Inspection on 14/07/05 for Bescot Lodge

This inspection was carried out on 14th July 2005.

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

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

Other inspections for this house

Bescot Lodge 06/09/07

Bescot Lodge 22/01/07

Bescot Lodge 06/01/06

Bescot Lodge 22/10/04

Bescot Lodge 25/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Bescot Lodge 76-78 Bescot Road Walsall West Midlands. WS2 9AE Lead Inspector Lesley Webb Unannounced 14 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bescot Lodge Address 76-78 Bescot Road Walsall West Midlands. WS2 9AE 01922 648917 01922 648917 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) United Care Ltd. Mrs Donna Wallace Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number OP (26) of places Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service users with mobility issues or who use wheelchairs are to use bedrooms near to the ramp located on the first floor. 2. The sluice facility is to be adapted as agreed with CSCI to Infection Control Standards. 3. A minimum of four care staff (one of which can be a senior/or designated person in charge of shift) must be on duty from 7.30am until 9.30pm when 26 service users reside at the home. If less than 26 service users reside at the home but whose needs dictate, then the same staffing ratios must be implemented as for 26. 4. Kitchen and domestic staff must be employed seven days per week. Date of last inspection 22nd October 2004. Brief Description of the Service: Bescot Lodge is a care home providing accommodation and personal care for older people. The home has 20 single occupancy rooms (some of which have en-suite facilities) and 3 double bedrooms. There are two lounges, a conservatory and separete dining room, all of which are decorated to a high standard. Parking facilities are located at the side of the home and there is a small enclosed garden to the rear (not accessible to service users with mobility problems). The home is located in a residential area of Walsall with shops, public transport and a few public house situated close by. The home was first opened in 1984 and was taken over by the new owners, United Care Limited in 2002. Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at 9.10am and stayed until 8pm. Time was spent interviewing service users and staff, observing care practices, looking at service users, staff and other records relating to the running of the home and touring the building before giving feedback to the Registered Manager. Since the last inspection building work has been completed to increase bed spaces and improve facilities, which was monitored by the inspector who undertook additional visits to the home while this was in progress. An additional unannounced visit was also completed due to CSCI receiving an anonymous complaint regarding low staffing levels, which was found to be upheld and resulted in a letter of serious concern being sent to the Registered Proprietor and a Condition being placed on the homes registration. CSCI have also received several telephone calls from members of staff seeking advice relating to employment matters. The National Minimum Standards relating to these and the subjects mentioned above were assessed to ensure care provision was not being affected. The inspector would like to thank both service users and staff for their help and co-operation throughout the visit, where she was made to feel welcome and full assistance was given. What the service does well: The home gives all service users and potential service users and their representative’s detailed information about services and facilities on offer at the home, which allows people to make informed decisions when choosing where to live. This information is both well presented and easy to read. Also the home completes comprehensive needs assessments prior to service users moving into the home, again to ensure the home can meet the needs of individuals. The home is both relaxed and welcoming, with this reinforced by service users who commented to the inspector that their visitors are always made welcome by staff. Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 6 There is a very good rapport between service users, staff and the manager, which was evidenced by the inspector during the visit to the home. Service users stated, “the manager is lovely, nothing is too much trouble for her” and “the manager always has time to talk to you”. What has improved since the last inspection? What they could do better: There are several areas that the home must improve to ensure the health and well being of service users that includes maintaining full employment records of staff, arranging annual hearing and sight tests for all service users, the following of Adult Protection policies and procedures in full and ensuring all staff undertake Adult Protection training. Priority however must be given to ensuring full and comprehensive nutritional screening and monitoring takes place for all service users that includes the regular monitoring of weight and implementation of remedial action where necessary. Further work must also be carried out to ensure service users are involved in the compilation and reviewing of their care plans and communication between staff and higher management. Outstanding issues with building/garden affecting safety of service users. Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 7 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. Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4. The home’s Statement of Purpose and Service User Guide are very good, providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to be made. Comprehensive needs assessments are completed by the home that ensure prospective service users and their representatives now the home they are entering can meet their needs. EVIDENCE: The inspector viewed copies of the Home’s Statement of Purpose and Service User Guide, both of which are given to service users and their families in order that they are aware of the services and facilities on offer at the home. Records and conversations with service users and staff confirmed that no one moves into the home before an assessment of needs is completed in order that service users and their families are confident that the home can meet their needs. Service users that the inspector spoke to stated that they or their families had visited the home prior to moving in so that they could meet staff and look at Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 10 facilities on offer, with one person stating, “my son and social worker helped me find this place, I came for respite first, liked it here so asked if I could stay, it suits me down to the ground”. The home does not offer intermediate care. Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 8. Service users are not involved in the reviewing of their care plans resulting in their views not being taken into consideration. The health needs of service users are not being met in full, with the potential to place service users at risk. EVIDENCE: Although each service users file that was sampled contained care plans that set out actions to ensure aspects of health, personal and social care needs of service users are met the inspector could not be satisfied that this is occurring in full due to inconsistencies in recording and monitoring practices. For example each persons file contained a nutritional assessment but these were not comprehensive in content and context. Also although staff stated that service users are weighed monthly records seen did not substantiate this. The inspector was particularly concerned when records stated that service users had lost weight but could find no evidence of remedial action (including recording dietary intakes) being taken or this information being incorporated in the monthly reviews completed by staff. Added concern with regards to these practices was evidenced when risk assessments maintained on service users files stated that they were at increased risk due to poor nutrition, pressure Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 12 sores and reduced mobility. All service users that the inspector spoke to confirmed that they are visited by the chiropodist and optician however none could confirm they have hearing tests with one person stating, “ I could do with my ears syringing, as I have difficulties hearing, but don’t know if they do it here”. The manager confirmed that hearing tests were not offered as an annual health check, but rather if someone appeared to be experiencing difficulties in this area. Staff that were interviewed generally were able to give examples of service users needs but when asked if service users are involved in the review of their plans responses ranged from, “I don’t know” to “they should be”. Records maintained by the home still did not clarify the matter. Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13. The atmosphere within the home is both friendly and welcoming, with service users supported to maintain contact with their families and friends. EVIDENCE: When asked if they see their families or friends many service users confirmed they receive visitors on a regular basis. This was verified throughout the visit to the home where families were seen visiting service users, many of which included taking them out for the day. All the service users that were spoken to confirmed that their families are made welcome by staff when visiting the home and that they could spend time in the privacy of their bedrooms should they wish to. No service user that the inspector spoke to was aware of the visitors room that has recently been built as an additional area where people can meet in private; therefore the inspector recommends that information regarding this new facility be sent to families of service users. One service user was particularly proud to inform the inspector that her son visits three times a week and talks on the telephone. Information regarding visiting times is included in the homes Statement of Purpose and Service User Guide, both of which are given to service users and their representatives at the time of moving into the home. Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home has a satisfactory complaints system with some evidence that service users feel that their views are listened to and acted upon. Arrangements for protecting service users are not satisfactory placing them at possible risk of harm or abuse. EVIDENCE: Since the last inspection there have been three verbal complaints made direct to the home and one anonymous complaint sent direct to CSCI. Records viewed confirmed that all complaints sent direct to the home have been appropriately investigated and acted upon. The complaint sent to CSCI related to low staffing levels and generated an unannounced visit to the home as part of the investigation process. The visit, discussions with staff and checking of records verified that staffing levels had not been maintained to a satisfactory level on three separate occasions potentially placing service users at risk. A Condition of Registration was imposed stating minimum staffing levels, with the risk of further enforcement action if not adhered to. CSCI was notified via a Regulation 26 report completed by the Quality Assurance Manager that a breech of Condition had occurred on one occasion for which disciplinary action is being taken against the responsible person. All service users that the inspector spoke to stated that they would approach the manager if they were unhappy with anything, with several stating, “ the manager always listens to you and sorts things out”. These comments were reinforced during the visit when the inspector witnessed one service user raise a complaint direct to the manager who not only listened, but offered support, Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 15 advice and reassurance to the individual. Using the line management structure to complain was reinforced by all staff interviewed, when asked how they would ensure service users complaints are dealt with everyone replied, “See the senior on duty or the manager”. Records confirmed that twelve of the twenty five staff have undertaken adult protection training in September 2004, however, when asking staff how they ensure service users are protected from abuse, staff responses varied with some staff unable to demonstrate knowledge in this area. There has been an incident at the home relating to service users finances, which CSCI have been notified about. Upon checking records and talking to the manager the inspector concluded that all appropriate parties apart from the police have been notified and informed. Since this incident the manager has reviewed the Adult Protection policy and sent letters to the families of service users reinforcing the safekeeping facility available within the home. The homes Service User Guide and Statement of Purpose do not state whether service users will be reimbursed if money is stolen from their rooms or persons, only if lost or damaged if deposited within the homes safe for safekeeping. The inspector instructed that amendments must be made to these documents in order that service users and prospective service users are fully informed of the homes policies and practices relating to service users monies and financial affairs. The inspector also instructed that written documentation must be supplied to CSCI detailing the contents and extent of the homes insurance policy. Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. Recent investment has significantly improved the appearance and facilities within this home, creating a comfortable and homely environment for those living there. Further work must be undertaken to ensure that all areas of the building and gardens are safe for service users to use. EVIDENCE: Building work has now been completed at the home creating additional bedrooms, all with en-suite facilities. In addition to this a conservatory has been built to ensure sufficient communal space is provided and a room is also now provided in order that service users can receive visitors in private if they so choose. The creation of several new adapted bathrooms has also increased the facilities within the home. In addition to this all but three Requirements identified in a previous inspection relating to the environment have also been addressed. From a tour of the premises the home was seen to be comfortable and generally well presented although there are areas that must still be addressed: Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 17 * The home must request a visit from the Environmental Health Department in order to seek advice regarding the facilities and layout of the kitchen as there appears to be inadequate food preparation areas, access to hand washing facilities and storage facilities which could pose heath and safety hazards and risks. * The home must request a visit from the Environmental Health Department in order to seek advice regarding the shed that is used to store food, and clarify that the roof is asbestos free. * The rotting window frames at the front of the building must be replaced or repaired to ensure the safety of service users and staff. * The ground around the building must be given attention; cleared of debris and weeds and a garden area made accessible to all service users. * Curtains or blinds must be fitted in the conservatory to promote service users privacy. * Toilet 6 needs the flooring sealed and the extractor fan repaired to ensure health and safety standards are maintained. * Bathroom 38 must be accessible to service users. The hoist in this bathroom must be replaced as a matter of urgency as the seat is damaged, resulting in the potential to cause injury and the hoist does not fit in the bath adequately when lowered. No records were available that demonstrated when this equipment had last been serviced. * The carpet in the dining room must be cleaned so that the stains are removed. It was also noted by the inspector when sampling records for one of the service users who use a double room that nothing was recorded that validated they had made a positive choice to do this. The inspector informed the manager that not only should this be evidenced, but also that when a shared room becomes vacant, the remaining service user is given the opportunity to choose not to share, by moving to a different room if necessary. Those service users spoken to were generally happy with their bedrooms, with one person stating, “ I like spending time in my room, I can watch what I like on T.V without being disturbed”. Records and conversations with service users also confirmed that everyone is offered a key to their bedroom, with some choosing to use this facility and others declining. Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30. No progress has been made to ensure staff employment documentation is maintained in full, resulting in the potential to place service users at risk. The arrangements for the induction of staff do not demonstrate that they have a clear understanding of their roles and work is required to ensure that staff numbers and skill mix can safely meet service users needs. EVIDENCE: A Condition of Registration is in place at the home instructing that a minimum of four staff must be on duty when 26 service users reside at the home or if less reside there but the needs of service users dictate this. This Condition was applied after three incidents since the last inspection when staffing levels posed potential risk to service users. Records viewed by the inspector confirmed that staffing ratios have been maintained appropriately since then, apart from one incident, which CSCI were informed of. In addition to care staff the manager works supernumerary hours and kitchen and domestic staff are employed seven days a week. Although staffing levels are being maintained, when interviewing staff and checking records the inspector found that on the day of inspection no staff on duty during the afternoon had undertaken accredited medication training, the senior on shift did not hold an NVQ qualification and one member of staff was witnessed entering the kitchen who did not hold a food hygiene certificate (the inspector did however witness the manager instruct this person to leave this area). The inspector stated that assessments must be completed that demonstrate staffing numbers and skill Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 19 mix of qualified and unqualified staff are appropriate to the needs of the service users and the size and layout of the home. Records and conversations with staff confirmed that training is always an ongoing provision within the home with courses including continence, fire, moving and handling and first aid being undertaken since the last inspection. Staff records sampled also confirmed that they receive induction training, but the inspector raised concerns about the effectiveness of this with the manager as these stated that new employees are instructed upon 66 different subjects over one or two days. This was further reinforced when interviewing staff, two of whom have being working at the home for approximately two months, as neither could state specifics of what they had been inducted upon, only that “we were told about policies, care plans and folders in the office”. A previous Requirement relating to the retention of staff employment documentation remains outstanding. None of the three files sampled contained the required documentation as listed in Schedules 4 and 6 of the Care Homes Regulations 2001. The inspector expressed particular concern for one member of staff who had been employed prior to satisfactory Criminal Record Bureau/Protection of Vulnerable Adults (CRB/POVA) disclosures being obtained. The manager stated that senior management had instructed her that this would be acceptable due to staff shortages within the home. The inspector agreed that this could occur but that a POVA first check must still be in place prior to commencing shifts along with additional documentation stated by the Department of Health (none of which was). The inspector stated that due to the outstanding Requirement relating to staff records and this new incident the home must seek approval from CSCI prior to employing anyone before receiving a satisfactory CRB/POVA disclosure. Previous Requirements relating to staff rotas and payment for attending training have been addressed. Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36 and 37. Lines of accountability within the home and with external management must be improved to ensure everyone is aware of their roles and responsibilities. The manager encourages involvement and communication, creating a positive and inclusive atmosphere, which benefits service users. Staff are appropriately supervised. The home regularly reviews aspects of it performance through a good programme of self-review and consultations, which include seeking the views of service users, staff and relatives. EVIDENCE: Every member of staff and service user spoken to praised the manager, with an abundance of compliments received including, “ the manager is brilliant, always there to help you and is very kind” and “the manager always listens to Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 21 you and sorts things out”. Records also confirmed that regular staff meetings occur as tools to aid communication, with one member of staff informing the inspector, “staff meetings are useful as they allow us to discuss issues as a group and give our opinions”. The inspector recommended to the manager that minutes of these meetings include details of agreed actions and timescales to further enhance this process. Two service user meetings have taken place this year, with minutes maintained. As in previous inspections the inspector strongly recommended that these occur more frequently as they are a format that enables service users to voice their opinions and become involved in decision-making processes. As with the staff meetings it was also recommended that these include details of agreed actions and timescales. It was pleasing to note that subjects discussed in service user meetings were then raised in the staff meetings in order that service users views were acted upon. The inspector could not be satisfied however that everyone employed in the home understands the line management structure, in particularly concerning external management as both the manager and staff said that they were unsure of external managements roles and responsibilities and no documentation was available within the home that clarified this issue. CSCI has received several telephone calls from members of staff since the last inspection seeking advice relating to employment matters such as paying for uniforms and CRB disclosures. Although CSCI cannot get directly involved in employment matters advice has been given to staff and the issues are being monitored in order that CSCI is satisfied that working conditions and the moral of the staff do not deteriorate and effect the quality of care provided in the home. The home has an excellent quality assurance system that includes a monthly health and safety audit, three monthly audits of records for staff, service users, medication, catering and the building. In addition to this, since the last inspection user satisfaction questionnaires and the views of families have been obtained that now require analysing and incorporating into an annual audit of the quality assurance system. A previous Requirement to ensure staff receive at least six formal supervision sessions per year has been met. Staff that were interviewed confirmed that they found this support useful with comments received including, “it allows you to raise training requirements or talk about problems”. Generally records in the home are well maintained. A previous Requirement to ensure monthly visits take place in line with Regulation 26 of the Care Homes Regulations 2001 has now been met. The Quality Assurance Manager for United Care Limited now undertakes these visits, unannounced, completing reports that are forwarded to CSCI. Also, for all but one case the home has reported relevant incidents and events in line with Regulation 37 Notices. The homes insurance and Registration certificate were found to be appropriately Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 22 displayed; however the inspector instructed that the photocopied version of the Registration certificate must be replaced with the original. Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 23 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 2 2 2 2 2 3 3 STAFFING Standard No Score 27 2 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 3 2 x x 3 2 x Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Service users care plans must set out in detail the action which needs to be taken to ensure all aspects of health, personal and social care needs are met Service users, where possible must be involved in the complilation and reviewing of care plans Care plans must be signed by the service user and/or their representative Comprehensive nutritional screening must be undertaken on admission and regularly thereafter, a record maintained of nutrition, including weight gain or loss, and appropriate action taken Service users must have access to annual hearing and sight tests All staff must undertake adult protection training The police must be informed of any allegation of theft of service users money The Statement of Purpose and Service User Guide must be amended and give clear information relating to the homes policies and practices in Timescale for action 31/10/05 2. OP7 15 31/10/05 3. 4. OP7 OP8 15 12(1) 31/10/05 31/10/05 5. 6. 7. 8. OP8 OP18 OP18 OP18 12(1) 10(1) 10(1) 10(1) 31/10/05 31/10/05 Immediate 30/07/05 Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 25 9. OP18 10(1) 10. OP19 16(1) 11. OP19 16(1) 12. 13. OP19 OP19 16(1) 16(1) 14. 15. 16. 17. 18. OP19 OP19 OP21 OP21 OP22 16(1) 16(1) 16(1) 16(1) 16(1) 19. OP22 16(1) 20. OP23 16(1) relation to service users monies and theft Information must be fowarded to CSCI detailing the contents and extent of the homes insurance policy and theft of service users money The home must request a visit from the Environmental Health Department in order to seek advice regarding the facilities and layout of the kitchen The home must request a visit from the Environmental Health Department in order to seek advice regarding the shed that is used to store food and to clarify that the roof is asbestos free The rotting window frames at the front of the building must be replaced or repaired The ground around the building must be cleared of debris and weeds and a garden area made accessible to all service users Curtains or blinds must be fitted in the conservatory The carpet in the dining room must be cleaned Toilet 6 needs the flooring sealed and the extractor fan repaired Bathroom 38 must be accessible to all service users. The hoist must be replaced Emergency call leads must be fitted in lounge 1 (REQUIREMENT ORIGINALLY MADE OCTOBER 2004) The home must address all issues identified in the Occupational Therapistr report on the building and facilities (REQUIREMENT ORIGINALLY MADE OCTOBER 2004) Where bedrooms are shared, written evidence must be available that demonstrates 30/08/05 31/10/05 31/10/05 31/10/05 31/10/05 31/10/05 31/10/05 31/10/05 30/08/05 30/08/05 30/08/05 30/08/05 Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 26 21. OP23 16(1) 22. OP24 16(1) 23. OP27 18(1) 24. OP29 Schedules 4 and 6 25. OP29 19 26. OP29 19 27. 28. OP30 OP31 18(1) 9 service users have made a positive choice to to this When a shared place becomes vacant, the remaining service user must be given the opportunity to choose not to share, by moving into a different room if necessary, with written records maintained of this decision Bedroom 16 requires the floor sealing around the toilet (REQUIREMENT ORIGINALLY MADE OCTOBER 2004) An assessment of risk must be completed for shifts where unqualified staff are on duty, paying particular attention to staff who do not hold medication, food hygiene and NVQ qualifications Information must be maintained within the home for all staff as listed in Schedules 4 and 6 of the Care Homes Regulations 2001 (REQUIREMENT ORIGINALLY MADE OCTOBER 2004) Written approval must be sought from CSCI for any staff to commence shifts prior to the home receiving a satisfactory CRB/POVA disclosure Additional documentation stated by the Department of Health must be in place for the member of staff who commenced shifts prior to the home receiving a satisfactory CRB disclosure All staff must receive induction and foundation training to NTO specifications The home must be able to demonstrate that there are clear lines of accountability within the home and with any external management, and that staff are aware and understand these 30/08/05 30/08/05 31/10/05 30/08/05 Immediate Immediate 31/10/05 31/10/05 Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 27 29. OP33 24 30. OP33 24 31. OP37 17 32. 33. OP37 17 An annual audit of the quality asssurance system must take place (REQUIREMENT ORIGINALLY MADE OCTOBER 2004) The results of user satisfaction questionnaires must be analysed, with the results published and made availible to interested parties including CSCI. These results must also be included in the annual audit of the quality assurance system and form the basis of future planning CSCI must be notified in writing via a Regulation 37 notification of any allergation of misconduct against anyone working within the home The homes original Registration Certificate must be prominantly displayed within the home 31/10/05 31/10/05 Immediate Immediate RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP13 OP32 Good Practice Recommendations It is recommended that families be made aware of the new visitors room It is strongly recommended that service user meetings occur more frequently than twice a year, with records maintained that include subjects discussed, agreed actions and timescales. It is recommended that minutes of staff meetings include details of agreed actions and timescales 3. OP32 Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 28 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bescot Lodge E55 S39568 Bescot Lodge V238720 140705 Stage 4.doc Version 1.40 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!