Inspection on 03/11/08 for Beechwood Lodge

This inspection was carried out on 3rd November 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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 06/02/2009.

CARE HOMES FOR OLDER PEOPLE Beechwood Lodge 148 Barnhorn Road Bexhill-on-Sea East Sussex TN39 4QL Lead Inspector Rebecca Shewan Unannounced Inspection 3rd November 2008 09:20 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.V372870.R01.S.doc Version 5.2 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.V372870.R01.S.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 (20) of places Beechwood Lodge DS0000021046.V372870.R01.S.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. 30th June 2008 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 - £590 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 DS0000021046.V372870.R01.S.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 judgments and individual quality ratings have been made 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 for ensuring quality care and good outcomes for people who use the service. This unannounced inspection took place during the morning and afternoon of the 3rd November 2008. Incident reports and previous inspection reports, held by the Commission for Social Care Inspection, were read before the inspection. The inspection of the home took six hours. Records such as care plans, staff files and medication records were also viewed. Sixteen service users were accommodated at the home at the time of the inspection. A tour of the whole home was undertaken and the Responsible Individual, three Carers and four service users were spoken with. What the service does well: What has improved since the last inspection? All controlled drugs are accounted for in a tamper proof, leather bound book and all entries are signed for by two staff. Service users are given ample opportunity to choose meals and meal times, in accordance with their wishes. Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 6 An up to date certificate of insurance is displayed in the home. Unnamed toiletries and Control of Substances Hazardous to Health (C.O.S.H.H) products have been removed from the homes toilet and bathroom areas. There is a system in place to ensure that a record is kept for each service user and of falls sustained by them. What they could do better: Pre Admission Assessments and pre admission information require updating to ensure that potential new service users whose needs cannot be met, are not admitted to home and to ensure that potential new service users have appropriate information to make an informed choice as to whether the home can meet their specific needs. Care plans are in need of review in order to provide staff with up to date information regarding the service users current level of need and limitations. They also require to be generated and reviewed with the service users involvement. Risk assessments require expanding to include all elements of risk associated with medication and provisions and facilities within the home. Daily care entries must also be reflective of the service users care plan. Urgent action is required to ensure that all medication entered into the home are appropriately accounted, in order to ensure the risk of error is eliminated. Activities require enhancing in order to provide service users with a wide range of stimulating, physical, mental and social activities. Complaint monitoring, staff recruitment procedures and staff training require reviewing, in order to ensure that service users and their representatives can be confident that any complaint made will be appropriately actioned and to ensure that they will be effectively safeguarded in the event of an allegation of abuse. Environmental risk assessments require implementing in order to ensure that service users and staff are safeguarded against the risk of hazards. Staff training needs enhancing to ensure that staff receive annual training that is both up to date and relevant to the needs of current service users. Staff recruitment files must be updated to include all items required under the Regulations and associated Schedules. New members of staff must be employed only after the appropriate recruitment and Safeguarding checks have been conducted. Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 7 Quality Assurance processes must also be enhanced to ensure that service users benefit from a home that is run in their best interests, with consideration given to their views and opinions. The staff induction and foundation programme and the format for regular formal supervision must be finalised and implemented. Financial and Business plans must be generated and provided to the CSCI, in order to provide evidence of the homes financial viable for the purpose of achieving the aims and objectives set out in the statement of purpose and the homes business projections for continuing to meet these aims. It is required that documentation necessary for inspection is made readily accessible. Improvements are required to ensure that notification is given to the CSCI of all accidents and incidents that occur within the home that have a detrimental impact on the well being of service users. 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. The summary of this inspection report can be made available in other formats on request. Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 8 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.V372870.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 6 Beechwood Lodge is subject to enforcement action and therefore no judgement has been made. EVIDENCE: Following the inspections of February and June 2008 there have been no improvements made to ensure that the home’s Statement of Purpose and Service User Guide shall comply with all the elements listed by the standard. At the previous inspection of February 2008 both documents were viewed and it was observed that the following items were not included. The documents would identify fees payable but not how these are calculated, how the care home will meet the service user’s special requirements (neither document referred to the care plan and/or how the home will undertake to comply with Care Standards Act 2000 and attendant regulations etc), the standard form of contract for the provision of services and facilities by the registered provider to service users did not identify the room number, the summary of the complaints procedure referred to CSCI being contactable only after all internal processes had been exhausted, the Statement of the aims and objectives of the care home stated that the provision of individual room keys were subject to request Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 10 or only where reasonably practicable, the age-range and sex of the service users for whom it is intended that accommodation should be provided was not specific about the age range, the criteria used for admission to the care home, including emergency admissions was not recorded, the arrangements for Resident to engage in social and religious activities, hobbies and leisure interests were also not recorded, the arrangements made for dealing with reviews of the service users care plans did not specify that this would be subject to the service users choice, the details of any specific therapeutic techniques used in the care home and arrangements made for their supervision were not specified and it was not specified that whether these documents are available in other languages or formats (e.g. large print, tape etc). The Responsible Individual reported that no changes had been made and neither document could be produced in order to provide evidence of this. This requirement is outstanding from previous inspections. Therefore this Requirement remains unmet. At the previous inspections of February and June 2008 it was required that the home’s contract should be checked for compliance with all the elements of the National Minimum Standard. At these inspections it was evidenced that bedrooms to be occupied were not recorded and the fees payable and by whom (service user, local or health authority, relative or another) were also not recorded. There was no evidence provided during this inspection to support that this has been actioned to date. The compliance date for this Requirement is 31/11/08. Following the inspection of June 2008 there have been no improvements made to ensure that the Home must use the information gathered during the preadmission assessment (and assessments from other agencies) to formulate a plan of care for daily living and longer-term outcomes. It was also required that Pre Admission Assessments are updated to include thorough details of the potential new service users level of need, current limitations/capabilities and their social preferences. Documentation viewed for the two newest service users highlighted that the same format from the inspection of June 2008 was in use and there was no evidence of the Pre Admission Assessment documentation having been updated or completed by the assessor in an improved manner. This requirement is outstanding from the previous inspection. Therefore this Requirement remains unmet. The Responsible Individual also reported that no changes had been made to ensure that the home could usefully include in its admission procedure a checklist to certify the issue of a Statement of Purpose, Service User Guide and contract; and whether other languages or formats were warranted. The presence of such a checklist would ensure that all potential and new service users are in receipt of the necessary documentation to ensure that they have made an informed choice about admission to the home. (See Recommendations Section). Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 11 Intermediate care is not provided by this service. Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Beechwood Lodge is subject to enforcement action and therefore no judgement has been made. EVIDENCE: In September 2008 the Responsible Individual was served a Statutory Requirement Notice that required there to be a system in place to ensure that all service users have a plan of care. The plan must be kept under review and updated as necessary with regard to any change in circumstances. The service users and/or their representative must be involved in producing the care plan where practicable. This was required to have been complied with by 31/10/08. Five care plans were viewed and it was evidenced that one resident had received a care plan review. The care plan generated from this review was not reflective of the service users needs and did not include up to date risk assessments. The remaining care plans had not been updated since the inspection of June 2008. Therefore this element of the Statutory Requirement Notice has not been complied with. Care plans viewed also highlighted that suitable risk assessments were not in place for service users. It was observed that a service user at risk from Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 13 absconding, one at risk of harm associated with using public transport and one at risk of wandering did not have risk assessments in their care plans. There were also no risk assessments in place for service users who are at risk of falls or pressure area sores. Therefore a Requirement has been made. (See Requirement Section). The previous inspection recommendation that daily care records are maintained for all service users on a daily basis has not been met. Daily care entries were observed and it was noted that entries made were between four and seven days apart. Entries made were not reflective of service users care and recorded entries specified bathed today or bathed and weighed today. Entries such as Assisted with mobilising and complaining of nausea, red sacrum noted, cream applied, please observe, fell and has bump to head – please check regularly and complaining of pain – GP review and paracetamol prescribed were observed not to have been followed up. There were no further entries, comments or reference made regarding a red sacrum, head injury, nausea, pain relief or further episodes of pain experienced. Therefore a Requirement has been made. (See Requirement Section). Service users are registered with one GP from one of four local surgeries. District Nurse appointments are arranged via the GP. Service users attend local Opticians surgeries for eye examinations and spectacle reviews. Audiology appointments are arranged via the GP, service users then attend the hospital for appointments. Community Psychiatric Nurse (CPN) referrals are made as needed. The home has direct access to an Incontinence Nurse who attends the home on an as required basis. The home has access to a Chiropodist who visits service users on a six weekly and as required basis. At the previous inspection a requirement was made that a clear audit trail of all medications entered into and discharged from the home is maintained, it was observed that this Requirement remains unmet. The medication administration records (MAR) were viewed and it was noted that there is an unclear audit trail of all medications that are disposed of and those entering and leaving the home. The Responsible Individual reported that the Assistant Manager is responsible for all medication ordering and that a book of all medications ordered is maintained. The book was not available for inspection. It was also observed that only medication amounts that are entered into the home, mid way through are recorded onto the MAR sheet. Therefore an immediate Requirement was made. (See Requirement Section). Following the inspection of June 2008 improvements have been made to ensure that the recording of Controlled Drugs entering the home and being administered are recorded in a bound, tamper proof book and two care staff sign for all Controlled Drugs administered. The controlled drugs were accounted for in a leather bound book and all entries were observed to be signed for by two staff. It is recommended that staff should have ready access Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 14 to a copy of the Royal Pharmaceutical Society Guidance, to ensure practice complies with best practice standards. (See Recommendations Section). Staff were observed providing personal support to service users in such a way that promoted and protected their privacy and dignity. Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Beechwood Lodge is subject to enforcement action and therefore no judgement has been made. EVIDENCE: It was observed that service users care plans do not have any recordings made of their individual interests/hobbies. There was no planned schedule of activities observed. Current activities consist of: Visiting drama group (once a month), singers (once a month), manicurist (once a month), hairdresser (fortnightly), church songs/hymn and Pat Dog (every Friday). Service users religious wishes are observed and arrangements are in place for service users to receive Holy Communion, if they wish. Holy communion is held on a four to six weekly basis. There are currently no day centre attendees at present. Contact with family and friends is positively encouraged, with visitors being able to attend the home at any time and in accordance with the service users wishes. There are currently no community activities or contact from external communities at the home. At the previous inspection of June 2008 it was required that service users are consulted regarding their leisure interests and an activities programme be implemented to reflect those interests and preferences and that service users Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 16 are consulted about their social interests, and make arrangements to enable them to engage in local, social and community activities. These requirements have remained unmet. Service users are treated with respect and there is a good rapport between staff of the home and service users. Care staff reported that the homes menus are devised on a four week rolling programme. All meals are home cooked with an alternative option available for each mealtime. Meals can be taken in the service users bedroom or in the communal dining room. Medical, therapeutic or religious diets are provided as needed. Drinks and snacks are available at all times. The meal served during the inspection was ample in quantity. The previous inspection recommendation that service users are given ample opportunity to choose meals and meal times, in accordance with their wishes has been actioned. Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 & 18 Beechwood Lodge is subject to enforcement action and therefore no judgement has been made. EVIDENCE: At the previous inspection of June 2008 it was required that a copy of all complaints received be maintained within the home and made available for inspection and that all staff receive training in Safeguarding Adults. The home has received one complaint since the inspection of June 2008. There was no evidence of a record having been made of this complaint. Staff spoken with stated they had not received any training in Safeguarding Adults and that they had not been informed of any dates for future training. The compliance date for these Requirements is 31/11/08. Following the inspection of June 2008 no improvements have been made to ensure that the recommendation that the complaints procedure is updated to reflect that the CSCI can be contacted at any stage during the complaint process. The current complaints procedure has not been amended and displays the wrong contact details for the CSCI Regional Contact Team. Therefore a Requirement has been made. (See Requirement Section). Following the inspection of June 2008 no improvements have been made to ensure that the recommendation that a directory of local advocacy services would be judged good practice has been actioned. There was no evidence to support that local advocacy services had been sourced and there was no list or Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 18 directory available to view. Therefore the Recommendation remains in place. (See Recommendations Section). The Responsible Individual reported that there have been no Safeguarding Alerts raised since the last inspection. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. New staff are currently employed without a CRB check having been obtained (See Staffing Section). Therefore a Requirement has been made. Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 26 Beechwood Lodge is subject to enforcement action and therefore no judgement has been made. EVIDENCE: The location, size and layout of the home is suitable for its stated purpose. The home, including the garden, is well maintained. All areas of the home are accessible to service users. The home has an ongoing plan of refurbishment in place. The homes large lounge area has recently been refurbished. At the previous inspection of June 2008 it was required that the raised semi circular patio outside the billiards lounge has sharp brickwork along edges and an unguarded ramped descent onto lawn is suitably risk assessed and repairs are made and guards are fitted to ensure service users safety. It was observed that no building works had been undertaken and the Responsible Individual reported that a risk assessment had not been completed to date. The compliance date for this Requirement is 31/11/08. Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 20 Following the inspection of June 2008 no improvements have been made to ensure that the recommendation that the Billiard lounge requires a risk assessment to be in place whilst it is being used for storage pending completion of refurbishment/maintenance work. It was observed that this room continues to be used as a storeroom for paint and other decorating/maintenance materials and the Responsible Individual reported that a risk assessment had not been completed. This requirement is outstanding from the previous inspection. Therefore this Requirement remains unmet. Following the inspection of June 2008 no improvements have been made to ensure that the recommendation that a copy of the April 2008 EHO report is sent to the CSCI. This had not been sent to the CSCI by the compliance date of 31/10/08 and was not made available for inspection. This requirement is outstanding from the previous inspection. Therefore this Requirement remains unmet. At the previous inspection it was recommended that 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 service users. The Responsible Individual reported that this has not been actioned. As this remains a pertinent issue due to the ongoing refurbishment and the needs of service users change, this recommendation remains in place. (See Recommendation Section). Staff have received training in Infection Control. Infection Control procedures were observed as being in place and staff were noted to be adhering to these. There is a daily cleaning programme in place. The home was observed to be clean throughout and free from offensive odours. Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Beechwood Lodge is subject to enforcement action and therefore no judgement has been made. EVIDENCE: Staff numbers on the day of inspection were two care staff am and two care staff pm. Staff spoken with stated that this is the normal staffing numbers and that usually there is a one waking night staff with either the Responsible Individual or the Assistant Manager on call. At the previous inspection it was recommended that the staff duty rota is made available to all staff and for inspection. The Responsible Individual and care staff reported that this document is not displayed for staff to see and it was not available for inspection. Therefore this recommendation remains in place. (See Recommendation Section). Care staff confirmed that the staff team consists of the Responsible Individual as the Registered Manager, six Carers (one of which is the Assistant Manager), one Cleaner/Cook, one cook and one handyman. Four carers are NVQ 2 or 3, in care, trained and one carer is currently undertaking the NVQ level 2 training. There were no records viewed to support this information, though discussions with staff reported this to be accurate. Staff records were viewed for the recruitment of staff. Of the files viewed three were for staff that have been newly recruited. All of the files were found not to Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 22 include proof of the staff member’s identity, a current CRB check, two references, documentary evidence of any relevant qualifications and training or a recent photograph. This issue has been a requirement that is outstanding from previous inspections, however due to no new staff having been recruited prior to the previous inspection, this requirement could not be assessed in June 2008. In view of the evidence collected at this inspection this Requirement remains unmet. Staff spoken with confirmed that they had received training in Fire Safety since the previous inspection. Training certificates on file provided evidence that staff have received training in Infection Control, Moving and Handling and Basic Food Hygiene in the last eight months. Therefore a requirement has been made. (See Requirement Section). At the previous inspections of April 2006, October 2006, June 2007 and June 2008 it was required that suitable induction and foundation programmes must be implemented to enable staff development. Newly recruited staff stated that they had received training but that it had lasted for a day or two. The compliance date for this Requirement is 31/11/08. It was also recommended that a staff training matrix is developed in order to clearly evidence that appropriate staff training had been undertaken. This has not been actioned and as it would provide evidence of the training provided and any training sessions planned for the future, a Requirement has been made. (See Requirement Section). Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 37 & 38 Beechwood Lodge is subject to enforcement action and therefore no judgement has been made. EVIDENCE: Beechwood Lodge Ltd owns the home, which continues to be managed by the Responsible Individual. Previous inspections of September 2005, April 2006, June 2007 and June 2008 identified that the owner did not wish to gain the necessary qualifications in care and care management, that are required to be the Registered Manager. It was reported that they would prefer to utilise their current qualifications to return to an unrelated profession; the Responsible Individual acknowledged that they needed to implement a different management option but would not be able to finance this now or in the foreseeable future. Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 24 At the previous inspections of February and June 2008 it was required that the registered person must be able to demonstrate how the home provides a good quality service for service users and the measures necessary to improve the quality and delivery of the service provided in the home. The Responsible Individual reported that no improvements had been made to Quality Assurance procedures but that a service user survey was due to be conducted. Staff and service user meetings have not been introduced. The compliance date for this Requirement is 31/11/08. The homes AQAA had not been returned prior to the inspection. It is a legal requirement that the home provides the CSCI with a current and up to date AQAA. This is the second non returned AQAA. At the previous inspection of June 2008 it was required that a financial and business plan is sent to the CSCI and is made available for future inspections. These documents were not available for inspection, the Responsible Individual reported that they have been produced and would be sent to CSCI prior to the compliance date. The compliance date for this Requirement is 31/11/08. It was a previous inspection Immediate Requirement that an up to date certificate of insurance is displayed in the home and a copy is sent to the CSCI. This has been actioned and a new certificate of insurance, due to expire in April 2009 was seen to be in place. The home does not take any responsibility for any of the service users finances and most service users have family, friends or representatives who protect their financial affairs. At the previous inspection of June 2008 it was required that a formal system of supervision for staff must be introduced. Staff reported that they have not received any formal supervision sessions. The Responsible Individual stated that formal supervision had been commenced but no recorded sessions could be produced to support this. The compliance date for this Requirement is 31/11/08. At the previous inspection of June 2008 it was required that documentation required under the associated Regulations and Schedules are made available for inspection. During this inspection the Responsible Individual was unable to provide the following documentation; the Statement of Purpose and Service User Guide, environmental risk assessments, a staff training matrix, a staff duty rota, the EHO report or a risk assessment for the billiards room. Other documentation could also not be viewed but these relate to requirements where timescales have yet to pass. The compliance date for this Requirement is 31/11/08. On the tour of the premises it was noted that there is a call bell system throughout the home. Appropriate fire equipment and fire exit signage was noted. At the previous inspection of June 2008 it was an immediate requirement that all C.O.S.H.H products and unnamed toiletries are removed from communal bathrooms and toilets and ensure that they are stored Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 25 appropriately. There were no unnamed toiletries or C.O.S.H.H products noted in any of the homes toilet or bathroom areas during this inspection. Following the inspection of June 2008 no improvements have been made to ensure that all accidents/incidents that affect the well being of service users are reported to CSCI in accordance with regulation 37. Records viewed highlighted that since the previous inspection there had been two episodes of a service user absconding and an incident between staff whereby the police were called to the home. This requirement is outstanding from the previous inspection. Therefore this Requirement remains unmet. In September 2008 the Responsible Individual was served a Statutory Requirement Notice that required there to be a system in place to ensure that a record is kept for each service user of falls sustained by them. Records viewed were correlated and it was evidenced that falls are now recorded appropriately and in the correct manner. Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 26 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 1 1 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 1 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 3 18 1 2 X X X X X 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 1 X 1 X 1 X 1 1 Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 27 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 15/12/08 5, 6, 4, 16 The home’s Statement of Purpose and Service User Guide shall comply with all the elements listed by the standard. (This was an outstanding Recommendation from the inspection in September 2005 and was made a Requirement in April and October 2006, February 08 and in June 2008) 2. OP2 5A (2) (b) That an amended copy of a Contract/Terms and Conditions of Residency is sent to the CSCI, in order that the specified changes to meet the National Minimum Standards can be verified. (This requirement is outstanding from previous inspections.) 30/11/08 3. OP3 14 (1) (2) (a) That Pre Admission Assessments are updated to include thorough details of the potential new service users level of need, current limitations/capabilities and their social preferences. DS0000021046.V372870.R01.S.doc 15/12/08 Beechwood Lodge Version 5.2 Page 28 (This requirement is outstanding from previous inspections.) 4. OP3 15 (1)(2) 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. (This is an outstanding Requirement from the inspection in April and October 2006,June 2007 and in June 2008) 5. OP7 15 That daily care records are 15/12/08 maintained for all service users on a daily basis and that they are reflective of the service users care plan. That service users must have appropriate risk assessments maintained in their care plan. That a clear audit trail of all medications entered into and discharged from the home is maintained. (This is an outstanding Requirement from the inspection in June 2008) **This is an immediate Requirement. 8. OP9 13 (2) That service users who self medicate have a risk assessment for self medicating in their care plan. That service users are consulted regarding their leisure interests and an activities programme be implemented to reflect those interests and preferences. DS0000021046.V372870.R01.S.doc 15/12/08 6. OP7 15 15/12/08 7. OP9 13 (2) 05/11/08 15/12/08 9. OP12 16 (2) (n) 15/12/08 Beechwood Lodge Version 5.2 Page 29 (This is an outstanding Requirement from the inspection in June 2008) 10. OP13 16 (2) (m) That service users are consulted about their social interests, and make arrangements to enable them to engage in local, social and community activities. (This is an outstanding Requirement from the inspection in June 2008) 11. OP16 22 (8) That a copy of all complaints received is maintained within the home and made available for inspection. That all staff receive training in Safeguarding Adults. That new staff are employed only after a satisfactory CRB check has been obtained. That the raised semi circular patio outside the billiards lounge has sharp brickwork along edges and an unguarded ramped descent onto lawn is suitably risk assessed and repairs are made and guards are fitted to ensure service users safety. That the Billiard lounge requires a risk assessment to be in place whilst it is being used for storage pending completion of refurbishment/maintenance work. (This is an outstanding Requirement from the inspection in June 2008) 30/11/08 15/12/08 12. 13. OP18 OP18 13 (6) & 18 (1) (c) (i) 19 (7) (b) 30/11/08 15/12/08 14. OP19 13 (4) (a) (b) (c) 30/11/08 15. OP19 13 (4) (a) (b) (c) 15/12/08 Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 30 16. OP26 23 (5) That a copy of the April 2008 EHO report is sent to the CSCI. (This is an outstanding Requirement from the inspection in June 2008) 15/12/08 17. OP29 19 & Schedule 2 That staff recruitment procedures are robust and ensure that recruitment practice must comply with the Care Homes Regulations 2001. (This is an outstanding Requirement from the inspection in April and October 2006,June 2007, February 2008 and in June 2008) 15/12/08 18. 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 service users. 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.) 15/12/09 19. OP30 18 (1) (a) (c) 30/11/08 20. OP33 24 The registered person must be able to demonstrate how the home provides a good quality service for service users 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) 30/11/08 Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 31 21. OP34 25 (2) (c) That a financial and business plan is sent to the CSCI and is made available for future inspections. A formal system of supervision for staff must be introduced. (This has remained an outstanding Requirement from the inspections of September 2005, April 2006 and June 2007) 30/11/08 22. OP36 18 (2) 30/11/08 23. OP37 17 (3) (b) That documentation required under the associated Regulation and Schedules are made available for inspection. That all accidents/incidents that affect the well being of service users are reported to CSCI in accordance with this regulation. (This is an outstanding Requirement from the inspection in June 2008) 30/11/08 24. OP38 37 15/12/08 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, Service User Guide and contract; and whether other languages or formats were warranted. Staff should have ready access to a copy of the Royal Pharmaceutical Society Guidance, to ensure practice complies with best practice standards. 2. OP9 Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 32 3. 4. OP17 OP19 A directory of local advocacy services would be judged good practice. 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 service users. That the staff duty rota is made available to all staff and for inspection. 5. OP30 Beechwood Lodge DS0000021046.V372870.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V372870.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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