Inspection on 06/09/07 for Bescot Lodge

This inspection was carried out on 6th September 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 22/01/07

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 Bhag Jassal Key Unannounced Inspection 6th September 2007 09:50 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.V349132.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.V349132.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 01922 649139 United Care Ltd Vacant Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26) of places Bescot Lodge DS0000039568.V349132.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 22nd January 2007 Date of last inspection Brief Description of the Service: Bescot Lodge is a care home providing accommodation and personal care for 26 older people with Dementia care needs. 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 houses situated close by. The home was first opened in 1984 and was taken over by the present owners, United Care Limited in 2002. United Care Ltd makes their services known to prospective service users in The Statement of Purpose and Service Users’ Guide. The Inspection Report is mentioned in the statement of purpose and how a copy can be obtained. The care home rates are reviewed annually and people using the service are notified one month in advance. The only additional charges to people who use the service are hairdressing and chiropody. This is clearly laid out in the terms and conditions. Fees for Bescot Lodge as of 1st April 2007 are: £337.29 (plus £10 if privately funded) to £358.66 (plus £10 if privately funded). All service users pay monthly. Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is on a Key Inspection, part of which included an unannounced visit undertaken on 6th September 2007. This unannounced visit started at 9.50 am and lasted 8 hours and 15 minutes. The home had 22 places occupied and four remained vacant. The judgements made within this report are based upon information supplied by the home, from interviews with staff, people who use the service and their relatives. During the course of inspection the assessment of information and care plans were case tracked for 6 people who use the service. Medication administration was checked. Staff records were seen to check staff rotas, recruitment procedures and training. Various documents were seen in order to check compliance with health and safety legislation. A tour of premises was also undertaken and observations of care practices and interaction between staff and people who use the service was also completed. Discussions took place with several members of staff and 10 people using the service were spoken to throughout the day of inspection. The Senior Carer/Person in Charge - Ms Margaret Springthorpe assisted in inspection process until the Acting Care Manager – Ms Tania Mason arrived at the care home at 11.30 am. What the service does well: The home makes every effort to provide individuals with good care to meet the assessed needs following a care plan. The home has a good key worker and staff supervision system in place. The home communicates well with the families, friends and representatives of people using the service and welcomes visitors. People who use the service say they are happy and content with living in a homely and caring place. The home provides a relaxed, comfortable and friendly atmosphere where people are treated with respect and dignified way. People using the service are often vulnerable both physically and emotionally and the Acting Care Manager – Mrs Tania Mason ensures that staff are Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 6 recruited with the ability to carryout personal care services for people sensitively and tactfully. The recruitment of good caring staff is critical to the running of care homes and the Acting Care Manager at Bescot Lodge care home undertakes this carefully. The home now has a good training programme in place. A majority of staff have received mandatory training in safe working practice topics, dementia care, adult protection, NVQ Level 2, and safe handling of medication. This training has ensured that more staff have the knowledge and skills to meet the changing needs of people who use the service. The home provides adequate standard of accommodation and facilities. What has improved since the last inspection? The home has revised its Statement of Purpose and Service Users’ Guide to reflect its new registration for 26 older people with Dementia care needs. The revised care needs assessment, care plans, risk assessments and recording formats have been introduced. A staff training and development programme, supervision and key worker systems have been implemented. A programme of social and leisure activities have commenced and more still be to done for specifically for people using the service with dementia. Adult protection training has been received by a majority of staff and the remaining to undertake this mode of training shortly. The environment of the home has been improved by implementing a rolling programme of redecoration and replacement of some bedroom floor covering. The dining room has been redecorated and new flooring and furniture have been provided. The conservatory has been provided with new blinds and furniture for the use of people using the service. The facilities in the ‘memory’ room have been improved. Management and safe handling of medication practices have been improved and all senior staff have received training in safe handling of medication. The staff recruitment procedures have been improved and all appropriate checks and references are now obtained, but these still need fine-tuning. The Acting Care Manager has revised and updated all the home’s policies and procedures to ensure they meet the current Regulations and legislation. Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Bescot Lodge DS0000039568.V349132.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.V349132.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): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Bescot Lodge provides detailed and clear information to people who will be using the service and their families to enable them to make decisions about whether or not to live at the home. Everyone receives full needs assessment prior to admission to the home to make sure that their needs can be met. EVIDENCE: The home has reviewed and amended its Statement of Purpose and Service Users’ Guide to reflect the recent changes in the home’s registration. This means that the prospective service users will have all the information they need to make a choice about moving into the care home. Admissions are not made to the home until a full assessment has been undertaken. The home is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the updated Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 10 Statement of Purpose and Service Users’ Guide. For people who are selffunding and without a care management assessment, they always receive assessment by the Care Manager. Six care plans/files of people who use the service were inspected, which contained pre-admission assessments of their needs, both from assessments by the home’s senior staff and other relevant professionals. Observations and discussions with people using the service, their visiting relatives, the Acting Care Manager, staff on duty indicated that the home continues to meet the needs of older people with Dementia care in a satisfactory and sensitive manner. It was seen from the staff training records that 13 members of staff have received training in Dementia care. The Acting Care Manager confirmed that those members of staff who as yet have not undertaken this mode of training will do so as a matter of priority. Bescot Lodge DS0000039568.V349132.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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Everyone who uses the service has an individual plan of care, which ensures that their personal, healthcare, and social needs can be met. Medication is administered and stored in a manner that safeguards everyone using the service. People using the service are treated with respect and dignity and their right to privacy is understood and upheld. EVIDENCE: People using the service undergo an assessment of their needs prior to admission to the care home. A care plan is produced, which is based on the assessment of needs. The home operates a good key worker system, which helps to ensure that the recommendations arising from the care plan reviews are implemented. Six care plans of people using the service were case tracked and examined in detail. There was evidence to show that the short-term goals and long-term goals aims and objectives were clearly identified and the quality and details of daily care recordings have improved since the last inspection. Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 12 The Acting Care Manager stated that the staff will continue to make further improvements and staff will be supported closely and supervised in this endeavour. Discussions with people who use the service showed that the home now has a strong ethos of involving them in all aspects of their life. The care plans that were read were clearly written and included an element of risk assessment. Information from the initial assessment had been written into the plan of care. The care plans are reviewed on a monthly basis by the senior staff. The Acting Care Manager also ensures that people using the service are assessed for their risk of pressure sores development, moving and handling and falls. In addition to this there is now a screening tool for malnutrition that helps to highlight those people using the service most at risk. The risk assessments are reviewed on a monthly basis or earlier if any changes in the care needs or potential risks have been identified. The care plans demonstrated that staff actively promoted the rights of people who use the service of access to the health services both within the home and the community. Appointments are planned or arrangements are made for professionals to visit frail people using the service. Records of all health checks/treatments are recorded in the individual care plans of people using the service. Wherever possible continuity of care for the service users’ declining state of health is assured. District nurses are called upon to assist with clinical help, equipment and advice where necessary. The Acting Care Manager promotes the key worker system robustly so that relationships between key staff and individuals are enhanced. Visitors are able to meet people using the service in their bedrooms, in the lounges and conservatory on the ground floor, which offers privacy when not being used. It was observed that people using the service were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. The Inspector spoke at some length with people using the service and all of them commented positively about their care and felt they have everything they need. Several people who use the service stated that “the carers are very good and they look after us very well”. Four other people using the service said “the carers are always there to help”. Generally people using the service appeared to be content, comfortable and happy. They were complimentary regarding the quality of their lives and the care they were receiving at Bescot Lodge care home. Medication practices are safe and protect the people using the service. There were some areas of improvement identified during the last inspection on 22 Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 13 January 2007. All the requirements have been implemented, including the review of the home’s medication policies and procedures to ensure that they reflected the current guidance and legislation. Discussions with the Acting Care Manager and the staff training records showed that all senior carers and several other carers have completed their training in safe handling of medication. However, it is the home’s policy that only the senior members of staff who have completed accredited medication training would be responsible for the safe handling and administration of medication. Medication rounds were observed during the inspection. Senior staff were seen to administer and record when medicines have been given. Records seen included medication received, administered and leaving the home. It was also seen that the mobile medication trolley was securely and safely stored after use in the dining room. The photographs of people using the service have been provided on medication sheets to avoid any risks of maladministration of medication. Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 14 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 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Everyone using the service is able to exercise choice with regard to social and leisure activities at the home. Relatives and friends are encouraged and assisted to maintain contacts with people using the service. The food provided at Bescot Lodge is of good quality and choices are always available. EVIDENCE: The home provides an activities programme in accordance with everyone using the service, their choices, preferences and capacities in relation to – social, leisure and cultural interests. People using the service, who were able to give opinion, were complimentary about the activities provided. People using the service are enabled to enjoy a full and stimulating life style with a variety of options to choose from. A record of activities participated in is kept and photographs of major events displayed in the home. People using the service were seen sitting in the lounges chatting to staff and visitors and in other communal areas within the home. Four people using the service stated that Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 15 they preferred to sometimes sit quietly in their bedrooms and staff respected this. Several people using the service spoken to stated that they were in regular contact with their family members and friends, and spoke about their visitors’ involvement and interest in their care matters. The visitors’ book kept in the home showed a considerable activity. A number of people using the service also keep contacts with the local community – for example, local shops, super market, pub and park. However, the home should organise more, varied and appropriate in-house activities and outings/trips for people using the service. The Acting Care Manager stated that she was researching into this and she will ensure that the activities provided are appropriate in meeting the particular needs of people who use the service. The staff will also receive appropriate training in meeting the social and leisure needs of people with Dementia care. Family and friends are encouraged to visit and the home has an “open” visiting policy. There was a steady flow of visitors during the day of inspection. The Inspector spoke to four visiting relatives, who stated that “its good to see the residents taking part in doing some activities, and its good for them”. Relatives of two service users stated that they visit the home at various times of the day as they wish. Three relatives who also spoke to the Inspector said they are given warm and friendly welcome by the staff whenever they visit. The Acting Care Manager stated that the people using the service are positively encouraged to exercise their choices, and control over their lives and daily living, subject to risk assessments in terms of safety, security and capacity to make certain decisions. The Acting Care Manager also stated that a close liaison is maintained with the relatives and representatives, where people using the service are not able to make certain decisions. The relatives of people using the service and their representatives are informed of the availability of the local Advocacy Service. The information about the Advocacy Service is included in the home’s Statement of Purpose and Service Users’ Guide. Several people using the service told the inspector “the home is good and its peace and quite here”. “The food was very nice well cooked and tasty”. The consensus of people using the service was the range, quality and choice of food provided was very good and the home catered for those people using the service, who have individual preferences and medical needs. Throughout the mealtime it was observed that it is relaxing and unhurried experience, those people using the service who required assistance were helped discreetly and with sensitivity. The Acting Care Manager stated that the four weekly menus are changed on a regular basis in consultation with the people who use the service. The Kitchen Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 16 is kept tidy. It is well equipped and has a well stocked food supply. The catering staff are trained in food safety and hygiene matters. Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service and their relatives know how to complain and any complaint made is listened to and acted upon. The home has an Adult Protection policy and procedure but people using the service would be better safeguarded if more attention was given to providing a safe environment, robust recruitment procedures and comprehensive training for staff. EVIDENCE: The home has a good Complaints Procedure in place, which is referred to in the home’s Service Users’ Guide and the Statement of Purpose. There is now a system in place to record all concerns and complaints. The home’s records showed that the Commission for Social Care Inspection (CSCI) has not received any complaint about the home over the last 12 months. However, the home had dealt with two complaints and resolved them to the satisfaction of the complainants. Two relatives of people using the service when asked were certain of how to formally make a complaint but they said they would quite happily talk to one of the staff in charge or the Manager. The home has not had to report any vulnerable adult protection issues. The home has good policies and procedures in place regarding restraint, dealing Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 18 with aggressive behaviours and prevention of abuse, which includes a whistle blowing policy. The Acting Care Manager stated that adult protection issues are discussed during induction training and supervision meetings. However, the staff training records showed that 15 members of staff have received training in abuse awareness. The Acting Care Manager stated that the remaining members of staff who as yet have not undertaken this mode of training will do so in early October 2007. People using the service were seen to speak easily to staff and were comfortable in their company. Several members of staff are now trained in Dementia care needs to ascertain their well–being, and also all staff to receive training in challenging behaviour in October 2007. Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is being maintained but needs some improvements to décor, fittings, equipment and safety matters. The home is not clean and hygienic in all areas. EVIDENCE: A tour of 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, all the issues identified in the report of the Occupational Therapist have been rectified, and all of the issues raised in the previous inspection report of the Environmental Health Officer have been appropriately addressed. Orientation signage throughout the building has been implemented by making signage more prominent and enlarged to assist the people using the service. The home also has improved the facilities in the ‘memory’ room by Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 20 implementing fresh décor, pictures, environmental reminiscence and musical therapy. The dining room has been redecorated, new suitable flooring and dining furniture have been provided. Since the last inspection, 14 bedrooms, rear entrance and main entrance hall have been redecorated. A number of carpets in bedrooms have been thoroughly cleaned. Several self-closures on doors have been fitted, and practice of wedging fire doors open has ceased. A domestic and laundry assistants now employed five days a week to keep the premises clean and hygienic. Appropriate storage space has been provided for mops and buckets. 9 members of staff have received training in infection control and 12 other members of staff to undertake this mode of training shortly. However, a previous requirement to ensure bathroom 38 on the first floor is accessible by providing a suitable bath hoist remain not met. This bathroom is currently not accessible to be used by people using the service, because it is now being used as a general store room. The flooring in the laundry and sluice room is still to be repaired/replaced. The toilet 6 on the ground floor still needs flooring to be resealed and extractor fan repaired. The garden areas at the rear of the premises still to be made accessible, secure and suitable to meet the needs of people using the service. During the tour of the premises on the day of inspection, the following issues were noted: Staff-call system in bedroom 17 was broken and needed repairing for the use of the room occupant. The hot water supply and temperature was tested in all bedrooms and communal hot water outlets and found either to be well below 43 Degrees C i.e. 31 Degrees C, or above 43 Degrees C e.g. 50 Degrees C in bedroom 3 and 52 Degrees C in bathroom on the ground floor. The Acting Care Manager called out a plumber in the same evening to rectify the problems with the hot water supply in order to ensure the safety of people who use the service. There were several extractor fans in bedroom en-suite facilities out of order and in need of repairing. In number of bedrooms the sinks surrounds needed resealing. The carpets in bedrooms 3, 18, 19, 23, and 34 needed replacing. The broken tile and missing water plug to be provided in the Bathroom on the ground floor. The sluice room needed a suitable extractor fan fitted. The care home was inspected by a Fire Safety Officer 4 September 2007. A suitable ceiling fan is needed in the conservatory for the comfort of people using the service. The dishwasher and fly-trap in the kitchen needed repairing, and fly screens on two windows and a door needed fitting for the safety of food. Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 21 Infection control practices, records and equipment were examined. The issues regarding the laundry and sluice rooms have been mentioned above for action. The home was found to be generally clean and tidy and free from any unpleasant odour with the exception of the bedrooms identified above. The Acting Care Manager stated that the floor covering in these bedrooms are to be replaced shortly. The Acting Care Manager have revised and updated the home’s policies and procedures regarding infection control. It was noted from the staff training records that 9 members of staff have received training in infection control/COSHH and those who have not yet received this mode of training must do so as a matter of priority. Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers of staff on duty on day shifts needs to be revised and improved sufficiently to meet the needs of people using the service with Dementia care needs. The recruitment procedures have improved but require fine-tuning to fully protect people using the service. The home continues to support staff to complete training, but not all staff are yet adequately trained to do their jobs. 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 included sampling six staff personnel flies, rotas and training records/certificates. In addition to these, meetings were held with several members of staff and care practices were observed. Observations at the home and the available staff rotas on the day of inspection indicated that the home is not adequately staffed at all the times to meet the specific needs of people with Dementia. There were 22 people using the service on the day of the inspection. They were using two separate lounges and some were wandering in other parts of the building. In order to supervise people adequately and provide meaningful activities there need to be at least Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 23 two carers deployed to each lounge area with a senior carer to provide support. It was noted from the staff rotas for the months of August and September 2007 that there are not always four carers on duty in the mornings and also not always three carers on duty during the afternoon shifts. The home employs a cook and a kitchen assistant to cover 7 days a week, a domestic and laundry cover for 5 days a week. However, there is no cook cover for the evening teatimes throughout the week and the carers are expected to cover duties in the kitchen in the evening teatimes. The care staff are also expected to cover laundry and cleaning duties at the weekends. The Acting Care Manager’s hours are in addition to the above required staff hours and are supernumerary to allow Mrs Tania Mason to manage the care home effectively and efficiently. There are two staff on waking night duty with a senior on call from home. During the Inspector’s meetings with staff, they stated that they feel under pressure and pushed for time in the mornings and afternoons and more particularly during the weekends. It was noted that, the numbers of people who use the service have increased and their dependency levels have risen, and the staff are now struggling to provide quality time and a good standard of care. In such circumstances the staff have little time to provide or organise structured and appropriate social and leisure activities including outings/trips for people with Dementia care needs. Staff were spoken to and all stated that despite some changes in staff recently they felt they were for the better and they were beginning to work as a team. There is good balance within the staff team, which includes experienced, mature and younger staff, who are embarking on a new career. The staff team also have a good ethnic mix. The relatives spoken with also made observations about the staff team “they all are working hard in to provide good care and attention to our relatives here”. People who use the service were full of praise for care staff stating “they are caring and kind and do anything for us”. In order to maintain a good standard of care and up-keep the cleanliness of the home throughout, the Registered Provider needs to review the staffing levels and provide adequate numbers of care and ancillary staff on duty at all times to meet the needs of the service users. It was noted from the staff training records and discussions with staff and the Acting Care Manager that 15 members of staff have completed their NVQ Level 2 qualifications, and three members of staff have completed their NVQ Level 3 qualifications. There are two members of staff currently undertaking their NVQ Level 2 training. The Acting Care Manager stated that the remaining members Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 24 of staff will undergo this mode of training shortly. It was also noted that a number of staff have undertaken their mandatory training in safe working practice topics. It was also noted that not all members of staff have received training in safe working practice topics and they will be put forward to undertake this mode of training shortly. Those members of staff who as yet have not completed their training in adult protection issues and Dementia care will do so shortly. All new staff to receive their induction training in accordance with the Skills for Care standards and requirements, and the staff confirmed that they are supported by the home for any training needs that they have. Since the last Key Inspection, the home has operated an acceptable recruitment procedure. On inspecting 6 staff files, it was noted that now all staff are POVA and CRB checked. Two written references are also obtained. However, it was noted that there were some gaps in theses areas, which must be fine-tuned. For example, a second written reference was not available on a member of staff’s file. The job application forms are fully completed and contain full employment history. The Acting Care Manager stated that any gaps in employment are also explored/discussed with the job applicants during the interviews. The home should continue to refine the staff recruitment processes/procedures in order to ensure the people who use the service are safe and protected from harm and abuse. There is evidence on files that staff receive statement of the terms and conditions of employment and appropriate job descriptions. There is now staff training and development programme in place, which is being implemented. Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 25 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 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Acting Care Manager is not registered with the Commission for Social Care Inspection. People who use the service can be assured that the home is run in their interests. Financial interests of people using the service will be safeguarded. The home generally promotes the health, safety and welfare of people using the service, but need some further improvements. EVIDENCE: The home is currently without a Registered Manager. However, the Registered Provider has appointed an Acting Care Manager – Mrs Tania Mason in November 2006. Mrs Mason has achieved her D32/33 Award, NVQ Level 4 and Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 26 RMA qualifications. Mrs Mason stated that her application to register with the CSCI will be completed and submitted to CSCI by the end of September 2007. There are clear lines of responsibilities and accountability within the home and the Acting Care Manager is well supported by the Registered Provider and the Regional Manager. The home has a formal staff supervision system in place and this is now being implemented. Observations made and discussions with people who use the service and their relatives and staff indicated that the Acting Care Manager is very approachable and she operates an “open” door policy. People using the service, who could express themselves stated that they are happy to approach the Manager and staff with any problems they might have and were confident that they would respond to them appropriately. Through discussions with the Acting Care Manager, she demonstrated that she is confident in her ability to lead a staff team whilst being fully aware of the individual needs of people using the service. There is an emphasis on continually improving her performance through research into best practice in older people and Dementia care. She has made contacts with the University of Bradford regarding their degree/diploma course in Dementia care. Equality and diversity for people using the service were seen to be promoted throughout the home within the assessments, care plans, and activities. Equality for staff is promoted through the opportunities for training at all levels. Quality Assurance takes place throughout the service in both formal and informal manner. Meetings, surveys, internal audits and day-to-day contacts, all provide records to show that the satisfaction of people who use the service is at the heart of the service. The staff and people who use the service indicated that since the arrival of the new Acting Care Manager there have been a lot of changes introduced in the home to improve the premises, care practices and administrative recording systems. Questionnaires to people using the service and their relatives and other stakeholders are to be distributed in mid-September to obtain their feedback on the quality of services and facilities provided by Bescot Lodge. The Acting Care Manager stated that she will analyse and prepare a report on the outcome of the feedback by the end of October 2007. The report will be made available in the home and a copy to the CSCI. In addition, the Acting Care Manager should consider developing systems for determining the views of people using the service with Dementia care needs, who are unable to verbalise their needs. Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 27 Financial records and administrative procedures relating to the handling of monies of three people who use the service were inspected and were found to be well ordered and maintained. The home keeps records to show that health and safety of people who use the service is promoted and protected. However, it was noted that the hot water supply in the bathroom on the ground floor was tested to be at 52 Degrees C and hot water in several bedrooms was either far below or above the required standard of 43 Degrees C. (See NMS OP19 above for more details). Temperature in all hot water outlets should be tested on a weekly basis and all tests records maintained to ensure the safety at all times of people using the service. Matters pertaining to fire safety needs to be maintained to the required standards and all the outstanding issues identified in the recent inspection report of the Fire Safety Officer should be addressed appropriately. All safety systems/equipment are checked and maintained and records of all tests/checks are kept up to date. However, it was noted that regular Fire Drills and Fire Prevention (Fire Marshall) training for staff have not been undertaken, which should be provided as a matter of priority. Risk Assessment needs updating. The fly-trap should be repaired/replaced and there were no fly screens fitted to the two windows and a door in the kitchen, and appropriate action should be taken to address these issues in order to ensure food safety at all times. The staff training records indicated that there were many gaps in mandatory training for staff that includes fire safety, first aid, health and safety, moving and handling, infection control/COSHH, and food hygiene. The Acting Care Manager stated that the Registered Provider is aware of this deficiency and they both are taking appropriate steps to rectify this unsatisfactory situation shortly. Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 28 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 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 1 2 X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 29 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 OP18 Regulation 13 (6) Requirement All staff must receive adult protection training to ensure that people who use the service are not at risk of harm or abuse. (Previous timescale of 01/04/07 not met). The Acting Care Manager must apply for registration with the CSCI as a matter of priority. Staff must continue with their training in dementia care and challenging behaviours in order to ensure that people who use the service their care needs are appropriately met. (Previous timescale of 01/04/07 not met). Timescale for action 31/10/07 2. OP31 8 (1)(a) 31/10/07 3. OP4 18 15/11/07 4. OP38 23 (2)(j) Action must be taken to ensure a 15/10/07 consistent supply of hot water at the safe temperature. This is to ensure that people using the service enjoy a regular supply of hot water without the risk of scalding. The temperature in all the hot water outlets must be tested and DS0000039568.V349132.R01.S.doc Version 5.2 Page 30 Bescot Lodge recorded on a weekly basis to ensure the safety of people using the service at all times. 5. OP8 17 Schedule 4 Service users who are unable to be weighed on conventional weighing scales must be screened for malnutrition using an appropriate method so that their health and well-being is appropriately monitored on a regular basis. (Previous timescale of 01/04/07 not met). 31/10/07 6. OP27 18 Care and ancillary staffing levels 15/10/07 must be reviewed and increased sufficiently in order to ensure the needs of people using the service are appropriately met. The registered manager must provide a wide range of social and leisure activities that are suitable for all service users including those people using the service with dementia. The home must either employ an activities co-ordinator or amend the Service Users’ Guide. (Previous timescale of 01/04/07 not met). The premises must be maintained in a good state of cleanliness and repair throughout in order to ensure the safety and comfort of the people who use the service. (Previous timescale of 01/04/07 not met). The home must ensure that its induction of new staff includes specific guidance in relation to Dementia care, and also in accordance with the Skills for Care standards/requirements. DS0000039568.V349132.R01.S.doc 7. OP12 16(2)(m, n) 31/10/07 8. OP19 16, 23 31/10/07 9. OP30 18 (1)(c)(i) 31/10/07 Bescot Lodge Version 5.2 Page 31 (Previous timescale of 01/03/07 not met). 10. OP38 13(36)12(10) The Acting Care Manager and senior staff must undertake risk assessment training to ensure the safety of people using the service. The home must ensure that all water outlets are regularly flushed, with records maintained. The home must ensure that all staff attends a fire drill at least annually, with records maintained. The home must ensure that all staff holds up-to-date certificates for moving and handling, first aid, food hygiene, health and safety, fire safety and infection control/COSHH in order to ensure the safety of people using the service. (Previous timescale of 01/04/07 not met). 31/10/07 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 OP7 OP33 Good Practice Recommendations It is recommended that the details and quality of daily care recording should be further improved. It is recommended that the Acting Care Manager should develop systems for determining the views of people using DS0000039568.V349132.R01.S.doc Version 5.2 Page 32 Bescot Lodge the service with Dementia care needs who are unable to verbalise their needs. 3. OP20 People who use the service should have access to external grounds, which are sufficient, safe and appropriately maintained for them to enjoy outdoor activity. It is recommended that the staffing rota clearly identify, which member of staff on each shift has completed dementia training. It is recommended that two written references are obtained on all new staff before they commence their employment at the care home. It is recommended that the system should be put in place to ensure that the essential repairs such as those identified in this report are dealt with promptly. The Acting Care Manager should undertake the Diploma of Higher Education of Dementia Studies. It is recommended that consideration should be given to appointing an activities co-ordinator in the home. It is recommended 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 safety. It is recommended 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. 4. OP27 5. OP29 6. OP19 7. 8. 9. OP31 OP12 OP38 10. OP38 Bescot Lodge DS0000039568.V349132.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection 1st Floor Chapter House South Abbey Lawn Abbey Foregate Shrewsbury SY2 5DE 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.V349132.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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