Inspection on 29/10/09 for Beechwood Lodge

This inspection was carried out on 29th October 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC 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

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 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 08/06/2011.

Key inspection report CARE HOMES FOR OLDER PEOPLE Beechwood Lodge 148 Barnhorn Road Bexhill-on-Sea East Sussex TN39 4QL Lead Inspector Michele Etherton Key Unannounced Inspection 29th October 2009 09:30 am ES0000021046.V2000080497.R01 .doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should:      Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by:  Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice  Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983  Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services.  Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.2 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 (0) of places Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.2 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. 15th May 2009 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. Accommodation comprises of twelve single bedrooms and four double bedrooms, all of which have en-suite facilities. Bedrooms are located on two floors. There is a shaft lift to enable service users’ ease of access to each floor. 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. There are well maintained rear gardens and car parking facilities at the front of the property. The current fees range from £460 - £850 per week. There are no extra charges made, except for personal items such as clothing and toiletries etc. Potential new service users can obtain information relating to the home by word of mouth, CSCI inspection reports, care managers and placing authorities, contacting the home direct and Social Services. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This home is subject to enforcement action. As the home is subject to enforcement action no overall or individual outcome area quality ratings have been made, however judgments have been recorded under each grouping of standards. The history of the registration of the home shows that there has been insufficient understanding of the need to meet requirements and to sustain lasting improvements. Compliance with the regulations has not been as a result of a robust system of quality assurance to ensure all the people using the service receive good quality care and outcomes. An inspection of this service has been conducted that has taken account of information we know about the home and information we have received from the home and from other stakeholders. This includes an (AQAA) Annual Quality Assurance Assessment form. This was overdue having not been completed by the provider within the timescales given. The AQAA has been completed to a reasonable standard by the previous appointed manager, and we had discussed with her upon its receipt that it would benefit from additional content to illustrate how the home is working to address identified shortfalls, how the home operates on a day to day basis and future development plans. Our inspection of this service has included site visits to the premises on 29th October and 2nd November 2009 during which time we visited some of the communal spaces and bedrooms in the home with resident’s permission. We interviewed four staff in addition to speaking with the cook and the provider. We examined a range of documentation to ascertain whether recording and document practices within the home have improved, and assess progress to wards meeting outstanding requirements. To ensure that we were able to seek the views of residents, we were accompanied on our first day at the service by an expert by experience. A report of their anecdotal evidence and impressions from discussions with residents has been incorporated into this report. Historically the home has been non compliant with regulation over successive inspections and has been the subject of statutory notices and enforcement action. Our random inspection of this service earlier in the year following the appointment of a qualified manager gave some indications that a trend of improvement was beginning, due mainly to her hard work. This key inspection has been undertaken in the knowledge that the appointed manager had left and we wished to assess whether the registered person has Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.2 Page 6 been able to sustain and build upon the improvements made to progress and further outstanding requirements. What the service does well: The home is well located close to public transport and within a short distance of shops. It is generally accessible and provides a clean warm comfortable and pleasant environment for residents to live in. The health support needs of residents are well met with evidence that appropriate interventions are sought and that links with healthcare professionals are good. Staff’ promotes the independence of residents and are supportive and encouraging of residents retaining control of their lives and are respectful of the choices and decisions they make Residents enjoy a varied and nutritious diet that takes account of their own preferences and affords them opportunities to choose from more than one option. Continuity within the staff team means that residents benefit from a familiar group of experienced staff who has been provided with updated knowledge and skills to better safeguard residents. What has improved since the last inspection? A number of improvements had been initiated by the appointed manager who has now left consequently some areas of improvement have not been progressed. A new statement of Purpose and user guide have been developed and issued to all residents, omissions of some information and recent changes mean this needs further review. All residents have now received an updated copy of their terms and conditions. The home has been able to demonstrate that it has appropriately gathered information about prospective residents prior to admission and undertaken formal assessment of needs. Daily care logs are being maintained and in the main are reflective of care needs. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.2 Page 7 Some updated risk information has been developed for some of the residents by the previously appointed manager but this has not been continued with or extended to the remaining residents. New more person centred plans of care have been implemented but have not yet been rolled out across all residents, consequently some residents retain old care plans that fail to reflect care needs and support adequately. People who self medicate have risk information in place, and all administering staff has received training. A new complaints procedure has been developed and displayed but staff awareness of the process is inconsistent. All staff has received adult safeguarding training, unfortunately discussion with staff highlighted a lack of understanding about local adult safeguarding protocols, and where they can access these, and who alerts might be raised with initially. Only one new staff member is currently under consideration for appointment and a clear CRB has been obtained already prior to their commencing work. Some improvement has taken place in the recruitment process but not enough to evidence this is sufficiently robust. A copy of the previous EHO of 2008 has been made available to us to view and we have also now been provided with access to the latest visit report, which has highlighted a number of health and safety issues that the home is required to address. A training plan has been developed and a programme of mandatory training implemented to ensure staff have updated their training this year, there is no evidence that a rolling programme of training has been established to ensure gaps in refresher training do not recur. The home has provided us with AQAA information, only after repeat requests for this to be completed, and only when an appointed manager was in place to complete it. Records that we have asked to see for the purpose of inspection have been available to view in the home, although some information within staff records is still missing, and some records have not been updated. What they could do better: Although we recognise that there has been some progress made to address outstanding requirements, this improvement has occurred only through the input of the previously appointed manager, we acknowledge that for the majority of more able residents outcomes are reportedly good. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.2 Page 8 Our concerns are that we have worked with the registered person prior to 2005 where inspection reports have repeatedly highlighted shortfalls, and have made clear that in the best interests of the service there is a need for the appointment of an experienced and qualified manager. This year, following the brief appointment of an experienced and qualified manager we saw initial signs of improvement and development of the service. Unfortunately, with their departure our inspection highlighted that service development has stalled apart from ongoing liaison with a trainer in regard to planned training, and improvements that the registered person must make under Health and safety legislation, some improvements implemented by the appointed manager have not been sustained. Although well meaning the registered person by his own admission does not wish to pursue the necessary qualifications to help him fulfil the day to day management of the service effectively. The staff’ team is not provided with the essential leadership, structure, knowledge and guidance they would receive from an experienced and qualified manager and consequently are unaware of gaps in their knowledge and experience, their competency to undertake their day to day practice is not monitored. The Registered person demonstrates a reactive approach to management; lacks insight and knowledge about the care needs of residents to pre-empt and plan for changes in need and care practice. Our inspection of this service has shown us that: There is a need for the provider to ensure that documentation is maintained to ensure accuracy of information. The Provider must ensure that prospective residents are admitted only if the home can evidence that all their needs can be effectively met. The staff team has a limited understanding of care plans that reflect the personal preferences or wishes of residents. New care plans formats have not been progressed for all residents, care plans and risk information have not been routinely reviewed and updated to reflect changes. Residents who self administer their medications must have secure storage facilities in their bedrooms. Staff should be familiarized with the process of making complaints and their roles and responsibilities in respect of raising alerts and safeguarding residents. Staff’ needs to be made aware of the general risk assessments for the home and where they can reference these. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 9 The provider must demonstrate that the process for the recruitment of new staff is robust and that suitable induction is established. The provider must undertake to establish a system of quality assurance to measure the quality of service available to residents, mechanisms to collect collate analyze and feedback the responses of residents in regard to how they view the service need to be put in place. He must further ensure that he undertakes quality monitoring visits to the service and completes documentation to evidence this in compliance with regulation 26 of the Care Homes Regulations 2001. The provider must ensure that notifications of significant events that occur within the home are forwarded within appropriate timescales to the Commission in compliance with Regulation 37 of the Care Homes regulations 2001. The provider must address shortfalls identified in respect of the environment that may impact on the health and safety of staff and residents, and ensure that appropriate and sound risk information is in place to safeguard them. The service must provide assurances as to the financial viability of the service in the form of financial and business plans and most recently signed off accounts. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 10 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 ES0000021046.V2000080497.R01.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Beechwood Lodge is subject to enforcement action and therefore no quality rating has been made. Statement of Purpose and user guide information has been redeveloped and issued to residents, recent changes mean this now needs updating for the purpose of accuracy. This information is not routinely made available to prospective residents to inform decision making. Terms and conditions information has been redeveloped and issued to the majority of residents. Prospective residents and/or their representatives are provided with opportunities to visit, and can be confident that an assessment of their needs will be conducted prior to admission. It is important that placements are offered only to those for whom the home is registered and able to care for. EVIDENCE: Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 12 Statement of purpose and user guide information has been updated and has been issued to all the present residents of the home meeting a previous requirement. Discussion with staff about their involvement in showing prospective residents or their families around the home indicates this information is not routinely provided to them, although a small brochure and price list are. When we examined Statement of Purpose and User guide information we found that this mostly meets the requirements of legislation although some recent changes mean this is no longer accurate. The documents have some small contradictions in information between them and would benefit from the inclusion of additional detail in regard to the level of staff training. The Home makes clear within the Statement of Purpose who it can provide support to and who it cannot, this also informs prospective residents of the needs of people they may encounter if they choose to reside at the home and can make their decision based on this information. However, there has been a recent admission of a service user who is not included in the category usually covered by the service’ Statement of Purpose. The omission of this information in the Statement of Purpose, places either the prospective resident or other people at risk of living in an environment where people may not fully understand their behaviour or care needs. The Registered Person made a decision based on their belief that the service could meet the person’s needs in full. This decision was based on full information from the family and was based on a view that the person’s needs at this time closely matched the needs of the majority of his residents. The Registered Person was made aware that categories of registration that are in place may not be altered without making an application to vary the categories of registration. Failure to make such an application may be subject to enforcement action The Statement of purpose must be a true reflection of the service provided by the home and as such a review is now required. Discussion with a relative of the most recently admitted resident indicates that they had an opportunity to look around and arrange for an assessment of their relative, they were provided with information about the home. From discussion with staff and the relative we are confident that the prospective resident received an assessment visit from a senior carer from the home and the provider prior to admission. Initial assessment information gathered informed the providers decision to admit, this information has subsequently been added to by the deputy manager post admission to form a comprehensive assessment of need and the development of a detailed care plan, we are satisfied that an outstanding requirement has now been met. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 13 From our discussions with staff it is clear that at the present time staff believe they are able to meet the needs of the current residents who they do not find challenging. Examination of daily logs and discussions with residents by the Expert by experience would support this; however, staff’ have received no training in working with people with dementia or related conditions. Whilst staff’ are able to meet residents day to day personal care and health needs, they lack awareness of the importance of nutrition, or how they might provide appropriate stimulation or manage more challenging behaviours if they occur. Action will need to be taken to improve the knowledge and skills of the home management and staff if they are to continue to support residents with these needs as their conditions take greater effect. We examined the files of all of the current residents and are satisfied that new terms and conditions information has been issued to all residents, in eight out of eleven files viewed we found signed copies of terms and conditions, the provider has assured us that the remaining three will be finalized shortly. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 14 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Beechwood Lodge is subject to enforcement action and therefore no quality rating has been made. Progress has been made in the development of more detailed support plans for some residents but not all. There is no mechanism for the routine review and update of these or risk information to reflect changes. Staff’ demonstrates an awareness of the physical health care needs of residents and seeks appropriate interventions from health care staff as needed. Residents’ safety will be improved by further development of the medication system. EVIDENCE: We have noted some progress in the development of more detailed personal support plans implemented by the previously appointed manager. However, only five of the ten long term residents have had their plan updated. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 15 New care plan formats provide staff with detailed information and guidance about supporting residents with personal care and health needs in their preferred manner. Unfortunately, for those residents who have had a new support plan developed for them, these have not been maintained, with any evidence of monthly reviews. We noted a change in support for one resident that has not been reflected in the current support plan, the provider indicated that this has now been reviewed but is waiting retyping and is not therefore available for staff to use, although discussion with staff indicates they are implementing the changes. Log books detailing the support provided to individual residents have replaced daily log sheets and now incorporate the night reports for individuals, good progress has been made with maintaining these and staff’ are keeping these up to date with no omissions. Examination of log books indicate that on the whole the day to day support of residents whose files we viewed is in keeping with the content of care plans, however some important information is still missing. In that we noted that the support plan for one resident does not make clear continence issues or the level of night-time disturbance and wandering and how these matters are to be managed. Another plan fails to record how often and who should be monitoring the air mattress pressure for that resident which could be crucial to maintaining the resident’s health, neither the resident nor staff’ are aware of whose responsibility this is. In response to concerns expressed by the deputy manager we have discussed the need to implement a pain management tool for one resident, only following discussion with the district nurse and GP. From our discussions with staff we are aware that some of the residents whose files we examined have some dietary issues and are in receipt of nutritional supplements, when and how these are to be taken is not made clear in care plan information, In our discussion with staff they demonstrate a commitment to encouraging and promoting the independence of the residents living at the home, and are respectful of the choices and decisions residents make about their day to day lives. Their support is not intrusive and is provided at a level that is acceptable to the individual resident. Comprehensive risk information has been developed for those residents whose care plans have been put into the new format, unfortunately in most cases these have not been reviewed since the departure of the appointed manager. However, we did note that the provider has recently reviewed some risk information for one resident but this has not been undertaken with regard to all residents. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 16 Health sections are incorporated into the new care plans and these give good information in respect of individual health needs, however this would benefit from the inclusion of a contacts sheet to record which and when health professionals have been involved. Some moving and handling assessments were noted for those with more significant needs, however, staff are unable to utilize hoisting equipment in the event of an emergency because this has neither been serviced nor have the staff been training in the use of hoists, currently staff encourage residents to get themselves up if they fall, or if they are unable to or are thought to be hurt call an ambulance. It has cone to our attention during the course of our visit to the home that there have been three recent admissions to the hospital, one for a serious injury. The Commission has not received notification of these events as required under regulation 37 of the Care Homes Regulations 2001, although the registered person indicated that he had done so in the case of one event but could not locate this information at the time of inspection. Examination of daily logs highlights that staff have an awareness of the day to day health of residents and seek intervention from health professionals if they have cause for concern. Weights are being recorded monthly. Staff’ is liaising with the district nurse in regard to any concerns they may have about skin pressure areas. Training information and discussion with staff informs us that all staff has received medication training, although we consider that three longer serving senior staff who last trained in 2006 would benefit from this being updated. When we looked at storage we found that medication trolleys are kept secured and medication keys are passed between shift staff to the person deemed to be most senior. When we asked staff about the storage of medication in residents rooms we found that some prescribed creams are being left in residents rooms who are not self administering, as the reasons for this practice would seem to be for staff benefit alone, this practice should be discontinued. Creams, boxed and liquid medications stored within medication trolleys are not routinely dated upon opening and this would help with auditing medications. From our discussions with staff about how self administering residents store their medications, and from discussion we have had with a resident we are not satisfied that secure and fixed storage facilities are available in the bedrooms of self administering residents and should be clearly reflected in self administering risk information, this required action remains outstanding. We examined MAR records, these are generally well kept with only two omissions in recording noted, when we audited the medication to ensure these had been given appropriately we found one omission was an oversight in Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 17 signing, but were unable to ascertain if the other omission had meant medication had not been administered because a new box of tablets had been started mid cycle and no opening date had been recorded to enable us to audit. We noted some handwritten entries and changes on MAR records and these were undated or signed by the person making the change, we have discussed the importance of ensuring such entries are signed and dated for the purpose of auditing and accountability in the event of errors. From our discussions with staff we are satisfied that the administration of prescribed nutritional supplements is happening however these are not routinely recorded on the MAR sheets, when we discussed this with staff they indicated that this had been a source of debate amongst staff but without management guidance they are unclear what they should be doing although some staff are indicating within daily logs that supplements have been given but this is inconsistent, we have asked that all prescribed medications are recorded onto the MAR sheet as and when they are administered. Although the home has made some progress this inspection has highlighted further shortfalls and we do not therefore consider the requirement to have been sufficiently met to better safeguard residents. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Beechwood Lodge is subject to enforcement action and therefore no quality rating has been made. Resident’s rights to choose and make decisions for themselves on a daily basis are respected and upheld, staff’ consults residents about what they would like to do and are seeking to develop a more appealing activity programme. Thought must be given to ensuring the needs of people with more complex conditions are also catered for. Residents enjoy the quality and variety of meals provided in the home, but timescales for delivery of meals varies and can be affected by events in the home. EVIDENCE: We have been advised that since the last random inspection one staff member has taken on the dual role of carer and activities organizer. When we spoke with the carer they advised that they have undertaken to consult all residents about their interests and what they might like to do in the home. As a result Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 19 residents are enjoying some new activities each month, and the activities organizer wishes to expand upon this if funds are available. Staff’ promotes and encourages the independence of residents and provides assistance as needed. The home is welcoming of family members and representatives and is supported of helping residents maintain important relationships. In discussion with staff and the cook we noted that one resident is having pureed food and that this is pureed together, one staff member stated this does not look appealing, however when we spoke with the cook they reported that this is by request of the resident themselves because in its separate portions she would probably not eat as much. Although it is not considered good practice to prepare food in this manner, we respect the right of the resident to make known their preferences and these should be made clear within care plan information, and subject to review. When we visited the home we were accompanied on the first day by an expert by experience who undertook to speak with every resident if they wished to about their experiences of living in the home and the quality of care and support they receive. Through anecdotal information received from residents and through impressions gained during her time in the home the expert by experience has made the following observations, in order to protect the identities of the residents spoken with we have paraphrased or amended some information in the report: “I was introduced to three residents in their own rooms and two in the lounge. I had the impression from the first lady, that she was allowed to do what she wanted with regard to staying in her room and not getting dressed until quite late. She was lucid and is still sorting out her affairs from her bedroom. She feels that the staff’ are caring and responsive. They now manage her medication. She has visitors but does not seem to socialize within Beech wood Lodge. Another lady has a small room and bathroom with such a small basin that the water slops over on to the floor. She has only one bath a week which she looks forward to, and would like to have more. She eats in her room, relies on the TV for entertainment; she retires to bed early so does not join in evening activities. She would like a larger room and bathroom. She has experienced some weight loss and attended the hospital for this to be looked at: she is now eating more but she does not eat the light evening meal. She finds the staff’ are caring and respond to the Call bell quickly. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 20 A lady with a somewhat larger room had some items from her old home which made it look more attractive. She said she has never been an outdoor person so that does not worry her too much. She enjoys having meals with her friend in the dining room – there had been a third good friend who has recently died, and is much missed. Two ladies who spend time together manage to get out each day independently either walking or using a taxi. They need to be let out and in again by staff members but that does not seem to bother them. Activities – although one of the staff is trying to develop these, they remain rather limited in scope at the moment, partly because so few of the residents (currently only eleven and several of advanced years) are supportive of these efforts! Singing and musical entertainment are staple fare, but the staff member is hoping to organize some outings for them, even going to the White Rock Theatre in Hastings some time; It is unclear what the transport arrangements for this will be at present. Meals/Mealtimes – I had the feeling that my comings and goings affected the meal time! This was because I needed to go back to the entrance hall when I needed the staff member to introduce me to the various residents in their rooms. When I rang the bell the cook would emerge from the kitchen and see if she could see where the staff member was, thought this only took a minute. Lunch was due to be served at 1.00 pm but it was 1.20 pm before anyone received a meal. This was nicely presented, hot and tasty, but the service was slow, so quite a gap between the first and last people being given their food. There was a choice of two main meals and puddings. One carer looked after the residents in the dining room – presumably the second carer took meals to three people in their rooms. The carer in the dining room brought in the medication trolley and gave out pills in small pots to two people, consulting some paper work first. She was the only staff member in the room while this was done. There do not appear to be any residents’ meetings when things of concern are discussed, nor did the residents seem to feel any need of this. Overall impressions – this is a bright house, especially in the front which faces south; the rooms are welcoming and attractive and appear to be clean. I saw a male cleaner about the house and someone working in the garden also. The owner comes across as pleasant and caring of the residents, but maybe rather overwhelmed by the ‘bureaucracy’ as he would see it, also a worrying situation financially if he remains low on numbers. Most of the people I spoke to said they would recommend the home to others who might need care. It feels to me as if the home meets the needs of people who are not too disabled or ill, but the low numbers at present make it difficult for staff to Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 21 provide activities that appeal to their clientele, indeed several of them seem to like their own company anyway. The two carers who were on duty while I was there seemed to be kept busy as the house is quite extensive. Water was available and within reach in the bedrooms I went into, but I didn’t see any water in the lounge for people to help themselves, not did I see fresh fruit put out anywhere that I recall.” Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Beechwood Lodge is subject to enforcement action and therefore no quality rating has been made.. Residents find staff approachable and feel listened to. Residents are better safeguarded by improvements to the recruitment and training of staff. However, staff’ demonstrates inconsistent levels of understanding about the process for making complaints and for safeguarding adults and this could lead to inconsistencies in practice. EVIDENCE: A complaints procedure has been rewritten, is displayed in the entrance to the home and all residents have received a copy of this within their user guide pack, although this is not available in other formats it is suitable for the needs of the present resident group. Staff’ is not entirely clear of the current procedure but generally thought that a complaints form needed to be filled in and they would help residents to do this if they needed to, this is then passed to the provider, manager or deputy manager. Complaints are rare within the service, and we are advised by the deputy that any minor concerns and grumbles are acted upon immediately. One staff member commented that this was difficult to answer as she felt that something’s have been brought in and staff have not been told about them” We consider it would be good practice for Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 23 the provider to go over this with them again to ensure they are responding appropriately to all concerns and complaints they receive. A complaint record book has been implemented and this records one complaint having been received since our last visit to the home in May 2009. Care should be taken to ensure that the present recording arrangements do not breach confidentiality, by allowing previous and subsequent complaints to be viewed if inadequate intervals are made between records. Progress has been made in the training of staff in adult safeguarding and all have now attended a course. However, when we asked staff about issues of abuse and how they might deal with such incidents, we were surprised that they seemed unaware of local safeguarding protocols and who the lead agency would be in for referring such incidents to, staff seemed unaware in their conversations of the protocols book and this was also evident in a subsequent safeguarding adults meeting attended by the provider who is unaware of the book and the process for making alerts, although the local authority advises that copies of this had been provided to the home previously. Whilst there is no indication that resident have been placed at risk it is important that the provider and staff are aware of their roles and reporting responsibilities in regard to the local adult safeguarding arrangements and who they should be raising alerts with in the first instance. The provider informs us that at present money is not stored or managed on behalf of residents. The provider indicated that if there was a need for a resident to purchase something this would be purchased for them and their representatives invoiced for the amount if the resident was unable to arrange payment themselves. Staff’ is generally of the opinion that there is no one within the home currently who has behaviours that are difficult to manage, however, when pressed staff seems uncertain of how they would manage people whose deteriorating mental state may cause more extreme mood changes or behaviours, or even what behaviours they might expect to see. It is important that staff receive appropriate training in regard to the needs of residents with dementia to help them understand and develop strategies for working positively with residents. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Beechwood Lodge is subject to enforcement action and therefore no quality rating has been made. Residents enjoy living in a clean comfortable and pleasant environment, and are able to personalize their own space. Maintenance can be reactive rather than proactive and staff and residents health and safety could be compromised by this and the inadequate assessment of environmental risks. EVIDENCE: The home offers a pleasant and comfortable environment; it is clean, warm and tidy. Residents are provided with opportunity to personalize their own space bringing as many possessions with them as they can fit into their room. There is no programme of maintenance in place and maintenance tends to be reactive rather than proactive. Whilst the general appearance is good and the Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 25 quality of furnishings and fabrics is of a high standard there are shortfalls within the maintenance of the service that could place residents at risk. As a consequence of a recent environmental health inspection the home has been required to address a number of significant areas to ensure the safety of residents and staff’ is not compromised. This includes the assessment of risks to the staff and residents from the environment. At the time of our visit the provider was engaged in seeking quotations for works required to be done by the environmental health department, a recent visit highlighted a number of health and safety issues in the environment that need to be addressed, some of which the Registered provider has already addressed. The provider is still to provide evidence that damp in the dining area is being attended to. A previous concern regarding one of the outdoor patios has been addressed by the installation of secure fencing initially with a view to decorative railings being installed in the future. The provider has maintained tests and servicing of fire alarm and fire fighting equipment although visual checks of equipment have drifted since July 2009. Fire drills have not been held since March 2009, the provider has indicated that he is pursing a new fire trainer and hopes that fire drills can be incorporated into the twice yearly training; he has been reminded of the need to ensure night staff participates in fire drills and a record is maintained to indicate all participating staff. The front door of the premises is kept locked although all staff has a key; this is to ensure that more vulnerable residents do not wander out onto the busy road. Whilst the majority of residents can come and go without the escort of staff some are unable to. Whilst the registered person has indicated he has an awareness of Deprivation of Liberty legislation, we have felt the need to gain stress the homes responsibility to seek deprivation of liberty authorization promptly, for those vulnerable residents who may be seeking to leave the building more frequently. The provider has also been asked to seek advice from the East Sussex fire and rescue service in regard to the front door which is also considered a fire door being kept locked at all times. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Beechwood Lodge is subject to enforcement action and therefore no quality rating has been made.. Needier residents would benefit from greater awareness by management and staff of the kind of support they need on a day to day basis. Procedures for recruitment of new staff are improving. The induction of new staff is undeveloped and not in keeping with skills for care. The home has shown commitment to the qualification training of staff, investment has been made to ensure staffs achieves all current mandatory training, however, a year by year rolling programme is still to be established. There is a limited understanding of what other training might be needed. EVIDENCE: Discussion with staff and residents indicates staffing levels to be satisfactory at this time for the majority of residents living in the home, although needier residents may not be given enough staff time to provide stimulation where they lack capacity to occupy themselves. When we spoke with staff about how shifts are run they told us that in general no one is appointed shift leader on those days when the “deputy” is not on shift, some thought seniority was determined by who is the longest serving staff member, others thought it was Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 27 more about who was first to the handover and took the medication keys from night staff. The provider should make clear within staff rotas who is the responsible person on each shift Staff confirmed that at present there is no key work system in place although some staff reported that the provider has indicated that he is considering adopting this way of working, but no firm plans are in place yet. There has been some progress in the way in which staff recruitment records are organized, with much of this documentation now contained in individual staff files and organized in a manner that makes finding specific information relatively easy, this system has been implemented by the previously appointed manager. Unfortunately much of the information in respect of vetting and checks of staff remains missing, and reference information by the home provider and appointed manager to address these shortfalls remains outstanding for most. We found only one staff member had reference information in place, most files still lacked all the documentation required within the legislation. Some progress has been made by the home provider to ensure that more thorough checks are made of new staff before they commence work, although it is still essential that they can demonstrate the process to be robust. We examined recruitment information for a prospective staff member who has been interviewed. We found that an application form has been completed a CRB check obtained and one employer reference, a second reference is outstanding, there is no medical statement, or evidence that within interview, verification had been sought from the applicant as to reasons for leaving previous care roles, ID has been provided, the provider stated that the outstanding reference would be pursued and that the prospective member of staff would complete medical information prior to commencing work. Whilst it is clear that previously induction within the home has been a basic orientation to the home, finding out where everything is and the shadowing of more experienced staff, with the appointment of the new manager we were informed that some progress had been made on implementing skills for care induction, and we found reference to this in the supervision notes of two newer staff. However when we asked one of the staff what they could tell us about the reference to the “skills for care induction log” noted in their supervision notes they responded “never heard about it” they also confirmed they had not completed any workbooks that we would usually expect to see in relation to this form of induction. The other member of staff was unavailable to talk with about this. Discussion with staff and examination of training records indicates that approximately 75 of the staff team has attained NVQ2 training. Previously identified shortfalls in the mandatory training of staff have been acted upon Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 28 and staff have experienced a significant amount of training this year already with only three staff overdue moving and handling training, 4 staff due food hygiene training, two staff due first aid training, three staff due fire training and five staff due infection control training, All staff have attended safeguarding training and all staff have received medication training although three would benefit from updates to this. Whilst staff are able to demonstrate a caring and supportive commitment to the well being of residents, lack of knowledge and guidance by the provider in respect of the specialist needs of some residents means that staff are not always aware of what they don’t know or understand, there is a limited understanding of delivering person centred care and what this may mean in practical terms, as a consequence for needier residents some needs or areas of support may become overlooked When we looked at planning for future training needs and refreshers we found that at present the provider has three further training dates booked for this year, this includes a course identified as a need for staff in respect of care planning as the provider would like staff to be more actively involved in this process. At present there are bookings for next year as refreshers for some mandatory training. Specialist training to ensure staff have the necessary skills and knowledge to work with residents who have varying degrees of dementia are also needed, in addition to courses on conditions that impact on older people such as diabetes, continence, pressure care, nutrition. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 29 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): Beechwood Lodge is subject to enforcement action and therefore no quality rating has been made. The appointment of an experienced and qualified manager had helped to raise standards; improvements have not been sustained since their departure. The registered person fails to demonstrate a clear understanding of their responsibilities as Manager. Residents are consulted, but mechanisms are not in place to collect, and analyze their responses and tell them what actions are being taken, or to undertake internal audit or review of service delivery. The health and safety of residents could be compromised by shortfalls identified. EVIDENCE: Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 30 Mr Jempson is Responsible Individual for Beechwood Lodge Ltd the registered person. He is also the Manager appointed by the Company and was registered in this capacity by the previous regulator NCSC in July 2002. Historically Mr Jempson has maintained that he has no desire to undertake the necessary care and management of care qualifications preferring to use the qualifications he does have to further his career elsewhere when time permits. A person was appointed between 1st April and 1st September 2009 to manage the service, as it is not Mr Jempson’s stated intention to remain registered in respect of the service. The Commission has taken a view previously in inspection reports that the service was providing a poor service in respect of management and record keeping. However People who live and receive care in Beechwood Lodge say they are happy with the care they receive and it meets their expectations. For those more vulnerable residents with dementia related needs, concerns have been raised regarding the ability of the home to provide the level of care and support needed, and two adult alerts were raised in December 2008. Investigations by the local safeguarding team substantiated concerns about the safety of two residents in particular, and the home was required to take actions to minimise some of the risk to their health and safety. Both alerts are now closed. Information provided by Mr Jempson in meetings, via telephone conversations and from written information sent to the Commission, has sought to show an improvement was occurring by the appointment of a manager. This inspection has looked carefully at the records, spoken with staff, spoken with people who live in the home and sought evidence that is reported above in order to record such improvement has occurred. In order to address the requirement’s that remain outstanding and to in-bed into sustainable practice the changes that the appointed manager started, the service needs a person to be registered in respect of it that has the skills, qualifications, knowledge and experience, and who has undertaken recent and ongoing training. Only when a person who has those skills is in day to day charge will staff understand the rationale for the training, the need for clear and comprehensive records and an understanding of residents’ changing care needs and how to react to them appropriately. The Registered Person does not have the necessary skills to effectively undertake the management of the home on a day to day basis and this is evident from the improvements implemented by the appointed manager during her employment at the home, and which have not been sustained since her departure. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 31 The provider has stated he has been unable to update his knowledge and skills owing to commitments to ensuring the residents welfare when care staff’ are attending training courses. Whilst there has been investment in ensuring staff training is brought up to date there is no strategic training plan and nothing further is booked beyond December 2009. Staff’ is unfamiliar with or do not understand the content of some of the documentation developed to meet outstanding shortfalls, and need to be reminded of the content and how it impacts on themselves and residents. An AQAA has been received by the commission some months overdue. This was completed by the previously appointed manager to a reasonable standard, some omissions in information were discussed with the then appointed manager, this documentation would benefit from additional information to illustrate the day to day operation of the home how shortfalls have been addressed and future planned improvements. Residents have told us that they asked about some day to day activities in the home and are able to express their views. The previous appointed manager has developed a resident survey questionnaire but there is little clarity as to how often this may be issued to residents, there is no current system in place for the collation, analysis, reporting on and feedback in relation to residents views, there is no system in place currently for the internal audit and review of the service. The provider is aware of the importance of reporting events to the commission but we have been unable to locate notifications that should have been received from the home in respect of three recent events that we became aware of during the course of our site visit to the home. We have issued a requirement for the home to notify the Commission in regard to significant events in compliance with current legislation. As a director of the company which runs Beechwood lodge the provider has the responsibility to ensure that Regulation 26 visits are undertaken monthly and a report developed from this in respect to service quality. The provider was initially unaware of his responsibility to do this but has agreed to do so forth with and we require evidence that this is now happening. Residents tell us that they enjoy living in the home; they feel safe and well cared for. They indicate that staff are kind and understand their needs, staff actively encourage the residents to maintain their independence, and are supportive and respectful of the individual choices and decisions residents make about their day to day lives. We have expressed our concerns as to the financial viability of this service and have sought clarification on this matter from the registered person who has Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 32 promised to provide supporting information. We are still awaiting financial and business plan information which has been outstanding since our last visit to the home in May 2009 when we issued a requirement for the Registered person to send us this information and also requested a copy of 2008/2009 accounts within the timescale given in the report. We are advised by the homes accountant that this information is still not available. The Registered person has provided us with a development plan, and whilst this highlights broadly areas that the home would like to develop it fails to give specific information or timescales in which this might be achieved, or how. When we met staff individually they advised that prior to the appointed manager working at the home they had not as a staff team met together routinely, during the time that the appointed manager was at the home they had attended one staff meeting, this was minuted in some detail. Staff said they valued being able to meet together to discuss big issues, and share information, one staff member indicated that staff had expressed concerns that handovers had been too short and this had been addressed, one staff member thought that sometimes things were left too long to build up before they are dealt with, another saw the importance of the staff meeting in “re-in forcing we’re a team instead of existing in our own little bubble”. Since the appointed manager left one staff meeting has been held with the provider but staff’ are unaware whether further meetings are planned and are not aware of any dates at this time. Staff said they felt able to report things either to the provider or to the deputy one staff member reported that in regard to requesting annual leave etc “we would put in a book don’t know if this is to be continued with” since the appointed manager left. Some said they would talk to the provider about something’s, but if it related to the care needs of residents then they would speak to the deputy. Staff commented that individual supervisions were only put in place when the previously appointed manager commenced working at the home, when we examined staff files we found that all staff had signed a staff supervision contract confirming they would receive supervision every 6-8 weeks. Since April 2009 when the appointed manager commenced work at the home all staff have received one supervision, with the deputy having had three, this has not been continued with since the appointed manager left, however the provider advised us that at the request of an NVQ assessor he had arranged supervisions for two staff completing their NVQ as this formed part of the assessment of their course. Since the departure of the appointed manager staff reported that they were able to access the provider privately if need be for informal chats, one staff Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 33 member stated she didn’t know what arrangements are at present stating “since the manager left felt everyone does what they want to do, no structure” We recognise that the previous appointed manager has helped to address some of the outstanding requirements and drive up standards and frequency of recording, availability of records, implement systems for the supervision and , monitoring of staff competency, develop detailed support plans for residents to inform staff and introduce risk assessment to ensure resident and staff safety is maintained. Unfortunately, some of this work was not completed and the registered person has not added to improvements or ensured that those in place are maintained consistently. When we looked at accident information we noted that overall levels of recorded accidents is at a low level, where residents have fallen or become ill requiring hospital admission staff have responded appropriately if not aware of their responsibility to notify relevant agencies. When we visited we noted some of the servicing of equipment has been conducted but could not find evidence that either the gas or electrical installation had been serviced recently. We are aware that the EHO has identified a number of health and safety shortfalls and these are requiring urgent attention by the provider to address. We asked to see the general risk assessment file and were provided with an out of date version, staff are generally not aware of the file or its content, staff have not received health and safety training, whilst some environmental risks have been identified these are not sufficient to ensure staff and residents are appropriately safeguarded, and this has also been identified by the EHO at the last visit.. The provider has continued to undertake routine health and safety checks of the building, tests the fire alarm and emergency lighting since the departure of the appointed manager, although timescales have drifted in respect of visual checks on fire equipment, and drills have not been carried out. The provider is keen to incorporate drills in with fire training twice yearly and is seeking a replacement trainer for this; we discussed the importance of all staff attending such drills including night staff, and also arrangements for familiarizing staff with fire procedures without unduly disturbing residents. A new fire risk assessment has been implemented with additional fire risk assessments for needier residents who may need to be evacuated in the event of a fire. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 34 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 3 2 2 3 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 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 2 2 x x 1 x x x 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 1 3 2 2 2 Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 35 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 Requirement Timescale for action 30/06/09 5, 6, 4, 16 That all residents are provided with an up to date and amended copy of the Service user Guide and Statement of Purpose 2. OP7 15 That residents must have appropriate risk assessments maintained in their care plan. 30/06/09 3. OP18 13 (6) & 18 (1) (c) (i) 13 (4) (a) (b) (c) That all staff’ receive training in Safeguarding Adults. 30/06/09 4. OP19 That staff have ready access to and are made aware of the homes general risk assessments. 30/06/09 5. OP29 19 & Schedule 2 That staff recruitment procedures are robust and ensure that recruitment practice must comply with the Care ES0000021046.V2000080497.R01.doc 30/06/09 Beechwood Lodge Version 5.3 Page 36 Homes Regulations 2001. (This is an outstanding Requirement from the inspection in April and October 2006,June 2007, February 2008 and in June 2008) 6. OP30 18 That a staff training plan is implemented to ensure that all staff’ receive up to date training in mandatory subjects and training that is relevant to the needs of residents. 30/06/09 7. OP30 18 (1) (a) (c) A suitable induction and foundation programmes must be implemented to enable staff development. (This has remained an outstanding Requirement, which has been repeated from the last seven previous inspections.) 30/06/09 8. OP33 24 The registered person must be able to demonstrate how the home provides a good quality service for residents and the measures necessary to improve the quality and delivery of the service provided in the home. (This is an outstanding Requirement from the inspection in June 2007) 30/06/09 9. OP34 25 (2) (c) That a financial and business plan is sent to the CSCI and is made available for future ES0000021046.V2000080497.R01.doc 30/06/09 Beechwood Lodge Version 5.3 Page 37 inspections. 10. OP7 15 Each resident must be provided with a plan of care that detail their care and health needs and how these are to be supported All care staff’ administering medication must receive certificated training to evidence they have achieve the appropriate competency to do so safely. Residents who self medicate should be provided with secure and fixed storage facilities within their own rooms. Administering staff must adhere to the medication policy and procedure to ensure safe practice in administration 30/06/09 11. OP9 13(2) 30/06/09 12 OP16 22 The Registered person must ensure that a process in place for the acknowledgement, investigation and management of concerns and complaints and that all staff have an understanding of this process. The registered person must ensure that a completed Annual Quality Assurance Assessment (AQAA) is returned to the Commission when requested and within the given timescales The registered person must ensure all records that are required by regulation are kept within the registered service and made available for inspection. The Registered Person as a ES0000021046.V2000080497.R01.doc 30/06/09 13. OP33 24 30/06/09 14 OP37 17 30/06/09 15 OP33 26 01/12/09 Version 5.3 Page 38 Beechwood Lodge 16 OP38 37 representative of an organisation must undertake visits to the care home in accordance with this regulation at least once per month, and shall interview with their consent and in private a sample of residents and care staff as necessary to form a opinion of the standard of care provided in the home, carry out an inspection of the home and prepare a written report on the conduct of the home which must be made available to the Commission. The Registered person shall give notice to the Commission without delay of the occurrence of the death, illness, and other significant events made clear within this regulation, and any notification made orally in accordance with this regulation shall be confirmed in writing. 01/12/09 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 OP1 Good Practice Recommendations The home could usefully include in its admission procedure a checklist to certify the issue of a Statement of Purpose, Resident Guide and contract; and whether other languages or formats were warranted. 2. OP9 Staff should have ready access to a copy of the Royal Pharmaceutical Society Guidance, to ensure practice complies with best practice standards. Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 39 3. OP17 A directory of local advocacy services would be judged good practice. 4. OP19 Periodic audits of the premises by specialists such as Occupational Therapists are recommended, to ensure the home maintains its capacity to meet the changing needs of its residents. 5. OP27 Staffing levels should be kept under review to ensure that the competency and number of staff are sufficient to meet the changing needs and dependencies within the resident group Beechwood Lodge ES0000021046.V2000080497.R01.doc Version 5.3 Page 40 Care Quality Commission Care Quality Commission Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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