained experience in assessing and meeting basic individual needs. Beechwood Lodge DS0000021046.V288488.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Beechwood Lodge is managed with the best of intentions in mind for the residents, but their individual wishes are not always met. Poor adherence to fire regulations and health and safety measures compromises the safety and welfare of residents. EVIDENCE: Beechwood Lodge has been owned by the same family for many years and continues to be managed by the proprietor. As at the last inspection, he again stated that he does not wish to gain the necessary qualifications in care and care management that are required to be the Registered Manager of a care home: he would still prefer to utilise his current qualifications and return to the legal profession. He acknowledges that, in order to conform to the requirements of registration, he needs to implement different management options than are currently in place and anticipates a solution being found within the next three months. Beechwood Lodge DS0000021046.V288488.R01.S.doc Version 5.1 Page 20 As with previous inspections residents commented that Beechwood Lodge is a comfortable home and ‘the staff are very nice’. Several said they like the fact that there are very few rules. The Inspector found that although there are no formal systems in place to monitor the quality of the service being offered, the Proprietor/Manager clearly does listen to comments and concerns, and actions them accordingly. The Proprietor/Manager explained that he does not actively seek feedback through anonymous satisfaction questionnaires but does keep cards & letters from residents and their relatives. He confirmed that he has a plan of things that need doing in the home and as with the radiators does respond to the views of the residents. However there is no written record. The policies seen were all dated 2002: the Proprietor/Manager explained that he is currently updating them. As recorded earlier in the report, three of the residents manage their own financial affairs and the remainder have a relative or solicitor who acts on their behalf. The home does not therefore handle personal monies for any resident. As found at previous inspections, there is no formal staff supervision programme in place. The Proprietor/Manager explained that there is a small staff team and a very low staff turnover, whereby on-going informal staff supervision can occur on a daily basis. Since the last inspection, staff have been trained in Moving & Handling (Feb. 06) and Fire training (Jan. 06). Health & Hygiene training for managing food, is planned for May 06 and Training in Health & Safety in the Workplace, which will include the control of infection, is also being arranged. As First Aid is included in the NVQ modules, those undertaking that training will be trained, but the Proprietor/Manager confirmed that it has not been arranged for other staff. Good practices in food management and infection control were seen during the visit to the home and the record supplied by the Proprietor/Manager of maintenance checks undertaken, show them all to be up to date. The Accident Log was also seen: there have been no records entered since November ’04. The Proprietor/Manager could not recall if there had been any accidents since that date. During the day, doors to some resident’s rooms were propped open; this practice must cease. The Manager and the residents concerned confirmed they do not wish to have their door closed whilst in them during the day: alternative arrangements must therefore be put in place that do not compromise fire safety for the residents. Beechwood Lodge DS0000021046.V288488.R01.S.doc Version 5.1 Page 21 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 2 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 2 Beechwood Lodge DS0000021046.V288488.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 (1)(2) 5(1)(2) Schedule 1 Requirement The Home’s Statement of Purpose and Resident’s Guide must include information regarding its service provision for respite care and also details of the services it does not offer. The Home must also consider including resident’s comments regarding the level of service offered at Beechwood Lodge. (This is an outstanding Recommendation from the last inspection in September 2005). The prospective resident must be informed in writing that the Home can meet their needs. The Home must use the information gathered during the pre-admission assessment (and assessments from other agencies) to formulate a plan of care for daily living and longerterm outcomes. There must be a current Risk Assessment and lockable storage, for any resident who wishes to self-medicate. There must be opportunities for DS0000021046.V288488.R01.S.doc Timescale for action 31/08/06 2. 3. OP3 OP3 14 (1)(c)(d) 15 (1)(2) 26/04/06 26/04/06 4. OP9 12 (4) 16 (2)(l) 16 (2)(n) 31/05/06 5. OP12 30/06/06 Page 23 Beechwood Lodge Version 5.1 Schedule 1(9) 6. 7. OP16 OP38 22 Schedule 4(11) 13 (4)(c) 8. OP29 17 (2) 9. OP30 18 (1)(a)(c) 10. OP31 9 (1)(2)(b) 11. OP36 18 (2) 12. OP38 12 (1) 23 (4) residents to join in activities together and information about them must be circulated. All complaints received must be logged and the investigation and any action taken be recorded. Radiators must be guarded (or have a low surface temperature), window restrictors must be fitted and the area of the home used for storage must be cordoned off, to maintain the safety of the residents. (This is an outstanding Requirement from the last seven inspections) Legislative requirements must be in place when recruiting staff. (This is an outstanding Requirement from the last inspection in September 2005) A suitable induction and foundation programmes must be implemented to enable staff development. (This is an outstanding Requirement from the last five inspections) The Proprietor/Manager must ensure there is an appropriately qualified manager in post. (This is an outstanding Requirement from the last inspection in September 2005) A formal system of supervision for staff must be introduced. (This is an outstanding Requirement from the last inspection in September 2005) All fire doors must be closed and the local Fire Authority for Beechwood Lodge should be consulted about appropriate methods of holding bedroom doors open. DS0000021046.V288488.R01.S.doc 26/04/06 31/07/06 27/04/06 31/08/06 31/07/06 31/08/06 31/05/06 Beechwood Lodge Version 5.1 Page 24 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 OP10 OP24 Good Practice Recommendations All staff should use the term of address preferred by the service user. Residents should have the opportunity to have a key to their room and should have lockable space within their room for medication, money and valuables (unless their risk assessment suggests otherwise). Beechwood Lodge DS0000021046.V288488.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection East Sussex Area Office 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 DS0000021046.V288488.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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