Inspection on 30/06/08 for Beechwood Lodge

This inspection was carried out on 30th June 2008.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beechwood Lodge 29/10/09

Beechwood Lodge 03/11/08

Beechwood Lodge 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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Beechwood Lodge 148 Barnhorn Road Bexhill-on-Sea East Sussex TN39 4QL Lead Inspector Rebecca Shewan Unannounced Inspection 30th June 2008 08:55 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.V365234.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.V365234.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.V365234.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. 14th January 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 residents’ 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 £450 - £525 per week. There are no extra charges made, except for personal items such as clothing and toiletries etc. Potential new residents 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.V365234.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This unannounced inspection took place during the morning and afternoon of the 30th June 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 seven hours. Records such as care plans, staff files and medication records were also viewed. Thirteen service users (known as residents) were accommodated at the home at the time of the inspection. A tour of the whole home was undertaken and the Responsible Individual, two Carers, a Cleaner, four Residents and one Relative/Representative were spoken with. The CSCI also conducted Service User and Staff surveys. Of which nil were returned. What the service does well: What has improved since the last inspection? There have been improvements made to ensure that the reference to the CSCI as the lead agency in complaints procedures has been revised. The main lounge carpet has now been deep cleaned and is clean and stain free. Some bedrooms have had lockable facilities installed. Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 6 The Responsible Individual has undertaken appropriate consultation with the authority responsible for environmental health for the area. A dedicated WC for kitchen staff has been implemented close to the kitchen. What they could do better: There are Statutory Requirements that have remained outstanding for at least one to five consecutive inspections, therefore these areas are now subject to a Statutory Requirement Notice. Information regarding the aims and objectives of the home must include all items specified under the National Minimum Standards and the associated Regulations, in order to assist potential residents to make an informed choice about their admission to the home. Contracts must be updated to provide residents with update data about fee payments and room occupancy. Pre Admission Assessments require improving to ensure that the assessor gains a clear overview of the potential residents level of need and limitation, before making a decision whether to admit the individual. Care plans are in need of review in order to provide staff with up to date information regarding the resident’s current level of need and limitations, they also require to be generated and reviewed with the residents involvement. Risk assessments require implementing and must include all elements of risk associated with medication and provisions and facilities within the home. Activities require enhancing to encourage residents to experience events that are meaningful and stimulating. Social contact with outside performers and groups must also be implemented, in order to provide residents with a wide range of stimulating, physical, mental and social activities. Complaints, protection and staff recruitment procedures and staff training require reviewing, in order to ensure that residents and there representatives can be confident that any complaint made will be appropriately actioned and that they will be effectively safeguarded in the event of an allegation of abuse. Staff training must be on going and appropriate to the level of needs of current residents, this includes Induction training for all staff. Quality Assurance processes must also be enhanced to ensure that residents benefit from a home that is run in their best interests, with consideration given to their views and opinions. Documentation required under the Care Homes Regulations 2001 must be made available for future inspections and urgent action is required to ensure that residents are aware that the premises are suitably insured. Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 7 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 residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beechwood Lodge DS0000021046.V365234.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.V365234.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 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Potential new residents do not benefit from receiving pre admission information that does not include all items specified by the Care Homes Regulations 2001. Evidence that the Residents contract has been updated is required to ensure that all residents are in receipt of an up to date contract. Pre Admission Assessments do not provide the assessor with a good overview of the potential Residents of individuals medical, mental health, social and personal care needs and provide the assessor with a clear overview of the Residents current needs, limitations and required assistance. EVIDENCE: Following the inspection of February 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 Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 10 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 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 Residents care plans did not specify that this would be subject to the resident’s 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. (See Requirement section.) 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 residents are in receipt of the necessary documentation to ensure that they have made an informed choice about admission to the home. At the previous inspection of February 2008 it was recommended that the home’s contract should be checked for compliance with all the elements of the National Minimum Standard. The Contract was viewed and it was observed that the following items were not included. 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. The Responsible Individual reported that this had been completed but could not provide a contract for inspection. Therefore a requirement has been made. The Responsible Individual reported that the Assistant Manager conducts Pre Admission Assessments. Pre Admission Assessments viewed and 75 were found to be very basic in content in that they did not detail the resident’s level of need, limitations/capabilities or their social preferences at the time of the Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 11 assessment. It was also observed that for the remaining 25 , there were no records of a Pre Admission Assessment having been conducted on the newest resident admitted. No changes were evidenced to have been made to the admissions procedure since the previous inspection. The Responsible Individual stated that no changes had been made. This has been an outstanding Requirement from previous inspections in April and October 2006. This requirement is outstanding from previous inspections. (See Requirement section.) Intermediate care is not provided by this service. Beechwood Lodge DS0000021046.V365234.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 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are offered a good provision of health care and personal support by care staff, though improvements are required to ensure that care plans, risk assessments and daily care records are reflective of this. All care is administered in way that protects residents privacy and dignity. Controlled Drug Medication procedures do not always ensure that all necessary precautions are taken to prevent errors occurring and that these medications are administered safely. Improvement is also required to ensure that there is a clear audit trail of all medications entering and being discharged from the home. EVIDENCE: Following the inspection of February 2008 there have been no improvements made to ensure that care plans must fully reflect residents’ changing needs. This is to be interpreted in the following ways: They must provide adequate guidelines for staff providing care; Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 13 Care plans must record who is invited to participate and who participates in the decisions made, most notably the resident or their representative. Of the care plans viewed 75 were inappropriately maintained and did not give the assessor accurate and up to date information relating to the individuals needs, limitations/capabilities or the level of assistance/intervention required. The remaining 25 did not have a care plan in place, despite having resided at the home since December 2007. As the Pre Admission Assessment is basic in its approach the formulation of a specific and individual plan of care for daily living and longer-term outcomes, cannot be effectively produced. Of the 75 of care plans in place none of these were observed to have been reviewed on a monthly basis. Many had been reviewed between three to six monthly intervals. Care plans that were in place were observed to have been written by care staff, with no acknowledgement of residents or their representative’s involvement. Residents reported that they are not involved in the care planning process, with one resident stating ‘What is a care plan?! – I’ve been told that I have one but I’ve never seen it’. 100 of care plans viewed also did not have risk assessments in place for pertinent elements of risk such as falls, epilepsy, nutrition or tissue viability. One resident care plan states ‘diagnosed with epilepsy so may be at risk of falls. Monitor and wherever possible take precautionary measures’. It was observed that no risk assessments or care plans had been generated to this effect. Daily care records had entries made relating to falls and actions taken by care staff after an event, though the number of falls recorded in the daily care record was not reflective of those recorded in the accident book. As this requirement is outstanding from previous inspections, this matter is now subject to a Statutory Requirement Notice. Daily records were also observed and it was noted that these were not recorded on a daily basis. Spaces of two to five days were observed between entries for all of the records viewed. There is a daily diary also kept in the office, it was noted that some resident’s data was documented in the diary but not for all residents, only those bathed or visited by relatives on that day. Therefore a Recommendation has been made. Residents are registered with one GP from one of four local surgeries. District Nurse appointments are arranged via the GP. Residents attend local Opticians surgeries for eye examinations and spectacle reviews. Audiology appointments are arranged via the GP, residents 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 residents on a six weekly and as required basis. 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 Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 14 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 the MAR sheet month are recorded onto the Mar sheet. Therefore a Requirement has been made. The stores for medication were viewed and these were found to be maintained in a clean and orderly manner. Controlled Drugs are maintained on the premises and were found to be recorded as administered by one carer. Administrations are recorded onto the MAR sheet only, which increases the risk of abuse of Controlled Drugs. Therefore an immediate Requirement was made. At the previous inspection of February 2008 it was recommended that staff should have ready access to a copy of the Royal Pharmaceutical Society Guidance, to ensure practice complies with best practice standards. The Responsible Individual reported that this guidance had not been obtained. Therefore the recommendation remains in place. Staff were observed providing personal support to residents in such a way that promoted and protected their privacy and dignity. Beechwood Lodge DS0000021046.V365234.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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are not able to enjoy a programme of internal activities to choose from. The home does not provide a wide range of social, cultural and recreational facilities. Specialist diets are provided for residents, with mealtimes being an unhurried social occasion. EVIDENCE: 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 holy communion four to six weekly and Pat Dog (every Friday). Residents spoken with commented that there is not a lot of social time – Get quite bored with the TV and radio’, ‘I would go to some activities – depending on what they were – if they were offered’ and ‘There are no activities – I’m very bored – if it wasn’t for the TV and radio I’d have no stimulation. Social stimulation is not encouraged either’. It was observed that residents care plans do not have any recordings made of resident’s interests/hobbies. Therefore a Requirement has been made. Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 16 Resident’s religious wishes are observed and arrangements are in place for residents to receive Holy Communion, if they wish. 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 resident’s wishes. There are currently no community activities or contact from external communities at the home. Therefore a Requirement has been made. Residents are treated with respect and there is a good rapport between staff of the home and residents. Residents reported that the home assists them to maintain their independence with their daily living and daily routines. The Responsible Individual 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 residents 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 and attractively presented. The lunchtime meal was observed to be unhurried. Residents spoken with commented that the ‘Food is excellent!’ ‘Food is good – lots of variety.’ ‘I enjoy lunch and supper as you get to see other people for a chat’, ‘Food is alright – don’t get told in advance what’s for lunch until you turn up for it’ and ‘Food is good – never know in advance what it is – have to ask staff in the morning. Good variety’. Therefore a Recommendation has been made. Beechwood Lodge DS0000021046.V365234.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 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a robust and efficient complaints procedure. Staff training in Safeguarding needs improvement to ensure that all staff receive up to date training. EVIDENCE: Following the inspection of February 2008 there have been improvements made to ensure that the reference to the CSCI as the lead agency in complaints procedures is revised, once the new arrangements are publicised has been addressed. The Responsible Individual reported that there is a complaints book in place, though this was not available for inspection. The complaints procedure was viewed and it was observed that the CSCI contact address was correct. The procedure states that in the event of a complaint, CSCI can be contacted after all internal processes have been exhausted, as opposed to at any stage. Therefore a Requirement and a Recommendation has been made. At the inspection of February 2008 it was recommended that a directory of local advocacy services would be judged good practice. It was observed that Advocacy services were not in place. The Responsible Individual reported that they did not know where to source these. A general discussion was held and the Responsible Individual was recommended to contact Age Concern, MIND Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 18 and Help the Aged for more information regarding Advocacy services available. Therefore the Recommendation remains in place. The Responsible Individual reported that there have been no Safeguarding Alerts raised by in the past 12 months. Staff records highlighted that there has been no Protection of Vulnerable Adults training provided for two years and staff reported that they haven’t had this training for this time scale. Therefore a Requirement has been made. Criminal Record Bureau (CRB) checks have been carried out on all existing staff. Both CRB and Protection of Vulnerable Adult (POVA) checks are carried out on all new staff. Beechwood Lodge DS0000021046.V365234.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): 19, 20, 22, 24 & 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides accommodation for residents that is generally safe, hygienic and odour free. In order to protect the health, safety and well being of residents and staff, urgent action is required to address Health & Safety issues evidenced. 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 residents. The home has an ongoing plan of refurbishment in place. At the previous inspection of February 2008 it was recommended that the gravel drive needs redressing to obtain a level surface. The Responsible Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 20 Individual confirmed that he gave consideration to this recommendation and a quote has been obtained, though the cost of the work required has been redirected to other areas of development/refurbishment within the home. It was also recommended that the raised semi circular patio outside the billiards lounge has sharp brickwork along the edges and an unguarded ramped descent onto lawn, which requires handrails, as this is potentially hazardous. The Responsible Individual confirmed that no changes had been made since the previous inspection. It was also observed to be unchanged. Therefore a Requirement has been made. The homes large lounge area is currently being refurbished. It was observed that there was no wall decoration at present The Responsible Individual reported that the whole area needs plastering and redecoration. In the dining area there was a large damp patch to the wall observed. The Responsible Individual confirmed that it is damp but a contractor has said that it is not coming from inside or outside of the building, but will need to be rectified. It was also reported that builders are scheduled to repair it in the coming months. During the inspection of February 2008 a recommendation was made that it should be considered that the residents would benefit from the introduction of a variety of dining room chairs to suit individual needs e.g. some with arms, sleigh bases, extra cushions. The Responsible Individual confirmed that he had considered this recommendation and no changes have been made to the dining furniture. It was also recommended that the billiard lounge requires a risk assessment, as it is also being used for storage pending completion of refurbishment/maintenance work. There were no records available to view relating to this issue. The Responsible Individual confirmed that a risk assessment, relating to the Billiards lounge, had not been generated since the previous inspection. Therefore a Requirement has been made. At the inspection of February 2008, the main lounge carpet was very stained. It was evidenced that the carpet had been deep cleaned and was found to be clean and stain free. The only showers available in the home are located in the en-suite facilities. It was recommended during the previous inspection that consideration should be given to providing shower facilities so that all residents have a choice. The Responsible Individual confirmed that he considered this recommendation and that no changes have been made since previous inspection. It was observed that bathing facilities remain unchanged. Periodic audits of the premises by specialists such as Occupational Therapists were recommended at the previous inspection, to ensure that the home maintains its capacity to meet the changing needs of its residents. The Responsible Individual stated that though the home has access to an Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 21 Occupational Therapist, funding has been an issue and so this has not been conducted. As this remains a pertinent issue due to the ongoing refurbishment and changing needs of residents, this recommendation remains in place. During the previous inspection it was recommended that all bedrooms should have lockable facilities. The Responsible Individual reported that safes have been purchased and that some, but not all, had been installed. Following the inspection of February 2008 it was required that the registered person shall undertake appropriate consultation with the authority responsible for environmental health for the area. The Responsible Individual reported that the EHO visited the home in April 2008, though there was no report or record of the EHO visit available for inspection to evidence that this information was true. Therefore a Requirement has been made. It was recommended at the previous inspection that the ranch doors between the kitchen and laundry room provide scope for contamination and should be replaced - subject to Environmental Health Officer (EHO) advice. The Responsible Individual reported that the EHO deemed the laundry area as safe. It was also reported that other recommendations were made relating to food diaries, no smoking signs being in place and risk assessments. The Responsible Individual confirmed that some, but not all, of these recommendations have been actioned. There was no report or record of the EHO visit available for inspection to evidence that this is the case. It was also recommended that external kitchen windows should have fly screens or there should be an insectocutor, to prevent the infestation of flying insects - subject to EHO advice The Responsible Individual reported that the EHO visited the home in April 2008 and didn’t mention this in his report. There were no insectocutors or fly screens observed. Further recommendations were also made in that consideration should be given to installing washing machines with a sluice cycle - subject to EHO advice. The Responsible Individual confirmed that the EHO deemed this unnecessary due to current residents accommodated. The Responsible Individual reported that if resident’s needs changed then appropriate action would be to readdress this issue. It was recommended that there should be a dedicated WC for kitchen staff close to the kitchen with washbasin, soap dispenser, paper towels or air dryer. It was evidenced that there is now a dedicated staff toilet to rear of kitchen. Paper towels and/or an air dryer have not been installed. It was observed that communal fabric hand towels were in place. On the tour of the premises it was evidenced that products such as air freshener, unnamed bubble bath/talcum powder/shampoo and bars of soap were freely available in both communal bathrooms. It was also observed that there were no paper towels noted in any bathroom or communal toilet area all towels were fabric and used communally. Therefore an Immediate Requirement was made. Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 22 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 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a staff team that have the necessary experience to the meet the needs of current residents. Staff recruitment procedures require improving, to ensure that residents benefit from the protection provided by all new staff having appropriate recruitment checks undertaken. Staff training is also in need of improvement to ensure that staff are in receipt of relevant training in specific subject matters. EVIDENCE: The Responsible Individual reported that there is a staff rota in place, though this was not available for inspection. 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. Therefore a Recommendation has been made. The Responsible Individual confirmed that the staff team consists of the Responsible Individual as the Registered Manager, ten Carers (one of which is the Assistant Manager), one cleaner, one cook and one handyman. Five carers are NVQ 2 or 3 in care trained and one carer is due to commence NVQ 3 soon. There were no records viewed to support this information, though Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 23 discussions with staff and the Responsible Individual reported this to be accurate. Staff records were viewed for the recruitment of staff. 50 of files were found to have unsigned contracts of employment on file. 100 of files viewed did not include proof of the staff member’s identity. 50 of files did not have a completed Application Form. 25 of files were viewed to contain evidence of induction training records. 50 of files viewed were found to contain two written references. This issue has been a requirement that is outstanding from previous inspections, however due to no new staff having been recruited since the previous inspection, this requirement cannot be reassessed. Should new staff be recruited and their staff files not maintained in accordance with the Care Homes Regulations 2001, enforcement action will be taken. Staff spoken with confirmed that they had received training in Infection Control, Food Hygiene (basic) and Moving and Handling in the last twelve months. There were no records made available to support this. The Responsible Individual reported that training in care planning is due to take place in July and Fire Safety training is also due to take place soon. Training records on file were noted to be for training that had taken place prior to the twelve month period required for inspection (2006 – early 2007). This requirement is outstanding from previous inspections. (See Requirement section.) At the inspection of February 2008 it was recommended that a staff training matrix is developed in order to clearly evidence appropriate staff training has been undertaken. The Responsible Individual reported that this document had not been generated and there was no evidence of a training matrix having been implemented. Therefore the Recommendation remains in place. Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 24 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, 36 & 38 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents do not experience the benefits of a home that is well managed and administrated. Quality Assurance processes and procedures are in need of implementation to ensure that the home is run in the best interest of residents and that there views are taken into consideration. Urgent improvement is required to ensure that the health, safety and welfare of residents and staff are protected at all times. EVIDENCE: Beechwood Lodge has been owned by the same family for many years and continues to be managed by the Responsible Individual. Previous inspections of September 2005, April 2006 and June 2007 identified that the owner did not Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 25 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 could not finance this at the present time. At the inspection of February 2008 it was commented on that 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 includes the timely submission of its Annual Quality Assurance Assessment to the Commission. The Responsible Individual reported that no changes to the Quality Assurance systems have been made since the February 2008 inspection. The Responsible Individual acknowledged that Quality Assurance must be conducted and stated that following today’s inspection Resident and staff questionnaires would be conducted. The Responsible Individual reported that residents meetings are held rarely and that they are usually poorly attended. There were no minutes of previous meetings held to view in order to confirm this information. There are no staff meetings held, the Responsible Individual reports that as he sees staff on a daily basis, he feels that there is no need to have meetings with them. 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 and failure to comply can result in enforcement action be taken. It was evidenced that there is no financial or business plan in place. Therefore a Requirement has been made. There was a Certificate of Insurance displayed, which was noted to have expired in April 2008. Therefore an Immediate Requirement was made. The home does not take any responsibility for many of the resident’s finances and most residents have family, friends or representatives who protect their financial affairs. 100 of the staff files viewed had supervision records on file, though it was noted that these were for the periods of Jan/Feb 2007. The Responsible Individual reported that as he sees staff on a daily basis he has ‘lots of informal supervisions’ and that ‘ there is no formal process in place – I don’t have time’. This requirement is outstanding from previous inspections. (See Requirement section.) A number of records required for inspection such as; the Statement of Purpose and Service User Guide, a copy of the EHO report, a copy of the staff rota, environmental risk assessments, staff training records, financial and business plans and Quality Assurance documentation were not available. Therefore a Requirement has been made. Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 26 On the tour of the premises it was noted that there is a call bell system throughout the home. The previous inspection recommendation that a sample First Aid kit is readily accessible to catering staff within the kitchen has been addressed. First Aid Kits were observed to be in place. The Responsible Individual reported that no environmental risk assessments have been completed since the previous inspection ‘simply because I don’t have time’. Accident records were observed to be well recorded, if not consistent with daily care record entries. It was also noted that none of these had been forwarded to CSCI as required under Regulation 37. Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 27 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 2 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 3 2 X 3 X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 2 3 2 2 2 Beechwood Lodge DS0000021046.V365234.R01.S.doc Version 5.2 Page 28 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 30/10/08 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 and in February 08) 2. 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 and June 2007) 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 DS0000021046.V365234.R01.S.doc 30/10/08 3. OP2 5A (2) (b) 30/11/08 Beechwood Lodge Version 5.2 Page 29 4. OP3 14 (1) (2) (a) 5. OP9 13 (2) 6. OP9 13 (2) 7. OP12 16 (2) (n) 8. OP13 16 (2) (m) 9. OP16 22 (8) 10. 11. OP18 OP19 13 (6) & 18 (1) (c) (i) 13 (4) (a) (b) (c) verified. This requirement is outstanding from previous inspections. That Pre Admission Assessments are updated to include thorough details of the potential new residents level of need, current limitations/capabilities and their social preferences. This requirement is outstanding from previous inspections. That a clear audit trail of all medications entered into and discharged from the home is maintained. 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. This is an immediate requirement. That residents are consulted regarding their leisure interests and an activities programme be implemented to reflect those interests and preferences. That residents are consulted about their social interests, and make arrangements to enable them to engage in local, social and community activities. 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 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 residents safety. DS0000021046.V365234.R01.S.doc 30/08/08 30/10/08 30/06/08 30/10/08 30/10/08 30/11/08 30/11/08 30/11/08 Beechwood Lodge Version 5.2 Page 30 12. OP19 13 (4) (a) (b) (c) 13. OP26 13 (3) 14. 15. OP26 OP30 23 (5) 18 (1) (a) (c) 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. That multiple person use hand towels are removed and replaced with a suitable single use alternative and that all bars of soap are removed and replaced with a single use dispensing system for hand washing. This is an immediate requirement. That a copy of the April 2008 EHO report is sent to the CSCI. 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.) 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) That a financial and business plan is sent to the CSCI and is made available for future inspections. That an up to date certificate of insurance is displayed in the home and a copy is sent to the CSCI. This is an immediate requirement. A formal system of supervision for staff must be introduced. DS0000021046.V365234.R01.S.doc 30/10/08 02/07/08 30/10/08 30/11/08 16. OP33 24 30/11/08 17. OP34 25 (2) (c) 30/11/08 18. OP34 25 (2) (e) 02/07/08 19. OP36 18 (2) 30/11/08 Beechwood Lodge Version 5.2 Page 31 20. OP37 17 (3) (b) 21. OP38 13 (4) (a) (b) (c) 22. OP38 37 (This has remained an outstanding Requirement from the inspections of September 2005, April 2006 and June 2007) That documentation required 30/11/08 under the associated Regulation and Schedules are made available for inspection. That all C.O.S.H.H products and 30/06/08 unnamed toiletries are removed from communal bathrooms and toilets and ensure that they are stored appropriately. This is an immediate requirement. That all accidents/incidents that 30/10/08 affect the well being of residents are reported to CSCI in accordance with this regulation. 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. That daily care records are maintained for all residents on a daily basis. Staff should have ready access to a copy of the Royal Pharmaceutical Society Guidance, to ensure practice complies with best practice standards. That residents are given ample opportunity to choose meals and meal times, in accordance with their wishes. That the complaints procedure is updated to reflect that the CSCI can be contacted at any stage during the complaint process. 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 DS0000021046.V365234.R01.S.doc Version 5.2 Page 32 2. 3. 4. 5. 6. 7. OP7 OP9 OP15 OP16 OP17 OP19 Beechwood Lodge 8. 9. OP27 OP30 home maintains its capacity to meet the changing needs of its residents. That the staff duty rota is made available to all staff and for inspection. It is recommended that a staff training matrix is developed in order to clearly evidence appropriate staff training has been undertaken. Beechwood Lodge DS0000021046.V365234.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.V365234.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. Re-publishing this information is in breach of the terms of use of that website. 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