Inspection on 22/01/07 for Bescot Lodge

This inspection was carried out on 22nd January 2007.

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 06/01/06

Bescot Lodge 14/07/05

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 and Mandy Beck Key Unannounced Inspection 22nd January 2007 09:30 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 Bescot Lodge DS0000039568.V326476.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. Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bescot Lodge Address 76-78 Bescot Road Walsall West Midlands WS2 9AE 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) 01922 648917 F/P01922 648917 United Care Ltd Post Vacant Care Home 26 Category(ies) of Dementia (26), Old age, not falling within any registration, with number other category (26) of places Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. No service users with mobility issues or who use wheelchairs are to use bedrooms near to the ramp located on the first floor. Separate kitchen and domestic staff must be employed seven days per week. The home will at all times comply with the action plan submitted 22 August 2006 6th January 2006 Date of last inspection 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 separate 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 DS0000039568.V326476.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by two inspectors with the home being given no prior notice. During the visit time was spent formally interviewing staff, examining records and observing care practices before giving feedback about the inspection to the Acting Manager. The people who live at this home have a variety of needs. This was taken into consideration by the inspector when case tracking three individuals whose care is provided at the home. For example the people chosen have differing communication and care needs, consist of male and female and have various cultural heritage. No relatives of residents were available to speak to during the visit. Since the last inspection the home has been registered to provide care for up to twenty-six people with dementia. Additional time was spent observing care practices, interactions between residents and staff, inspecting the environment and formally interviewing staff in order to assess needs being met and quality of service in this area. Fees charged for living at the home range from £327.00 to £347.00 per week. There is also a £10.00 ‘top-up’ fee dependant on the bedroom used. What the service does well: The inspectors sat in the dining room and ate lunch with the residents. Both menu options were sampled and found to be well presented and tasty. Staff were witnessed assisting discreetly and providing meals in sizes as per residents preferences. Residents confirmed that meals provided are acceptable, with comments made including, “the food, its alright, its nice”. Generally recruitment practices and records appear appropriate, safeguarding people living at the home. Practices observed indicate that where possible staff attempt to communicate and build relationships with residents. For example a member of staff was witnessed talking in a reassuring manner, sitting at eye level and attempting to reassure a resident who appeared distressed. Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The manager must ensure that the statement of purpose and service user guide are updated to show the recent changes in the home registration. These documents should also demonstrate how the home intends to meet the needs of people with dementia. All service users must have a contract and terms and conditions of residency given to them upon admission, the manager must make sure that service users are aware of who will be paying their fees and how much these fees are. There must be more consistency in recording of service users information relating to their care, the manager must also be able to show how they have involved the service user in this process. There is evidence that residents are confident their complaints will be listened to and acted upon, however work is required to ensure staff receive training in adult protection and that policies in place at the home protect residents from abuse. Further efforts must be made to ensure signage and other aids are in place to promote independence for people with dementia and that infection control practices safeguard people. Particular attention should be given to ensuring signage is large enough, appropriately sited and allow residents to find their way around the building (and to locate the sensory room). The home employs domestic staff that are on duty in the mornings, seven days per week. As the tour of the premises occurred during the afternoon the inspector was concerned with some areas of the home still required cleaning. The Acting Manager agreed this was not acceptable, confirming that action would be taken to address this issue. Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 7 Since the last inspection the home has been registered to provide services to people with dementia, with the majority of staff currently in the process of undertaking training in this area. No staff that were interviewed demonstrated sufficient knowledge of people with dementia, reinforcing the need for everyone to complete the current training in this area. Also since the last inspection the Registered Manager has left with a new person appointed in November 2006. Previously she managed care homes for the elderly one of which was registered to accommodate up to seven people with dementia. A condition of registration is in place that states the home must comply with the contents of the action plan it supplied when registering for dementia care. In this it states that the manager will complete the Diploma of Higher Education of Dementia Studies. The new manager must undertake this qualification as her current qualification in dementia is equivalent to that which care staff are undertaking, with the Diploma more appropriate for the position of manager. 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. Bescot Lodge DS0000039568.V326476.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 Bescot Lodge DS0000039568.V326476.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): 1,2,3,4 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users do receive information about the home but this does not reflect the actual service provided. Service users do have their needs assessed prior to admission in most cases. Service users who have dementia cannot be assured that staff has the collective knowledge and skills to meet their needs. EVIDENCE: Prospective service users do receive information about the home but the quality of this information could be improved. The current service user guide contains information that is out of date and does not reflect the recent changes in the homes registration. This means that service users may not have all the information they need to make a choice about moving into the home. Only one of the service users that were part of the case tracking process had been given a contract on admission that detailed their fees and who would be responsible for paying them. None of the service users had received a copy of Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 10 the homes terms and conditions of occupancy what this means for service users is that they may be unsure of the service the home will provide to them and what they can expect whilst they are living there. The manager must also make sure that all service users understand and sign their contracts. Three service users files were seen as part of the case tracking process, all but one of them contained an assessment of need that had been undertaken by the manager. One service user who had been admitted for a respite break had no current assessment and the home was using an assessment from a previous admission. This must not happen service users needs must be reassessed before every admission to ensure that any changes in care needs can be identified and addressed. Since the last inspection the home has changed it details of registration with the CSCI and can now provide care for service users with dementia. At present none of the staff have completed their specialist training in Dementia Care this means that staff may not have the necessary knowledge or skills to meet the needs of those service users with dementia. Staff spoken to during the inspection admitted that they have limited knowledge of dementia because they had only just started their training but they were looking forward to completing it because they felt it would be very interesting. Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can feel assured that their health care needs will be met and that medication will be administered in a way that protects their wellbeing. Service users will be treated with respect and dignity at all times. EVIDENCE: All but one of the service users that were part of the case tracking process had their own individual plan of care, these plans had been drawn up once the assessment had been completed. The manager also ensures that service users are assessed for their risk of pressure sore development, moving and handling and falls. In addition to this there is now a screening tool for malnutrition that helps to highlight those service users most at risk. There were some minor shortfalls that may mean some service users do not receive prompt attention, for example one service user was identified as being at high risk of developing pressure sores but there was no management plan in place to address this, similarly another service user was noted to have lost one stone over a four week period but there was no written evidence to show that the home has taken any action to address this issue. The manager must make sure that all care plans and risk assessments are reviewed at least on a Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 12 monthly basis and that there is evidence that service users have also been included in the overall process. Service users have access to community specialist services such as chiropody, dentistry and visiting from the optician. The home also has regular visits from district nurses and service users doctors. Care staff record events in service users records but they do not consistently record on a daily basis, in some cases service users had no entries for over four days. Staff must also be mindful of what they are writing in records for instance, one entry stated “kept buzzing for silly reasons”, staff should be reminded that what may seem silly to them may be of great importance to the service user. Other entries recorded episodes of physical aggression but there was no record of how the situation had been managed by staff neither had this been addressed in the service users care plan. Medication practices are generally safe and protect the service user. There were some areas of improvement identified during inspection that must be addressed such as completing risk assessments for those service users who administer their own medication, staff must also record the amount of medication administered where a variable dose is prescribed. The manager must also review the medication policy to ensure that it reflects current guidance and legislation. Service users are treated with respect and dignity, throughout the inspection we observed staff approaching service users courteously and when assistance was needed it was given in a sensitive and respectful way. All service users were dressed in their own clothes although it was noted that most of the female service users were not wearing tights or stockings, the manager must ensure that service users are dressed in a way that they are accustomed to and this should be recorded in their service user plan if it is their choice not to wear them. Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users can be assured that the home will provide some activities for them to take part in although improvements could be made. Meals are of good quality and offer service users choice and a balanced meal. EVIDENCE: At present the home does not employ an activity coordinator to help keep service users active throughout the week. Any activity that is arranged is done so by the care staff. This may mean that at times organised activities may be cancelled because the care staff do not have enough time to spend with the service users in recreational activity. Service users did comment during the inspection that care staff always tried to help them and they were given choices about living at the home, such as what time they got in the morning and what time they wanted to go to bed. Service users are able to see their visitors in the lounges or in the privacy of their own rooms should they choose to do so. There are no restrictions on visiting times but relatives are asked to give consideration to service users when visiting late at night or early in the morning. Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 14 Mealtimes were observed during the inspection, the meals were also sampled and found to be very tasty. On the day of the inspection service users had a choice of cheese and potato pie with baked beans or a pork chop with vegetables and mashed potato. The home operates a four weekly menu so that meals can be planned in advance, should service user not like what is on the menu the home will offer an alternative. Throughout the mealtime it was observed that it is relaxing and unhurried experience, those service users who required assistance were helped discreetly and with sensitivity. Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 15 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is evidence that residents are confident their complaints will be listened to and acted upon. Further work is required to ensure staff receive training and that policies in place at the home protect residents from abuse. EVIDENCE: The inspector examined the complaints folder. The last recorded complaint was found to be dated April 2006, with a total of three recorded complaints in 2006. The records for these complaints include details of investigations and outcomes. No evidence could be found of two complaints referred to the home to investigate by the Commission for Social Care Inspection (CSCI). This was discussed with the Acting Manager, with the inspector explaining the homes responsibility to maintain a record of all complaints, regardless of where they originate. Of the five residents comment cards received by the CSCI prior to the inspection all state they have been informed of the homes complaints procedure and know who to speak to if unhappy. It is recommended that the frequency of residents meetings increase as an additional venue where residents can raise issues or concerns. A selection of protection policies and procedures were examined with all apart from the complaints policy requiring amending in order to comply with Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 16 relevant legislation. For example the homes Elder abuse policy states ‘the manager should report the allegation to the national care standards commission (NCSC) who will determine how the allegation is to be investigated and who is to be involved’. As the inspector explained the NCSC no longer exists and it is not the responsibility of the Commission for Social Care Inspection (CSCI) to determine who is responsible to investigate allegations. A second policy was found that appears more appropriate but still contains out of date information. The restraint policy was viewed in order to assess compliance with an action plan supplied by the home as part of its change of registration to provide services to people with dementia, where its states the home will be introducing a general policy for restraint of a service user and taking guidance from the Department of Heath. This policy was found to be very basic in terms of content, make no reference to people with dementia and did not reflect recent changes in legislation (for example the Mental Health Act). A second restraint policy was found that concerned the inspector due to its contents to such an extent that the Acting Manager was instructed to remove immediately. Examination of records and discussions with staff indicate that work must be undertaken by the home to ensure greater numbers of employees receive training and guidance in Adult Protection and understanding physical and/or verbal aggression by residents with dementia. For example of the twenty-six staff employed at the home ten have not received training in Adult Protection and of the sixteen who have this occurred in 2004. The majority of staff are enrolled on dementia training where aggression forms one of the modules, however at the time of inspection no one had yet completed this. When feeding back the findings of the inspection to the Acting Manager concern was raised that the Acting Manager had recorded that all policies and procedures had been reviewed in November 2006 despite the majority of those sampled relating to protection requiring amending. Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 17 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 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally residents live in a safe and homely environment. Further efforts must be made to ensure aids are in place to promote independence for people with dementia and that infection control practices safeguard people. EVIDENCE: A tour of the premises both internally and externally was undertaken. Many of the requirements identified in previous inspections are either partly met or met in full. For example debris has been removed from around the grounds of the home, blinds have been fitted in the conservatory and the majority of issues identified by the Environmental Health Department have been actioned. A previous requirement to ensure bathroom 38 is accessible by providing a bath hoist remains not met. A new hoist was found to be located in this room but Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 18 upon examination the inspectors found it is not to be compatible with the bath, as it does not allow people to be lowered into the bath. The home has started to implement orientation aids for people with dementia (as per the action plan that forms a condition of its registration). These include the provision of handrails, signage and visual aids in a sensory room. Further work is still required in order that the home fulfils its obligations in this area and that people with dementia can access areas of the home they wish to, whilst still maintaining their independence. Generally the home is furnished and maintained to a satisfactory level, creating a comfortable place for people to live. Particular attention however must be given to cleaning or replacing carpets that are badly stained, addressing the strong odour in one of the toilets and ceasing the practice of wedging doors open (fitting self closing devises that are linked to the fire alarm system). Minor works are also required in other areas of the building to ensure it is safe, comfortable and homely for people residing there. Infection control practices, records and equipment were examined. The home has a small laundry room that contains all required equipment. The flooring in parts was found to be damaged and dirty and a mop was seen standing in stagnant water. The Acting Manager confirmed that there is no appropriate storage facility for mops and that there is no procedure for sanitizing of mop heads. There is a separate sluice room with a mechanical disinfector, promoting good infection practices, however the flooring was found to require attention as this is not sealed and as with the laundry was also dirty. The home employs domestic staff that are on duty in the mornings, seven days per week. As the tour of the premises occurred during the afternoon the inspector was concerned with some areas of the home still required cleaning. The Acting Manager agreed this was not acceptable, confirming that action would be taken to address this issue. The inspector instructed that further efforts must be made for staff to undertake infection control training, as many do not hold up to date certificates in this area. Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally the numbers and skill mix of staff adequately meets resident’s needs. Improvements in some areas would ensure the needs of residents with dementia are fully understood by staff. EVIDENCE: A number of records were examined to determine if the home is meeting its obligations in relation to recruitment and selection, staffing ratios and training. These include sampling three staff personnel files, rotas and training certificates. In addition to these several staff were interviewed and care practices were observed. In addition to care staff the Acting Manager works supernumerary hours and kitchen and domestic staff are employed seven days a week. Since the last inspection the home has been registered to provide services to people with dementia, with the majority of staff currently in the process of undertaking training in this area. No staff that were interviewed demonstrated sufficient knowledge of people with dementia, reinforcing the need for everyone to complete the current training in this area. It is recommended that the staffing rota clearly identifies which member of staff on each shift is qualified in this area, in order that the home can demonstrate it is meeting its obligations to provide trained staff (as per the action plan that Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 20 forms a condition of registration). The inspector was unable to assess accurately the numbers of hours staff work each week as the Acting Manager has only recently introduced overtime-monitoring systems. Of the three staff files examined, two contained evidence that staff hold National Vocational Qualifications. A training and development plan is also in place but this does not evidence that all staff either hold this qualification or that arrangements have been made for them to undertaken this. Generally recruitment practices and records appear appropriate, safeguarding people living at the home. Files sampled contained documents including application forms, references, forms of identification and a photograph, apart from one persons file that did not contain any references and the photograph in place did not allow for identification of this person due to it being a photocopy of poor quality and age. It was also noted that one persons file contained a job description and contract of employment for a care assistant when the person is employed as a senior carer. Evidence was found by talking to staff and examining records that they receive inductions prior to commencing shifts; however further work is required to ensure this includes specific guidance in relation to dementia. Other specialist training that some staff have undertaken includes care of the deceased, skin care, continence and eye care for people with dementia. Practices observed indicate that where possible staff attempt to communicate and build relationships with residents. For example a member of staff was witnessed talking in a reassuring manor, sitting at eye level and attempting to reassure a resident who appeared distressed. Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 21 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): 31,33,35,36,37 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The systems for safeguarding resident’s personal finances are good, offering protection to those living there. Further work is required to ensure the health, safety and welfare of residents is appropriately managed. EVIDENCE: Since the last inspection the Registered Manager has left with a new person appointed November 2006. The Acting Manager informed the inspector that she has twenty years experience in care, eight of which are at management level. Previously she managed care homes for the elderly one of which was registered to accommodate up to seven people with dementia, explaining that Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 22 she applied for the position at Bescot Lodge in order to expand her experience in this area as it is registered to provide care for up to twenty-six people with dementia. The Acting Manager holds both a National Vocational Qualification level 4 in care and the Registered Managers Award, the D32/33 assessors award and Dementia Care Asset level 2. A condition of registration is in place that states the home must comply with the contents of the action plan it supplied when registering for dementia care. In this it states that the manager will complete the Diploma of Higher Education of Dementia Studies. The inspectors explained that this must still be undertaken by the new manager as her current qualification in dementia is equivalent to that which care staff are undertaking and that the Diploma is appropriate for the position of manager. All but two requirements identified in the previous inspection have been met or partly met. These include introducing a safe contents record, obtaining information relating to the maximum amount of money that the safe is insured to hold and providing personal protective equipment in the sluice room. Work must now be undertaken to ensure issues identified by the Environmental Health Department are incorporated into the kitchen risk assessment and to provide risk assessment training for all senior staff. The home has a professional recognised quality assurance system in place that includes an annual audit, management reviews, quarterly internal audits, resident’s surveys and staff questionnaires. In the main the contents of these were found to be acceptable however it was noted that the staff questionnaire and survey analysis of October 2006 details action points but not of outcomes achieved. Also the quality assurance policy states that internal audits will be undertaken every three months but records indicate this has not occurred since September 2006 and the last external audit of the whole system was December 2005 (policy states this should be annually). The inspectors acknowledge that the Acting Manager has only been in post since November 2006 and has been prioritising work, with particular attention given to building relationships with residents and staff, but recommend that she completes an action plan that will formalise priorities, work required and timescales for achievement. Work must be undertaken to review and where required amend policies and procedures to ensure they comply with relevant legislation. The policies folder was viewed, with the Acting Manager recording that she reviewed all policies in November 2006. The inspectors questioned the accuracy of these reviews, as many of the protection policies (see complaints and protection section of this report) do not comply with recent changes in legislation. It was also noted that only three of the staff employed at the home have signed a form at the front of the policies folder stating they have or are in the process of reading its contents. The inspector sampled the monies and records of three residents held by the home and found them all to be in order apart from one persons monies being more than that recorded on the personal allowance sheet by fifty pence. The Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 23 Acting manager states that this occurred, as the hairdresser did not have the correct change. It is recommended that this information be recorded on the personal allowance sheet in order that records accurately reflect monies held. All staff files contained evidence that they receive formal supervision, however the amount of these sessions vary and non contained evidence that supervision is being provided at least six times per year, as recommended in the National Minimum Standards for Older people. It was also noted that no staff meeting have taken place since November 2006. Generally health and safety is adequately managed with appropriate checks in the majority of areas, ensuring residents wellbeing. Areas requiring attention include arranging for water outlets to be regularly flushed (with records maintained), evidencing that all staff have undertaken a fire drill at least annually, monitoring water temperatures (the last record for this is November 2006) and ensuring sufficient numbers of staff hold up to date certificates in moving and handling, first aid, food hygiene, health and safety and fire. The need for appropriately qualified staff was reinforced when observing a resident being hoisted from wheelchair to lounge chair. Staff were observed reassuring the resident throughout the process, setting equipment correctly but not ensuring the sling was not twisted. It is recommended that the staffing rotas clearly identifies at least two persons on each shift who holds up to date certificates in all of these areas. The Acting Manager has reviewed and amended all risk assessments relating to health and safety and the environment. It was noted that the majority of these are generic in terms of contents, give non-specific information and do not reflect what or where is being assessed. For example the majority state as a method to reduce risk ‘support staff’ but do not detail how and all state residents and visitors may be a risk when these groups of people do not access some areas of the building. It is recommended that action be taken to address these areas. Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 1 2 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 3 X 2 Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4,5,6 Requirement The registered provider must ensure that the service user guide and statement of purpose are reviewed to reflect the change in the home’s registration category. The registered provider must ensure that all service users are issued with terms and conditions of occupancy upon their admission. The registered provider must ensure that all service users are issued with a contract and that this contract has been signed and dated by the service users. The registered manager must ensure that all staff continue with their training in dementia care and behaviour that challenges. The registered manager must ensure that risk assessments are reviewed on a monthly basis. Where risks are identified as a result of an assessment there must be a clear management or Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 26 Timescale for action 01/04/07 2 OP2 5,5A 01/04/07 3 OP4 18 01/04/07 3 OP7 13(4), 01/04/07 risk reduction plan to demonstrate how that risk will be minimised The registered manager must be able to demonstrate that service users have been involved in their care planning and it’s reviews. The registered manager must ensure that service users are weighed upon admission and at least monthly thereafter with records kept. The registered manager must be able to demonstrate that appropriate action has been taken if service user weight loss is recorded. The registered manager must find appropriate screening tools for malnutrition for those service users who are unable to be weighed on conventional weighing scales. The registered manager must ensure that service users identified through risk assessment as being at risk of pressure sore development that there is a clear risk reduction plan in place and that it is kept under regular review. The registered manager must ensure that all staff record on the MAR sheet when they have administered creams or lotions to service users. Where medicines are prescribed with a variable dose staff must record the actual dose administered to service users. i.e. 1 or 2. There must be risk assessments in place for those service users Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 27 4 OP8 17 sch 4 01/04/07 5 OP8 17 (1) sch 3 (n) 01/04/07 6 OP9 13(2) 01/04/07 who administer their own medication. Service users medication plans must have a current photograph on them. Medication must not be prescribed “as directed”, all medicines and creams must have a route of administration, a dose and a frequency of administration. Any allergies the service users have must be included on the MAR sheet. The medication policy must be reviewed to reflect current best practice. The registered manager must provide activities that are suitable for all service users including those service users with dementia. The home must be able to demonstrate that residents are offered leisure and recreational activities in and outside of the home which suite their needs, preferences and capacities. The home must be able to demonstrate that budget is available for activities. The home must either employ an activity co-ordinator or amend the service user guide. (previous timescale of 31/03/06 not met) A record must be maintained of all complaints, including investigation and outcome. All protection policies and procedures must be reviewed and comply with relevant DS0000039568.V326476.R01.S.doc 7 OP12 16(2)(m, n) 01/04/07 8 OP12 16(2) 01/04/07 9 10 OP16 OP18 22 13(6) 01/02/07 01/04/07 Bescot Lodge Version 5.2 Page 28 legislation and local authority adult protection guidelines. All staff must undertake adult protection training at least every three years. All staff must undertake aggression training. Toilet 6 needs the flooring sealed and the extractor fan repaired part met. Requirement originally made January 2006. Bathroom 38 must be accessible to all service users. The hoist must be replaced – not met. Requirement originally made July 2005. The home must address all issues identified in the Occupational Therapist report on the building and facilities - part met. Requirement originally made October 2004. The home must address all issues identified by the environmental health department – part met. Requirement originally made January 2006. The home must improve orientation signage throughout the building for people with dementia. The home must improve the facilities in the sensory room. All stained carpets must be cleaned or replaced. The odour from the ground floor toilet must be eliminated. Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 29 11 OP19 16, 23 01/04/07 12 OP26 13(3)(4) The home must cease the practice of wedging fire doors open. Any doors that are required to be open must be fitted with self-closing devises that are linked to the fire alarm system. The flooring in the laundry and sluice room must be repaired. Appropriate storage facilities must be provided for mops and buckets and a written procedure introduced for the sanitizing of mop heads. All areas of the building must be clean and hygienic. All staff must undertake infection control training. The home must be able to demonstrate that all staff hold a NVQ qualification or are working towards achieving this. The home must ensure all staff personnel files contain a recent photograph and two references. The home must ensure that its induction of new staff includes specific guidance in relation to dementia. Arrangements must be made for the manager to undertake the Diploma of Higher Education of Dementia Studies. The home must ensure that all policies and procedures comply with relevant legislation. The kitchen risk assessment must be reviewed to incorporate issues identified by the environmental health department – not met. Requirement originally made January 2006. DS0000039568.V326476.R01.S.doc 01/04/07 13 OP28 18(1)(a) 01/04/07 14 15 OP29 OP30 Sch 2,4 18(1)(c)(i ) 9 01/03/07 01/03/07 16 OP31 30/09/07 17 18 OP33 OP38 24 13(3-6) 12(10 01/04/07 01/04/07 Bescot Lodge Version 5.2 Page 30 The manager and senior staff must undertake risk assessment training – part met. Requirement originally made January 2006. The home must ensure that all water outlets are regularly flushed, with records maintained. The home must ensure that all staff attend a fire drill at least annually, with records maintained. The home must ensure that all staff hold up to date certificates for moving and handling, first aid, food hygiene, health and safety and fire. 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 3 4 5 6 7 Refer to Standard OP4 OP16 OP26 OP27 OP29 OP33 OP33 Good Practice Recommendations It is recommended that the manager obtain a copy of the guidance from the National Institute of Clinical Excellence (NICE) on Dementia care That the frequency of residents meetings increases. It is recommended that the manager obtain a copy of the Department of Health guidance “infection control in care homes” June 2006 That the staffing rota clearly identifies which member of staff on each shift has completed dementia training. That staff are given new job descriptions and contracts when changing roles. Greater efforts should be made to comply with timescales for action, as detailed in the homes quality assurance policy and procedure. That the Acting Manager completes an action plan that will prioritise work that needs completing. DS0000039568.V326476.R01.S.doc Version 5.2 Page 31 Bescot Lodge 8 9 OP33 OP35 10 11 12 OP36 OP36 OP38 13 OP38 That all staff read and understand policies and procedures relevant to their positions. If the hairdresser does not have the correct change to give to residents and gives them above what they should receive, that this is recorded on the personal allowance sheets. That all staff receive at least six formal supervision sessions per year, with records maintained. That at least six staff meetings take place every year, with records maintained. That the staffing rota clearly identifies at least two persons on each shift who holds up to date certificates in moving and handling, first aid, food hygiene, health and safety and fire. That any risk assessments for health and safety and the environment are reviewed and amended so that they are specific to the area being assessed. Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Bescot Lodge DS0000039568.V326476.R01.S.doc Version 5.2 Page 33 - 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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