Inspection on 17/11/06 for Beulah Lodge Rest Home

This inspection was carried out on 17th November 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 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 01/12/05

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 Helen Martin Key Unannounced Inspection 17th November 2006 12:15 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.V316730.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. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 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.V316730.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 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 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. 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 provides care staff, working a roster, which gives 24-hour cover. Staff are also employed for catering and domestic duties. Current fees for the home range from £301.69 to £390.00 per week. Additional costs include hairdressing, personal toiletries, chiropody, newspapers, transport and personal telephone. Full information about the fees payable, the service provided and the home’s Statement of Purpose are available from the owners. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place on 17th November 2006. The visit included talking with the manager, two care staff and six people who live in the home. The owner was present for some of the time. Some judgements about the quality of life within the home were taken from observation and conversation. Some records were looked at. A tour of the premises was undertaken. The home has given the CSCI a completed pre-inspection questionnaire and this information has been used within this report where appropriate. Postal surveys from seven residents, one of their relatives, one health and social care professional and three GPs have been received by the CSCI and have been used within this inspection process. Currently there are seventeen residents accommodated with three vacancies. There is one larger room which can be used to accommodate married couples or partners who wish to live together by choice. Comments made by residents spoken with at the time of this visit included: ‘I enjoy living here’ ‘I like the home very much’ ‘I looked around and had details in writing about the home’ ‘The food is very good, excellent, I get a choice of food and can ask, very satisfactory’ ‘I like to get up early and staff give me my breakfast early’ ‘I can choose when to sleep and get up as I feel like’ ‘I enjoy the games’ ‘I enjoy the music and movement’ ‘My family visits me often’ ‘I get my clothes back quickly from the laundry’ ‘I am given my medication on time, everything is on time’ ‘When I came here I couldn’t walk but they got me up and walking again’ Comments received in postal surveys included: ‘Its nice here; I’m happy here’ ‘This house is very comfortable and clean’ ‘The staff are very helpful and kind’ ‘I sometimes need someone in the middle of the night, but if I ring the emergency bell someone always comes’ ‘The meals are quite nice and tasteful’ ‘…fresh vegetables are only offered once a week…would like daily fresh fruit and vegetables’ ‘I thoroughly enjoy the dancing and singing on a Friday afternoon’ Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Some improvement to medication guidelines would better protect residents. A review of the availability of fresh fruit and vegetables may be beneficial to some individuals. A review of the staff roster and training would better protect residents. Their quality of life may be improved by the continued refurbishment of the home. Residents would be better protected by the qualification of the manager and a review of policies and procedures, staff supervision and gas safety checks. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beulah Lodge Rest Home DS0000023890.V316730.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 Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information they need in order to decide whether to move into the home. They are assessed to ensure that the home can meet their needs. EVIDENCE: All residents said they were very happy at the home. Many have connections with the local area and value being able to maintain contact with familiar places and friends. Residents spoken with said that they had the opportunity to look around and received written information about the home before they decided to move in. This was confirmed by the manager. There is a combined statement of purpose and service users guide, which gives comprehensive information about the home, the complaints policy, terms and conditions of accommodation together Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 10 with outside contacts. This is available in large print. The document has been reviewed recently and a draft dated 2007 was seen; the home may wish to consider further review of the section ‘Further Information, Local Contacts’ in order that contacts more local to Tunbridge Wells can be provided before the final document is distributed to residents. The last inspection report is kept within the home and available to residents. Prospective residents are assessed before they move in, in order to ensure that the home is suitable to meet their needs. 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. Intermediate care is not provided. Whilst the home aims to care for people throughout all stages of older age, where this is not possible support is given until a more suitable placement can be found. The manager said that since the last inspection one resident with mental health difficulties had moved out of the home. It was stated that two current long standing residents who suffer from anxiety, do not have a mental health diagnosis. However, the manager explained that specialist health care professionals could be accessed if necessary and staff guidelines are available. The manager demonstrated a good understanding of the needs of individuals that the home could and couldn’t meet. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are treated with respect. Arrangements are in place to maintain their privacy and dignity. Residents’ personal, health and social care needs are reflected in care plans. Some improvement to medication guidelines would better protect residents. EVIDENCE: Each resident has a holistic care plan which records good detail about the person. Documentation seen reflected their changing health and social care needs. Care plans are reviewed on a regular basis and include details about risk assessments, personal information and contacts. Notes are recorded daily and kept in the care plan folder. Care plans included information on consultation and referral to medical professionals, such as GP, district nurse, optician and chiropodist. Residents may either register with a general practitioner or keep their own if moving Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 12 locally. One resident explained that when they first came to live at the home, they couldn’t walk, but that through exercises, the staff had got them walking again. Arrangements are in place for the administration of medication. Storage is secure. A monitored dosage system is used. Records for the administration of medication and a signature list of staff who administer this are kept. Controlled drugs are stored and recorded appropriately. ‘Homely remedies’ are not kept and all medication needed on a ‘when required’ basis is prescribed. Staff demonstrated a good understanding of individual residents’ medication, including when to administer on a ‘when required’ basis, although the latter is not recorded. Staff stated that no residents refuse prescribed medication on a regular basis and should this be the case, liaison with the GP would take place and be recorded. It was mentioned that one resident is completely selfmedicating and the GP agrees with the practice; they go out to attend their own GP appointments without the need of support from staff. Residents spoken with said that they are given their medication on time. Residents spoke very highly of the staff team and felt that staff treated them with respect. During the inspection, staff were seen to attend to their needs in privacy and respond quickly when asked. Residents spoken with were all happy with their care. They said that they got their clothes back quickly from the laundry. Beulah Lodge aims to be a home for life and good support is given in the later stages of life. Both the manager and staff demonstrated a good understanding of and sensitivity to the issues involved. Families are able to visit as often as they wish and health care professionals can be accessed where appropriate. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are recognised as individuals and are able to exercise choice over their lives. They benefit from activities that they enjoy and are able to keep in contact with their family and friends. They enjoy the meals, although a review of the availability of fresh fruit and vegetables may be beneficial to some. EVIDENCE: Residents move into Beulah Lodge knowing the nature of the service, which is homely, fits into the local area, friendly and with a ‘family’ feel. Residents consider the home meets their expectations. They are able to make choices within the constraints of group living and their own abilities. Residents spoken with said that they were able to choose whether to spend time in their rooms or in the communal areas. At the time of this visit, some were in the lounge watching television, in the dining room, in their rooms or going to and fro. They said that they are able to choose when they want to get up and retire and that the routines of the home are flexible. Staff spoken with demonstrated a good understanding of residents’ choices within the home. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 14 Some activities are provided by the home. Residents spoken with are happy to watch TV or videos, do puzzles and read. A visiting monthly library service for books and videos is available. Others and comments received said they enjoy the games and weekly music and movement sessions provided. Residents enjoyed a fancy dress Halloween party to which their relatives and friends were invited. Birthday parties and trips to pantomimes at Christmas are arranged. A ‘trip to the seaside’ in the home was organised earlier in the year with fish and chips and a visiting Punch and Judy show. The manager described visiting local organisations, school children and musical entertainment. Residents are involved with the home’s garden. Those more able spoke of keeping up connections with the local area, going into town to meet friends and using the local shops. Some residents go out with their relatives. There are churches close by should residents wish to attend. Residents are encouraged to keep contact with their relatives and friends if they wish. Visitors are welcome in the home at any reasonable hour. Residents spoken with said that they enjoyed regular visits from members of their family. All residents spoken with and some comments received said that the food was very good and that they were always asked for their choice. Mealtimes can be flexible depending on residents’ choice and needs and individuals can eat where they wish. The main meal of the day is written on a board in the dining room. At the time of this visit, food in the kitchen was available and being prepared by staff in the evening after the manager had gone home. A variety of teatime snacks were prepared during this visit. Staff demonstrated a good understanding of residents’ preferences. Two postal surveys received stated that fresh fruit and vegetables are not provided every day and that one resident would like this. The manager explained that fresh vegetables were provided every day; a sizeable homegrown marrow was seen in the kitchen. It was stated that fresh fruit could be bought if residents asked for this. Previous inspection identified that residents said their family or friends had usually brought the fruit seen in their rooms. A record of food consumed is kept. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of residents and their representatives are listened to and receive appropriate consideration. They are protected from potential abuse. EVIDENCE: At the time of this visit, residents were at ease talking with staff and the manager who listened to their views. Staff seen demonstrated a good understanding of residents. There are positive relationships between both staff and residents with a good balance between professionalism and friendliness. The manager said that no complaints had been received, although the home had the facility to record these should this be the case. Residents confirmed that they had no complaints. Numerous cards and letters of thanks have been received by the home. There is a written complaints procedure available to residents. Procedures are in place to protect residents from potential abuse. Discussion took place regarding two incidents that have taken place since the last inspection, one requiring the fire brigade and the other the police. It was evident that the home took prompt and appropriate action in order to safeguard residents. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a clean, tidy and comfortable environment, although their quality of life may be improved by the continued refurbishment of the home. EVIDENCE: The home is comfortable and warm. All the areas seen were clean and tidy and this was confirmed by comments from residents. The good sized rear garden is used by a number of residents and is a quick route to the main shopping areas. 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. There is no longer a smoking area provided within the building. Individual rooms reflect the occupants personalities and have personal effects and in some cases furniture. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 17 Both the owner and the manager described refurbishment plans for the home. It was mentioned that all rooms would be provided with lockable facilities when the refurbishment programme is complete. Since the last inspection some bedrooms have been redecorated and have new furniture. It was mentioned that the home was awaiting delivery of new carpet for some areas. All rooms are en suite with two separate additional assisted bathrooms and a shower room. The manager stated that the extractor fan in a top floor toilet is now working. 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 shaft lift provides easy access to all floors. There is both stepped and level access into the house. Aids and equipment to give increased confidence and support are provided as necessary. The last report from an environmental health officer in November 2005 indicated that hygiene levels within the home were of a high standard. It was mentioned that the home’s method of waste disposal had been agreed with the environmental health officer. Cleaning chemicals are stored throughout the home and staff have keys and access to these. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An appropriately recruited and qualified staff team care for, understand and anticipate residents’ needs and wishes. A review of the staff roster and training would better protect residents. EVIDENCE: There were sufficient staff on duty to meet residents’ care needs at the time of this visit. Comments from residents included that if they needed to use the staff call bell at night, someone always came. Care staff on duty were very committed to their role and knowledgeable about the running of the home. Staff are very responsive to residents’ needs and have time to listen. There is good interaction between staff and residents. The manager works in a handson capacity if necessary. The roster is planned to allow additional cover to be worked if necessary, rather than using agency staff. Staff multi task, being used as carers, cooks or cleaners where needed. The manager said that they were in the process of recruiting two specific cleaners. The home also employs a handyman. On each shift, staff on duty will decide a shift leader. There are usually two care staff on duty during the day with one waking and one sleeping member of staff on duty at night. The manager stated that they would review the written roster to confirm that all staff employed are included together with their surnames and allocated tasks. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 19 A core of staff have worked at the home for some years. There have been some recent staff changes. The manager said that it was difficult to recruit suitable staff. Staff seen at the time of this visit demonstrated a good understanding of residents. There are positive relationships between staff and residents with a good balance between professionalism and friendliness. Staff follow a recorded induction process. The manager stated that they would undertake a review to ensure that the induction process and records are in line with ‘Skills for Care’ recommendations. It was stated that all staff, with the exception of three, had obtained NVQ qualifications. The manager said that now staff had completed their NVQs they would concentrate on updating any ongoing training that was needed. It was said that medication and nutrition training was booked and that they would look into more specialist courses for dementia and mental health. Previous inspection identified that staff felt that training in mental health awareness would help them in working with residents. Documentation was kept within staff files. Due to the nature of the records held it was not possible to fully ascertain whether all appropriate course updates had been undertaken. The manager said that they would develop a training matrix. The recruitment procedure in place within the home aims to ensure that suitable staff are appointed to meet the needs of residents. The files of two newer care staff evidenced an appropriate recruitment procedure, including application, interview, protection of vulnerable adults and criminal records bureau check, proof of identification and two references. The home undertakes an equal opportunities and health check survey from applicants. The manager explained that qualifications were checked together with any gaps in employment, which were recorded. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home, 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. Residents would be better protected by the qualification of the manager and a review of policies and procedures, staff supervision and gas safety checks. EVIDENCE: The manager has many years experience of working with older people, including a number in a managerial role. Since the last inspection, the manager has commenced the NVQ Registered Managers Award qualification. Residents and staff consider the manager is available and approachable. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 21 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 indicated that any comments they had about the service would be listened to. It was stated that quality assurance questionnaires were given to residents, their families and health and social care professionals and feedback was given to the home. The home provides a comprehensive range of written policies and procedures, which are available for staff, although many were either undated or did not evidence regular review. The home is not an appointee for any resident. The manager described appropriate and accountable systems in place regarding the auditing of residents’ monies. The home has the facility to hold small amounts of cash on behalf of some residents, which is stored individually and securely. As some rooms have lockable facilities and some will be provided with these as part of the refurbishment programme, residents are encouraged to let the home hold any cash they may have on their behalf. Transaction records are maintained, which are signed by the resident and held with receipts for expenditure. One resident’s cash checked tallied with accounts seen. The manager works on a regular basis in a hands on capacity and through this carries out work based supervision. Both the manager and staff said that issues are discussed as they arise. The manager said that informal staff meetings were held when necessary, although these were not recorded and daily handovers took place. There is no formal recorded one-to-one supervision system in place; the manager stated that they would review this. Records of accidents and incidents are recorded appropriately. The manager stated that all appropriate accidents and incidents had been notified to the CSCI since the last inspection. Discussion took place regarding two incidents that have taken place since the last inspection, one requiring the fire brigade and the other the police. It was evident that the home took prompt and appropriate action in order to safeguard residents. Other records looked at as part of this site visit have been mentioned previously within this report where appropriate. Information provided within the home’s pre-inspection questionnaire and documentation seen at the time of the visit indicated the regular testing and maintenance of equipment and systems within the home. However, the last gas safety check was undertaken in September 2005. Both the owner and the manager assured the inspector that the home had a contract with an agency and that the check was due. It was said that this would be chased up. Records were seen for the testing and maintenance of the fire alarm and emergency lights together with fire drills within the home. An external company has Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 22 undertaken a fire risk assessment. Issues regarding staff training have been mentioned previously within this report. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 X 18 3 2 3 3 3 3 3 3 3 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 3 2 X 3 2 3 2 Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 24 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 OP30 Regulation 18(1)(c) Requirement The registered person shall ensure that at all times suitably qualified, competent and experienced persons are working at the care home. In that, ongoing training for care staff must be reviewed to ensure that courses have been appropriately updated. All necessary courses must be undertaken or booked by 01/01/07 Timescale for action 01/01/07 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 Refer to Standard OP9 Good Practice Recommendations It is recommended that staff should be provided with written guidelines for the administration of medication on a ‘when required’ basis. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 25 2 OP15 It is recommended that a review should be undertaken to confirm that the home provides residents with adequate fresh fruit and vegetables. It is recommended that the manager complete their stated intention to continue to refurbish those areas of the home that need it according to their maintenance plan. It is strongly recommended that the manager complete their stated intention to review the staff roster to ensure that all staff employed by the home are recorded together with their surnames and allocated tasks. It is recommended that, with regard to staff training, the manager complete their stated intention to: 1. Undertake a review, to ensure that the induction process and records are in line with ‘Skills for Care’ recommendations. 2. Develop a staff training matrix in order to fully evidence that appropriate course updates have been undertaken. 3 OP19 4 OP27 5 OP30 6 OP30 Now that NVQ training has been successfully completed, a wider range of training should be offered including mental health awareness/dementia training. In that, the manager said that they would look into the provision of more specialist courses for dementia and mental health. This recommendation has been repeated from the previous inspection dated 1st December 2005. 7 OP31 The manager should register to undertake NVQ level 4 in management and care to ensure she holds these qualifications by 2005. In that, since the last inspection, the manager has commenced the NVQ Registered Manager’s Award; it is strongly recommended that this course should be completed as soon as possible. This recommendation has been repeated from previous inspection dated 20th August 2003, 23rd December 2003, 8th December 2004, 2nd June 2005 and 1st December 2005. Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 26 8 9 OP33 OP36 It is recommended that written policies and procedures should provide evidence of regular reviews. It is strongly recommended that the home should introduce a formal recorded system of one-to-one staff supervision. It is strongly recommended that, although the home has a contract with an agency for gas safety checks, the manager should complete their stated intention to chase the check due in September 2006. 10 OP38 Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Beulah Lodge Rest Home DS0000023890.V316730.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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