Inspection on 01/12/05 for Beulah Lodge Rest Home

This inspection was carried out on 1st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beulah Lodge Rest Home 07/10/08

Beulah Lodge Rest Home 11/04/08

Beulah Lodge Rest Home 17/11/06

Beulah Lodge Rest Home 08/12/04

Beulah Lodge Rest Home 07/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Beulah Lodge Rest Home 1 Beulah Road Tunbridge Wells Kent TN1 2NP Lead Inspector Mrs Ann Block Announced Inspection 1st December 2005 09:17 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 Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 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. Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beulah Lodge Rest Home Address 1 Beulah Road Tunbridge Wells Kent TN1 2NP 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) 01892 548447 01892 539040 Beulah Lodge Rest Home Limited Mrs Christina Carol Rusha Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Care of one service user under 65 years of age, whose date of birth is 21 December 1940. 2nd June 2005 Date of last inspection Brief Description of the Service: Beulah Lodge is registered for 21 older people. A small number of residents also have mental health difficulties. Beulah Lodge is a detached property with 19 single bedrooms and 1 bedroom which can be shared on request, all have en-suite facilities with WC. There are telephone points in 2 bedrooms, call points and TV points to all bedrooms. There is a shaft lift to all floors. The owner has 20 years experience in running residential homes and the Manager has 19 years experience working with the elderly in a residential setting and holds a Certificate in Supervisory Management. The home is a listed building in a residential area of Tunbridge Wells, close to Victoria Place shopping centre. There are a number of smaller family run shops close by. The Home is on a local bus route and there is a main line station in the town. There are gardens to the front and rear of the building with a small car park to the rear of the building. There is an outbuilding housing Company offices to the rear of the house. Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission was represented by Ann Block, Regulatory Inspector, who carried out an announced inspection of Beulah Lodge between 9:17 am and 5.00 pm. A number of residents, staff on duty and a visitor agreed to speak with the inspector both in private and in small groups. The manager was on site for part of the inspection. The inspector is familiar with the service, assessments against standards were made from conversations, records and observation from this inspection and from previous experience of the service. Written and verbal feedback was provided to the senior on duty at the end of the inspection. As part of the inspection process comment cards were received from service users and relatives. Comments made included: ‘I think my gran is very well cared for the staff are always very helpful and friendly.’ ‘I find the atmosphere friendly and relaxed and consider mild under perfection preferable to the opposite.’ ‘I find all the staff helpful and friendly’. ‘The staff are always friendly and helpful at all times and make you feel welcome’. “We have no worries about being here at all.” What the service does well: Residents or their relatives can visit the home. Residents are assessed before admission to identify whether the home can meet their needs. Residents are treated as individuals with the dignity, rights and respect due to older people. Written care plans support staff’s sound understanding of each person. Health care is well managed. Aids to mobility and safety are provided as necessary. Residents and families are supported throughout the stages of older age. Residents can follow their own pursuits and activities. They can maintain Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 6 contact with friends and family and use the facilities in the local area. Visitors are made welcome and often become part of the ‘family’. Home cooked food is provided with flexibility of timing if necessary, dietary needs are met. Residents have opportunities to talk about the service and if necessary, make a complaint and be listened to. Beulah Lodge offers a homely and comfortable environment with all en suite rooms. Residents have their needs met by staff who residents think are kind and caring, who enjoy working at the home and providing a good standard of care. Servicing of supplies and equipment is carried out. 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. Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 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 Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 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): 1,2,3,4,5 & 6 Residents can make a choice whether Beulah Lodge will be suitable for them through a sound admission process. EVIDENCE: Many residents moving into Beulah Lodge have either chosen to come there from their own knowledge of the home or had family who researched homes in the area. A relative was looking round the home and was able to meet residents and staff. All said they were very happy with the home. Many residents had connections with the local area and valued being able to maintain contact with familiar places and friends. None spoken to had seen written information about the home, there is a statement of purpose and service users guide. Residents spoke of meeting the manager before they came into the home. Documentation in residents care files and the letter to the resident stating the home can meet their assessed need confirmed the assessment process. More recently a few residents have come from out of area, one is planned to arrive shortly. The file evidenced good contact with the care manager with written detail of the person’s needs already recorded. The Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 9 manager did not want to contact the care home the person was currently in, as she felt this caused staff to ‘prejudge’ the resident, often she found unfairly. Each resident has a statement of terms and conditions between the home and themselves. The first four weeks is a trial period to see whether the home is suitable, the trial period may be extended by mutual agreement. Where a room is available respite care may be offered. Whilst Beulah Lodge aims to care for people throughout all the stages of older age, where this is not possible support is given until a more suitable placement is found. To ensure that systems remain in place to meet the need of those with mental health difficulties, the registration of the home should reflect this. Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 10 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): 7,8,9,10 & 11 Residents are recognised as individuals who are treated with respect and dignity with their own hopes and aspirations set out in their care plan. Small improvements in recording would better evidence this process. EVIDENCE: Beulah Lodge is particularly good at meeting individual needs as far as possible within a residential home. Residents and staff accept the differing personalities of each person, a number mentioned how both staff and residents supported those with special needs. Staff have an excellent understanding of individuals, often shown by the way in which needs are anticipated, thus reducing anxiety. Each resident has a care plan which records good detail about the person as confirmed in conversations with residents. Records of residents’ daily lives substantiated that health care was well met with appointments made for specialist and ancillary health care. Records include any specific health problems which staff said would be dealt with. The recording system could better evidence these observations. Residents spoke of having chiropody, dental, optical and district nurse visits with record made Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 11 of such visits. Staff spoke highly of the district nurses and how supportive they were of the client group. Residents may either register with a general practitioner or keep their own if moving locally. Medication is administered by monitored dosage system as far as practical. Practice includes confirming medication administration with professionals if there is a query. Records are held to evidence that medication has been administered as per prescribers’ directions. Where medication was recorded as refused, staff said this was by the residents informed choice. To ensure the resident’s doctor is aware that medication is being refused, there should be evidence of any such discussions with a record of the outcome. Where a resident self medicates, staff said they monitor that medication is being taken and that the person’s doctor would have agreed to the practice. Staff administering medication have had safe handling of medication training. A resident who needed medication mid morning said that staff never forgot to give it to her on time. Residents spoke very highly of the staff team and felt that staff treated them with respect. They spoke of situations where their privacy was maintained. One resident said she liked having her door open to watch people going by, but when personal care was given staff always made sure it was carried out in private. Residents are asked by what name they want to be called and this is recorded in the care plan and used consistently. Beulah Lodge aims to be a home for life and good support is given in later stages of life. As the home is a small unit, residents have an almost family atmosphere. Any death affects the group and is dealt with sensitively with residents able to be involved in the grieving process. Family can be included in the later stages of a resident’s life. Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 12 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): 12,13,14 & 15 Residents live in a setting which recognises them as individuals with the right to exercise control over their lives, who they see, what they eat and what activities they want to do. EVIDENCE: Residents move into Beulah Lodge knowing the nature of the service, that it is homely, fits into the local area, friendly and with a ‘family’ feel. Residents considered the home to meet their expectations of such a service, commenting particularly on the friendliness of the staff. Residents who wish to continue with church attendance have churches close by. Each Friday a music and movement session is held, staff provide other activities when time allows. Residents were considering when Christmas decorations would be put up and where they would go. A visiting library service is provided. A number of residents have their own magazines and newspapers, one resident spoke of the lengths the owner had gone to, to make sure she got a particular daily newspaper as it meant such a lot to her. Those more able residents spoke of keeping up connections with the local area, going into town to meet friends and using the local shops. Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 13 Visitors are welcomed into the home by staff and residents much as into an extended family. The visitors’ book recorded a number of regular visitors. One visitor spoke of how she felt comfortable when visiting her friend. As already mentioned, a particular strength of Beulah Lodge is the manner in which residents are treated as individuals with their individuality respected. Residents spoke of how their personal preferences were met and this was confirmed in practice. One person said she preferred to remain in her room where she liked to read or listen to the radio in private. Staff knew this was her choice and took her meals and drinks up to her, making sure she wasn’t ignored or became lonely. Food is basic home cooking. Opinions of the food again varied. The majority of residents said the food was nice, one commenting this had resulted in a small weight gain, others saying there was limited choice of menu. One resident said she didn’t eat meat and was able to have fish pie when the remainder had mince for lunch during the inspection. Staff have a good awareness of individual preferences such as one persons liking for ice cream for dessert. Staff said they would be able to make snacks but only with food left out for use in the fridge, as the main larder and freezer would be locked. Residents said that family or friends had usually brought the fruit seen in their room. Drinks are taken round mid morning, afternoon and later evening, staff willingly make additional drinks on request and for visitors. Most residents eat in the dining room, some choose to eat in their rooms and said they were very grateful they were able to, a few eat in the lounge. Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 & 18 Residents have access to people who listen to any concerns and will take action. EVIDENCE: Residents said they felt quite confident that any complaints about the service would be taken seriously and would be listened to. One resident said that if she mentioned that something wasn’t quite right, prompt action was taken, she never had to ask twice. The general opinion was that this was a home for a group of people and it was impossible to get everything right 100 of the time but overall they had no cause for complaint at all. Comment cards received as part of the inspection also recorded no cause for complaint. A complaint procedure is posted in the hallway. Residents can place an election vote if they choose. Staff understand the risks of abuse with some having had training as part of their NVQ course. Residents felt they were well protected from risk. Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 15 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): 19,20,21,22,23,24,25 & 26 Residents have a homely, well maintained and comfortable environment in which to live. Better attention to cleanliness of the environment will reduce the risks of cross infection. EVIDENCE: The owner aims to provide a good environment in which to live. The kitchen was completely refurbished earlier this year. A shaft lift provides easy access to all floors. There is a dining room and lounge on the ground floor, with a second day area on an upper floor. Residents prefer to use the ground floor areas, the additional lounge being used in part for storage and was chilly on the day of inspection. A resident said she had used it once when visitors came with an active little boy, but otherwise it was very rarely used. The good sized rear garden is used by a number of residents and is a quick route to the main shopping areas. Trees in the grounds have recently been trimmed to reduce leaf drop and give better light, much to the delight of a resident. There is both stepped and level access into the house. Individual rooms reflect the Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 16 occupants personalities and have personal effects and in some cases furniture. Many residents have chosen to display favourite family photos. Rooms are well decorated and well furnished. Residents feel they are warm enough and can control the heating. Aids and equipment to give increased confidence and support are provided as necessary. A recent Environmental Health Officer visit awarded the home the silver award for kitchen standards. The fire safety office had visited following a recent fire in a resident room, the manager said he was satisfied with fire safety standards and the fire risk assessment. Whilst cleaning staff are employed, recently the need to ensure personal care is given and catering is carried out, such staff have changed role. There was evidence of a drop in standards of cleanliness. This is of concern as some of the baths, bathrooms, toilets and an en suite toilet were not cleaned to an acceptable standard to reduce the risks of cross infection. In one toilet there were no suitable facilities to dispose safely of paper towels. Two toilets had not had the paper towel dispenser refilled. Toilet riser seats were not cleaned thoroughly. Staff are unable to obtain cleaning materials or toilet requisites when cleaning or management staff are off duty as the cupboards are locked. The extractor fan again wasn’t working in a top floor toilet, this fault had been noted at previous inspections. All rooms are en suite with two separate additional assisted bathrooms and a shower room. Residents said how much they liked being able to have a bath, as often they hadnt been able to have one at home. A toilet is located close to the communal areas. Staff have their own toilet and sleep in area. There is a separate laundry room on the lower floor. A resident mentioned how good clothes care was. She said she liked to change her underwear daily, the clothes would be taken in the morning and retuned by afternoon. Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 17 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): 27,28,29 & 30 Residents are cared for by a staff team who understand and anticipate residents’ needs and wishes. Carrying out POVA first check would better protect residents. EVIDENCE: Residents consider that there are sufficient staff to meet their needs. Whilst residents have use of a call system, they said they rarely needed to use it as staff knew individual routines. One person said that if she had had to buzz, staff came promptly Residents said that staff were very responsive and had time to listen. The unanimous view from residents and visitors was that the staff were ‘marvellous’, ‘kind’, ‘friendly’, ‘you never hear them say a bad word about anyone’, ‘considerate’. They felt that whilst staff were busy, they weren’t too busy to be asked for help. Staff at this and previous inspections generally consider there is adequate staffing, the only pressures being when there are short term high care needs. The manager works in a hands on capacity if necessary. The roster is planned to allow additional cover to be worked if necessary, rather than using agency staff. The cook and domestic staff multi task, being used as carers where needed. On the day of inspection the cook was working as carer and the domestic as cook. On each shift, staff on duty will decide a shift leader. There is one waking and one sleeping member of staff on duty at night. A core of staff have worked at the home for some years. There have been some recent staff changes due to retirement, unsuitability for the standards of Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 18 care expected and career change. The manager said that it was difficult to recruit good staff. Staff seen at both this and previous inspections have shown a very good understanding of residents, as confirmed in practice. There were excellent relationships between staff and residents with a good balance between professionalism and friendliness. Over the past year staff, including catering and domestic staff, have achieved NVQ level 2 in Care. Staff said the NVQ assessor had praised them for the quality of their work. Staff felt that training in mental health awareness would help them in working with residents. Staff follow a recorded induction process which includes duties shadowing a more experienced member of staff. Files of recently recruited staff showed that overall sound recruitment practices had been followed. Sufficient information had been obtained to assess whether the person would be suitable to work with older people. The residents were not fully protected as, whilst the manager said that a criminal records bureau declaration had been applied for, one person was already working but had not had a POVA first check carried out. Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 19 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): 31,32,33,34,35,36,37 & 38 Residents benefit from a needs led and safe service, which is run in their best interests by a manager and staff who are committed to providing a good quality of life for older people. Correct notification of incidents must be made to evidence residents had been properly protected from such risks. EVIDENCE: The manager has many years experience of working with older people, including a number in a managerial role. The manager is still looking into provision for the NVQ Registered Managers award. Residents consider the manager is available and approachable. Staff take on responsibilities in the manager’s absence but recognise final responsibility as being the managers and have systems to contact her if necessary. All spoken to felt that the manager was committed to providing a good standard of service and had the needs of older people at heart. Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 20 It is felt that as the home is small, residents would not benefit from having formal meetings. There is a lot of formal and informal chat and feedback on a day-to-day basis. Residents said that any comments they had about the service would be listened to. Residents are generally supportive of the group and understand that the home accommodates a group of quite different people. Most said they feel very lucky to be living at Beulah Lodge. Residents fully participated in the inspection process but were unaware that a report was written following inspections. A current certificates of employer’s liability insurance was seen. The home can hold money for safekeeping on behalf of residents. Some families choose to send a cheque which is cashed through the homes account. Records of expenditure are held with each person having their own locked cash tin. Some receipts are kept. Where appropriate copies of the record sheet are sent to families. A tin checked had more money in than was recorded. The manager said this was because she often bought things but forgot to take the money out. The resident concerned was quite happy about the way his money was managed and was grateful that someone was able to keep an eye on it for him. The manager works on a regular basis in a hands on capacity and through this carries out work based supervision. There is no formal diaried supervision system in place. Staff said that issues would be discussed as they arose. Staff breaks are held in the inner hallway, which is also the smoking area. Handovers take place there with general discussion about the home whilst records are updated. Over the last two years there has been an improvement in overall record keeping. The manager is aware that rightly, her focus is on providing good care to older people, but now better recognises the importance of maintaining good records as part of her accountability and registration. From discussion with residents and staff, there is a good awareness of health and safety. Those staff with key responsibility for food handling have now attended a full basic food hygiene course. Other staff have had food hygiene awareness training. A record of fire drills is held. As there is no fire training matrix, and records are not held in date order, it is very difficult to identify whether all staff have attended a drill within recommended intervals. Other fire safety records indicate that fire safety is taken seriously. Records of servicing of supplies and equipment show that routine maintenance is up to date. An accident record is held which compiles with Date Protection. The accident record and other information provided evidenced that there had been a number of accidents, deaths and incidents which had not been notified to the commission as required by regulation. The manager was reminded of the regulation with a copy of guidance given to the senior during the inspection. Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 21 The owner is available in the home regularly and takes an interest in the overall running of the home. The manager said she prefers to pass the inspection report for him to read and for him to point out any areas that need action. Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 22 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 3 3 2 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 1 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 2 3 3 1 Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP2626.1 Regulation 13(4) Requirement At all times there must be suitable facilities for drying hands which reduce the risks of cross infection. Facilities must be in place by 20 December 2005 and thereafter 2 OP2626.1 16(2)(k) 13(4) All areas of the home which are occupied or used by residents must be kept clean and hygienic. This will include that suitable cleaning materials are available to staff at all times and suitable facilities for the disposal of waste are provided. This requirement applies particularly to toilets, en suites and bathroom and any other area where there is a risk of cross infection. By 20 December 2005 and maintained thereafter 3 OP2929.3 19(5) Where any member of staff is engaged to work at the home before a satisfactory criminal records bureau certificate has been received, a POVA first check must be made. DS0000023890.V260405.R01.S.doc Timescale for action 20/12/05 20/12/05 20/12/05 Beulah Lodge Rest Home Version 5.0 Page 24 4 OP3838.7 37 Any event which affects the wellbeing of residents must be notified to the commission without delay. Any verbal notification must be followed up promptly by written notification. Guidelines to Regulation 37 were provided to staff at the home during the inspection. From 20 December 2005 and thereafter 20/12/05 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 OP11.2 Refer to Standard Good Practice Recommendations The latest inspection report should be readily available to interested persons. It is further recommended that the manager and staff use the report both to praise the positive outcomes and to provide a tool to improve less positive outcomes. It is strongly recommended that application be made for variation of condition of registration to include those people who have mental health difficulties. Whilst practice suggests that health concerns are monitored and responded to, records should evidence tracking of any health concerns. Where medication is frequently refused, there should be evidence of any such discussions with a record of the outcome. Staff should have access to food stocks to enable residents to be provided with a snack at times in addition to planned meal times. The extractor fan in the top floor toilet should be repaired. This fault has been identified at inspections over the past DS0000023890.V260405.R01.S.doc Version 5.0 Page 25 2 OP44.1 3 OP88.1 4 OP99.1 5 OP1515.3 6 OP1919.2 Beulah Lodge Rest Home two years. 7 OP3030.1 8 OP3131.1 Now that NVQ training has been successfully completed, a wider range of training should be offered including mental health awareness/dementia training. The manager should register to undertake NVQ level 4 in management and care to ensure she holds these qualifications by 2005. This was included in the inspections of 20 August 2003, 23 December 2003, 8 December 2004 & 2 June 2005 Where money is held for safekeeping, the system should ensure correlation between expenditure and money held. Records of fire drills and practices should be held in a manner which can evidence that all staff receive fire drills within recommended intervals. 9 10 OP3535.1 OP3838.2 Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beulah Lodge Rest Home DS0000023890.V260405.R01.S.doc Version 5.0 Page 27 - 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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