Inspection on 06/01/06 for Bescot Lodge

This inspection was carried out on 6th January 2006.

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 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 Unannounced Inspection 6th January 2006 09:20 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 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.V276677.R01.S.doc Version 5.1 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 01922 648917 United Care Ltd Mrs Donna Marie Wallace Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26) of places Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 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. The sluice facility is to be adapted as agreed with CSCI to Infection Control Standards. 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 so, then the same staffing ratios must be implemented as for 26. Separate kitchen and domestic staff must be employed seven days per week. 14 July 2005. 4. 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.V276677.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at 9.20am and stayed until 5.30pm. Time was spent talking to residents, formally interviewing staff, observing care practices and looking at records before giving feedback to the registered manager. As this is the second inspection to take place over the past twelve months both this report and the one published in July should be read when looking at how the home is meeting national minimum standards. By the end of the visit the inspector was satisfied that generally the home offers a good service to residents with the majority of requirements identified in previous inspections now fully met. The inspector would like to thank everyone for his or her help and assistance shown throughout the visit, where she was made to feel very welcome. What the service does well: Medication practices within this home are very good with no errors found on the day of inspection. A member of staff was observed giving residents their medication, all of which was given correctly. When talking to the member of staff they demonstrated knowledge and understanding of medication practices and procedures. Staff should also be congratulated for their efforts to promote resident’s privacy and dignity. Throughout the day staff were witnessed knocking on doors before entering, offering assistance in discreet ways and talking to residents with respect. Many residents that the inspector spoke to reinforced these practices as the norm. For example one said, “the staff are lovely here, they always ask if you need any help but don’t stop you doing things for yourself”. Compliments were also made about meals and drinks provided at the home. For example one person said, “every couple of hours the staff will always ask you if you want a cup of tea and they always offer a little snack to go with it. Even if you don’t want something that’s on the menu they will always try to give something else”. Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 6 Records also demonstrated that the majority of staff employed at the home have undertaken fire, first aid and food hygiene training and that equipment including wheelchairs, small electrical items and the lift are all appropriately maintained. What has improved since the last inspection? What they could do better: 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 DS0000039568.V276677.R01.S.doc Version 5.1 Page 7 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.V276677.R01.S.doc Version 5.1 Page 8 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 the following standard(s): 6. EVIDENCE: The home does not offer intermediate care; therefore standard 6 is not applicable. Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 9 and 10. The medication at this home is well managed, promoting good health. Personal support in this home is offered in such a way as to promote and protect resident’s privacy and dignity. EVIDENCE: It was noted by the inspector that previous requirements instructing that residents care plans detail all aspects of health, personal and social care needs, that where possible residents should be involved in the compilation and reviewing of care plans and that care plans must be signed by the resident have now been met in full. Also since the last inspection the home has introduced nutritional screening and records also indicate that residents have access to hearing and sight tests. The inspector observed a senior care assistant administering medication and found this responsibility to be completed appropriately. The member of staff demonstrated knowledge and understanding when discussing medication procedures and was able to explain the legal context of covert practices, consent and pharmacy instructions. Records also confirmed that all staff that Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 10 administer medication have undertaken accredited training. The home uses a monitored dosage system for managing medication, all of which was found to be appropriately recorded and stored when examined. In addition to this the supplying pharmacist visits the home every 3 months with records of these visits showing no issues identified. All of the 3 staff that were interviewed confirmed that residents are given the choice to self medicate, with replies including, “we carry out a risk assessment and given residents the choice when they move in. If they want to look after their medication they can but if the risk assessment is high we ask them to sign a disclaimer because it’s still their choice”. Throughout the visit the inspector witnessed staff treating residents with respect and maintaining any wishes for privacy. For example staff were observed knocking on bedroom doors before entering, talking in appropriate tones and offering choices of rooms to relax in. In addition to this the inspector was pleased to observe that when residents received telephone calls staff took a ‘hands free’ telephone to their bedrooms in order that they could talk in private. These practices were further reinforced when interviewing staff, all of which were able to give examples of how privacy is promoted. For example, “making sure people have their own space. They should have the choice of staying in their room, we just make sure they don’t isolate themselves but respect their rights to privacy”. Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 12, 14 and 15. Activity records do not demonstrate that the home offers daily variation. Opportunities to access the community are poor, with little evidence that the home initiates off-site activities that could enrich resident’s lives. Staff have good knowledge of residents rights and responsibilities. This ensures people living at the home can exercise choice and control in their lives. The meals in this home are good, offering both choice and variety and catering for special dietary needs. EVIDENCE: The inspector scrutinised the activity records maintained from September 2005 to December 2005. These stated that activities had taken place including bingo; nail care, ball games, hair care, armchair exercise and card games. Records also indicated that a musical entertainer visits the home once a month. No records for the months examined detailed any external activities. The contents of the activity records were reinforced by all staff that were interviewed, none of which were able to give examples of external activities offered or participated in. The manager stated that these are offered but that many residents do not wish to participate. The inspector stated that even if only a few people wish to join in activities they must still be given this choice. Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 12 The inspector also expressed surprise that an entertainer only visits the home once a month as many people spoken to during the visit stated this is one of the most enjoyable activities offered at the home. It was also noted by the inspector that no budget is available for activities and that the service user guide states that the home employs an activity co-ordinator when this is not true. Records did however demonstrate that residents are offered the choice to bring personal items to the home when they move in and advocate details are available if requested. The inspector instructed that advocacy details be included in the service user guide in order that this information is readily available to everyone. All staff that were interviewed demonstrated knowledge of residents rights to exercise choice and control. For example staff explained that residents meetings take place in order that the views of people can be gained in relation to meal choices, care staff and other aspects of the home. The home operates a 4 weekly rotating menu that offers both hot and cold meals. Individual records are also maintained detailing residents chosen meals however the manager stated that these are destroyed after each month. The inspector discussed this practice and instructed that records must be maintained for a minimum of 3 years. Staff were asked how they ensure residents receive a well balanced diet and replies included, “we now complete nutritional assessments and contact experts if concerned about well being” and “we complete dietary intake chards to monitor the needs of residents with special requirements, we make sure menus offer choices of foods and are well balanced and if we have any concerns we contact the GP”. Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 13 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 the following standard(s): Standards assessed at previous inspection. EVIDENCE: It was noted by the inspector that since the last inspection staff have undertaken adult protection training and the statement of purpose has been amended to include information regarding the homes policies and practices in relation to residents monies. Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 19. Generally the standard of the environment within this home is good, providing residents with an attractive and homely place to live. EVIDENCE: Since the last inspection many of the requirements relating to the environment have now been met or partly met. The home arranged for the environmental health department to visit to seek advice regarding the kitchen facilities, with work in progress to address issues identified. Bathroom 38 is still not accessible to all residents due to parts still being on order to repair the hoist. The inspector found that the conservatory is not used as there is no heating facility in this area and on the day of inspection this room was very cold (CSCI received notification after the inspection that issue had been addressed). The manager also stated that work would start in the near future to make the garden area accessible to all residents. Generally the inspector found the building to be pleasantly decorated and maintained to a high standard. Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards assessed at previous inspection. EVIDENCE: It was noted by the inspector that since the last inspection previous requirements relating to staff recruitment records and practices have been met, with all those sampled contained the required information. Records also demonstrated that all staff received induction training to NTO specifications. Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 and 38. Generally the systems for safeguarding resident’s personal finances are good, offering protection to those living there. Further work is required to ensure all practices within the home promote and safeguard the health, safety and welfare of residents. EVIDENCE: It was noted by the inspector that all requirements relating to quality assurance and record keeping have now been addressed. The inspector sampled the monies and records of 6 residents held by the home and found all to be in order. In addition to monies valuables are also held on behalf of residents if they so wish. Records are maintained individually, including receipts where appropriate. When assessing the recording systems in place the inspector instructed that a safe contents book be implemented as Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 17 they present system does not detail the total amount stored in the safe and could potentially cause issues if ever money was to go missing. In addition to this the inspector also instructed that the home find out how much the safe is insured to hold as the statement of purpose states a maximum of £50 will be held for each person but on the day of inspection 3 of the 6 finances sampled exceeded this amount. When assessing health and safety practices within the home the inspector was concerned that the sluice room potentially posed risk to staff. On the day of inspection there was no soap, paper towels or disposable gloves. Also suitcases and a carpet cleaner were being stored in the room and large amounts of items were being stored on the floor making it impossible to clean appropriately. The inspector instructed that only items for use in the sluice should be stored in this facility and those must be located on shelves for effective cleaning to take place. Records confirm that the majority of staff hold up to date first aid, moving and handling, food hygiene, health and safety and fire certificates, with dates being arranged for the few remaining staff that still require these qualifications. The majority of staff who require mandatory training are domestic staff and the manager stated 2 of these are due to require and would prefer not to undertake training. The inspector explained that this should be documented with a signed declaration that the home is not liable if an accident or incident were to occur. When looking at safe working practice risk assessments these were found to be in place but some were basic in terms of content and context. The manager stated that staff undertake risk assessment training as part of their health and safety training and that she had undertaken training in this area about 5 years ago. The inspector instructed that the manager undertake further training in this area to ensure her knowledge is appropriate to the position of registered manager. The inspector also instructed that the kitchen risk assessment be reviewed and updated to incorporate the issues identified in the recent environmental health inspection. Safety records demonstrate that the lift was serviced May 2005, small electrical appliances were tested September 2005, wheelchairs were serviced November 2005 and hoists October 2005. COSHH data sheets were viewed and found to be in order however, the inspector recommends that data sheets for products no longer used in the home be removed for ease of reference. Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 18 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 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X 2 2 X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 2 X X 2 Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 19 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 OP12 Regulation 16(2) Requirement 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. Advocacy details must be included in the service user guide. Individual records of meals taken by residents must be maintained for a minimum of 3 years. The home must address all issues identified by the environmental health department. The ground around the building must be cleared of debris and weeds and a garden area made accessible to all service users – Part met. Requirement DS0000039568.V276677.R01.S.doc Timescale for action 31/03/06 2 3 4 OP12 OP15 OP19 16(2) 16(2) 16(1) 31/03/06 30/01/06 31/03/06 5 OP19 16(1) 31/03/06 Bescot Lodge Version 5.1 Page 20 6 OP19 16(1) 7 OP21 16(1) 8 OP21 16(1) 9 OP22 16(1) 10 OP35 13(5) originally made July 2005. Curtains or blinds must be fitted in the conservatory – Requirement originally made July 2005. Toilet 6 needs the flooring sealed and the extractor fan repaired – Part met. Requirement originally made July 2005. Bathroom 38 must be accessible to all service users. The hoist must be replaced – 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. A safe contents record must be maintained that is stored separately from individual residents records. 31/03/06 31/03/06 30/01/06 31/03/06 30/01/06 11 OP38 13 The manager must be aware of the maximum amount of money that the safe is insured to hold. 10/01/06 There must be a supply of liquid soap, paper towel and disposable gloves and aprons maintained in the sluice room. Items must not be stored on the floor in the sluice room. Only items for use in the sluice room must be stored in this facility, with appropriate shelving provided. Any staff who are due to retire 30/01/06 and do not wish to undertake training must sign a declaration stating responsibility in the event of an accident or event. The kitchen risk assessment must be reviewed to incorporate 12 OP38 13 Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 21 13 OP38 13 issues identified by the environmental health department. The manager and senior staff must undertake risk assessment training 31/03/06 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 OP38 Good Practice Recommendations That data sheets for products no longer in use be removed. Bescot Lodge DS0000039568.V276677.R01.S.doc Version 5.1 Page 22 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: 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. 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