Inspection on 15/05/06 for Bewick Lodge

This inspection was carried out on 15th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Bewick Lodge 11/03/08

Bewick Lodge 15/01/07

Bewick Lodge 04/01/06

Bewick Lodge 20/06/05

Bewick Lodge 12/10/04

Bewick Lodge 15/06/04

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

CARE HOMES FOR OLDER PEOPLE Bewick Lodge Waverly Crescent Lemington Newcastle Upon Tyne Tyne & Wear NE15 8AN Lead Inspector Mrs Irene Bowater Key Unannounced Inspection 15th May 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bewick Lodge Address Waverly Crescent Lemington Newcastle Upon Tyne Tyne & Wear NE15 8AN 0191 264 7267 0191 264 7296 bewick@fshc.co.uk 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) Bewick Waverley Ltd Mr Anthony William Kavanagh Care Home 45 Category(ies) of Dementia - over 65 years of age (45) registration, with number of places Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 8 beds can be used for service users who do not require nursing care, category DE(E). 4th January 2006 Date of last inspection Brief Description of the Service: Bewick Lodge is a 45-bedded care home with nursing providing care for older people with enduring mental health problems. The home is purpose built and is physically attached to another home on the same site. The home is set in large landscaped gardens, close to local amenities and has good local transport links. The home has 45 single bedrooms 18 of which have en-suite facilities. There are two floors with lounges and dining rooms on each floor. There are sufficient bathing and toilet facilities in all areas. Stairs and a passenger lift access the first floor. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over eight hours and was carried out by two inspectors. Letters and other correspondence in relation to the two previous complaints are available at the CSCI office. The Company have responded to all of the issues raised and continue to work with CSCI and other agencies. Over the course of the day a tour of the premises took place and residents, relatives and staff were spoken to. Care records and other home records were also inspected. Surveys of residents were also carried out. What the service does well: What has improved since the last inspection? Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 6 The home continues to make improvements to the environment and care since the last inspection. There is evidence that redecoration and replacement of furniture carpets and bedding is taking place. Surveys also included comments that general improvements are being made in the home. There are now enough domestic staff employed over a seven-day period. There is a marked difference in the cleanliness and freshness in the home. The requirements from the previous inspections are being met and an improvement and refurbishment plan with completion dates has been provided to the Commission. The staff continue to work with specialist nurses and other agencies to improve the care for the residents. The staff now make sure that the residents personal care and dignity is maintained at all times. Surveys also included comments that general improvements are being made in the home. What they could do better: The admission and care planning records need further work so that they are clear and detailed about the care provided. The care plans need to show how the staff deal with challenging behaviours and individual residents mental and general health needs. Improvements are needed to the medicine records. The recruitment of an activities organiser is necessary to improve the quality of live for residents living in the home. Some resident’s said that they were unhappy about the practice of staff putting plastic aprons onto all of the residents at mealtimes. Comments included; ‘I don’t know why I’m wearing this. I am not a baby’ ‘They just put these on.’ The inspector asked for a napkin and was provided with one. The carer was asked to offer resident’s napkins and these were used by the residents to maintain their dignity. The staff daily practices at meal times need to be reviewed. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 7 The refurbishment and redecoration programme needs to continue within the timescales agreed. The provision of suitable bathing and showering facilities need reviewing to make sure residents needs are met. NVQ level 2 training and supervision needs to restart so that they can continue to improve the lives of residents in the home. The registered manager needs to develop the staff team and start a quality assurance programme. The maintenance records need to be completed and signed. The registered manager needs to contact the fire officer about using door wedges and furniture to keep bedroom doors open. 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. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 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 Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (6 is not applicable) The quality in this outcome is poor. This judgement has been made using evidence including a visit to this service. Assessments of residents needs are not consistently completed and so this potentially puts residents at risk of not having their needs identified and met. EVIDENCE: Six resident’s assessments were examined and there was an inconsistent approach to completing assessments before and on admission. Gaps were found in the sample in relation to health and social care needs. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 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 The quality in this outcome is poor. This judgement has been made using available evidence including a visit to the service. An inconsistent approach to care planning does not ensure that service users personal and health care needs are met which may place them at risk. The procedures for the safe administration of medicines are not being followed placing residents at risk. Residents do not always feel that they are treated with respect and so this may potentially affect their well-being. The specialist training of staff will ensure that residents at the time of their death receive appropriate care and attention. EVIDENCE: A sample of six care plans indicated an inconsistent approach. Assessments of peoples needs such as their physical, psychological, spiritual and social needs are not consistently completed. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 11 Resident A who had been admitted in April had not had a full assessment completed which included oral health, sensory needs, observations and admission, medical and psychological history, diet, falls, recreation, social history, cultural, spiritual and personal routines and habits. Resident B who was admitted in March 2006 did not have a care plan written until the middle of April 2006.The assessments and risk assessments at this time were still incomplete and the Nutrition assessment and the Mini Mental Status were not completed at all. Resident C who is registered blind, with poor appetite, low weight and is restless had no care plans written. This resident did not have any nursing observations taken on admission. Risk assessments were inconsistently identified and evaluated. Resident D pressure sore assessment indicated high risk but that person had no care plan identified. Resident E had their last monthly risk assessment evaluated in March. This resident had also not had their mental health assessment since 2004. The manager expected this mental test score to be completed three to six months or sooner. Care plans are sometimes all the same and photocopied with the persons name inserted. The care plans did not show that consultation with the resident or their representative takes place nor record the persons own preferences and choices of how their needs are to be met. The daily records were detailed and useful. All residents are able to use NHS facilities. There is evidence that advice is being sought from specialists regarding pressure sore care, continence care and nutrition. The staff are using “doll therapy” in the home with good results. The care plans and effects of this therapy are not detailed in the care plan. The home has procedures in place to make sure that the staff administer medicines safely. The medicine administration records showed no gaps in recording. The records are now being written out in full. The hand written directions still need two signatures to reduce the possibility of mistakes. The medicine administration records still need to have suitable identification of residents to reduce the possibility of mistakes. The treatment room has been tidied and the Controlled Drug warning light is now working. A random audit of the Controlled Drugs was satisfactory. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 12 The medicine administration round took a considerable time in the morning starting at 10.00am and not finishing until 11.30am. The lunchtime round was to start a 2.00pm and a discussion with the nurse and the manager took place about the appropriateness of the medication times and the intervals of medicine administration. Observations and views shared on the day of the inspection indicated that resident’s privacy is respected. Care was provided behind closed doors. Residents have access to a public telephone and can have their own phone in their bedrooms. Arrangements in the laundry indicate that people wear their own clothes at all times. The staff practice of putting plastic aprons on all of the residents at mealtimes does not respect people’s dignity as some residents object and one person said he was not a baby. Since the last inspection a member of staff has started a Palliative care course. There was evidence that residents who were very poorly were receiving a good level of personal and health care. Their needs were being met in a sensitive and dignified manner. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13,14,15 The quality in this outcome is poor. This judgement has been made using available evidence including a visit to the home. Social activities do not provide stimulation and interest for residents living in the home. Support from relatives and representatives provide residents with opportunities to maintain their previous lifestyles. Residents are not fully supported to make choices and take control over their lives. Meals are nutritious and varied and offer a healthy and varied diet for residents. EVIDENCE: The home has been without an activities co-ordinator for some time. One of the carers is helping with activities. However on the day of the inspection there were no structured activities. Resident’s were observed to spend long periods of time sitting in their chairs and asleep. Carers were observed to sit with people in the lounge. The televisions in both lounges were on all day with little interest in the programmes. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 14 One service user who is a Roman Catholic has not had the opportunity to meet with a priest. Some of the residents said they enjoyed sing a longs. The manager agreed that there was a lack of activities and stimuli. Visitors are able to come and go and were positive about the care home and felt welcome when they visit. Service users are able to manager their own finances for as long as possible. People are able to bring their own possessions with them from home such as furnishings and keep sakes. There is little evidence of service users actively making choices in the home. As mentioned previously some people objected to plastic aprons being placed on them at mealtimes. Personal preferences are not recorded in care plans. Upon arrival at 9.30am the inspectors observed residents sat wearing plastic aprons waiting for breakfast. The tables were bare with no cutlery, tablecloth or condiments. Breakfast consisted of a choice of cereal, toast, cooked breakfast tea and coffee. People said that they had enjoyed their meal. The food was presented well. The inspector shared lunch with the residents. At lunchtime the table cloths and menus had been placed on the tables. This looked more homely. Cutlery and condiments were not in use. Lunch consisted of mince and onion pie, vegetables and potato. The alternative was omelette. Residents were encouraged to eat by the care staff. Alternatives such as sandwiches and bananas were given to people who did not want the other choices. Staff were attentive and gentle with residents. The nurse on duty was not present throughout the lunchtime meal. The staff said that should residents not eat well at meal times that they would inform the nurse for them to take action. The staff had an understanding of the residents individual dietary needs. One resident has breakfast porridge fortified with full fat cream and milk. Drinks, fruit and snacks are freely available and given throughout the day. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 The quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the service. The complaints procedures are comprehensive with evidence that residents and representatives’ views are listened to and acted upon. The Adult Protection procedures ensure residents are protected from harm. EVIDENCE: Since the last inspection the complaints records are fully completed. From December 2005 to February 2006 the Commission has investigated two complaints. An action plan about how the home is going to improve has been received and there is evidence from this inspection that improvements continue to be made. A relative indicated that they knew who to complain to if they were unhappy. The relative felt confident in the care staff in the home. The records show that in house Adult Protection training for staff has taken place with records kept. The registered manger confirmed that external training is being sourced to make sure that all training matched the Local Authority guidance. The staff knew what to do should there be any suspicion of abuse taking place. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, 26 The quality in this outcome is poor. This judgement has been made using available evidence including a visit to the home. The lack of a safe outside area restricts residents’ freedom of movement outside of the home. There has been some investment in the home, which will improve the conditions for the people who live there. There are still some outstanding requirements that have the potential to place residents at risk. EVIDENCE: The home is purpose built over two floors and it is set in extensive wellmaintained gardens which residents can only access when supervised by staff. There is no free access to a safe, secure area for residents who have mental health problems. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 17 There have been many improvements to the home since the last inspection. The registered persons have produced an action plan, which details the redecoration and refurbishment of the home within set timescales. On the day of inspection all of the residents were living on the ground floor whilst the upstairs corridors, lounges and dining rooms were being redecorated. The registered manager confirmed that when the redecoration upstairs was completed the residents would be moving up stairs so that the downstairs corridors and lounges could be redecorated. It was confirmed that the residents and their representatives had been consulted about the move and refurbishment programme. The dining room and reception area downstairs have been redecorated to a good standard. The refurbishment programme shows that carpets, bedding, furniture, curtains are being replaced. The radiator covers are being replaced on a monthly basis and those still with plastic guards are now clean and free from debris. There are bathrooms and toilets close to all communal areas and bedrooms. Eighteen of the bedrooms have en-suite hand washbasin and toilet. There are three bathrooms on each floor only one bathroom on each floor has an adapted bath that can be used by the residents. There are no showering facilities in the home. The bath seats and rubber non-slip bath mats were generally grimy mouldy. A random inspection of the bedrooms found that improvements continue to be made. The bedrooms are clean and there is evidence of a redecoration programme. The new furniture and bedding make the rooms look homely in style. The new wardrobes are not yet fixed to the wall to prevent any toppling accidents. One identified bedroom had a strong odour and the flooring in the en-suite remains marked and stained. The sluices were tidy and generally clean. The shelving that was removed at the last inspection from the downstairs sluice has not been replaced. The sluices were locked and the disinfector was working. Liquid soap and paper towels are available in resident areas although this is not provided in all resident’s bedrooms. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 18 A cleaning schedule and fresher. is now in place and all areas of the home are cleaner Since the last inspection the clinical waste is securely stored outside the building. The laundry is separate from resident areas was clean and free from odours. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The lack of a consistent, fully trained staff team has had a detrimental impact on the quality of care provision in the home. Improvements taking place with staff records will ensure residents are protected from harm. EVIDENCE: The home always has a first level registered mental nurse on duty throughout a twenty-four hour period. Given the current occupancy the home is staffed as follows: 1 Registered Nurse 8am to 8pm 4 care staff 8am to 8pm 3 care staff 8pm to 8am to 8am Since the last inspection there have been improvements in the employment levels of domestic and laundry staff. There are now adequate staff employed over a 7-day period. The home has been without an activities co-ordinator for some time and one the carers is helping with activities. This has had an impact on the quality and daily lives of the residents who live in the home. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 20 All of the kitchen staff are shared with the adjoining home. Four staff have NVQ level 2 and three staff have NVQ level 3. Only 22 of care staff currently holds this qualification. Six staff files showed that staff have Criminal Record Bureau checks, proof of identification, contracts, application forms completed and induction records. Two of the files did not have two references available. The registered manager is addressing this. There is evidence in the staff files that all staff have induction and training records. The training records show that staff have received training in care planning, Dementia Care, Challenging Behaviour, Health and Safety, Administration of Medicines, Control of Infection, Pressure sore care, and a nominated qualified nurse has started a Palliative Care course. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 The quality in this outcome is poor. This judgement has been made using available evidence including a visit to the home. Without strong leadership, guidance and direction to staff there is no guarantee that the residents will receive consistent quality care. The systems for consultation and quality monitoring are being developed and introduced. Further improvements in the residents personal accounts are needed to ensure all their best interests are protected. There are health and safety practices, which pose potential risks to residents, staff and visitors. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 22 EVIDENCE: The Registered Manager has been in post since June 2005.He is a first level registered Mental nurse with previous experience of working with older residents with mental health problems. He has completed the Registered Managers Award. He is aware of the many concerns in the home and is trying to address the issues and build a supportive team. Monthly visits and reports from the Company’s representative are completed. The new manager has held resident and relative meetings to consult with residents’ and their representatives. The last organised meeting was cancelled due to poor attendance. A formal system of quality control is being introduced in the home. There is a central non-interest bearing account for dealing with residents’ personal allowances. Residents’ personal allowances are held in a central noninterest bearing account. The Company is planning to change the systems to enable residents accrue interest on their own money, however this has not occurred to date. The home maintains detailed records of all transactions with cross-referenced receipts. Not all of the transcriptions have two signatures. According to the manager formal supervision for staff is occurring but records were not available. This standard will be monitored at the next inspection. All utility contracts were available and up to date. The homes electrical wiring certificate was not available for inspection and the manager agreed for a copy to be sent to CSCI as Head Office had the document. Monthly fire safety checks of the emergency lighting and fire fighting equipment were not recorded but servicing certificates were inn place. Staff have not received fire instruction and drills at the appropriate intervals. An immediate requirement was issued to the home to ensure that night staff are trained by 22 May 2006. A response was received from the Regional Director on the 17 May 2006 to confirm that the staff received the training on the 15 May 2006. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 23 Accident recording and reporting is in place with detailed monthly reviews taking place to try to reduce further risks to the residents. Training in safe working practices is now taking place and the home has a Moving and Handling trainer and a Fire Warden is to be trained in May 2006. It was observed that bedroom doors are held open with wooden chocks and small items of furniture. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 2 X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 X X 2 Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement Timescale for action 01/07/06 2 OP7 12,13,15 3. OP8 12,13, The registered persons must ensure that all residents have comprehensive assessments completed before and at the time of admission to the home. The registered persons must 01/07/06 ensure that all residents care plans sets out the detail the action, which need to be taken to ensure that all aspects of the health, personal and social care needs, are met. The care plans must be reviewed at least once a month, updated to reflect changing needs and current objectives for health and personal care and actioned. 01/07/06 The registered persons must ensure that the staff psychological health is monitored regularly and preventative care provided. The individual health care needs of residents’ must be reviewed actioned and recorded. Nursing observations must be recorded and risk assessments completed at least monthly. Timescale of 30/04/06 not met. DS0000000419.V289550.R01.S.doc Version 5.1 Bewick Lodge Page 26 4. OP9 13 5. OP12 12,14,15, 16 6. OP14 12,15,16 7. OP19 23 8. OP20 23 9. OP21 23 The registered persons must ensure that handwritten directions on the Medicine Administration Records (MAR) have two witness signatures. All residents require suitable identification on the MAR Sheets. Timescale of 20/06/05 and 30/04/06 not met. The registered persons must ensure that residents are given the opportunity for stimulation through leisure and recreational activity both within and outside the home, which suits their needs, preferences and capacities. Up to date information must be circulated to residents in formats, which suit their capacities, and all activities must be recorded. Timescale of 30/04/06 not met. The registered persons must ensure that as so far as practicable enable residents to make decisions with respect to they are to receive and take their wishes and feelings into account. The registered persons must ensure that the premises are kept in sound construction and in a good state of repair internally. The registered persons must repair and repaint damaged paintwork on doors and skirting boards and clean all radiators and radiator guards and replace the plastic on the guards. Timescale 01/12/05 not met. The registered persons must ensure that there are suitable bathing and showering facilities provided to meet the assessed needs of the residents. There must be a ratio of 1:8 assisted DS0000000419.V289550.R01.S.doc 01/07/06 01/07/06 01/07/06 01/10/06 30/09/06 31/10/06 Bewick Lodge Version 5.1 Page 27 10. OP21 23 11. OP21 23 12. OP24 16,23 13. OP26 13,23 14. OP26 13,23 15. OP28 18 16. 17. OP29 OP30 2,9,19 12,18 baths/showers available. Timescale of 01/05/06 not met. The registered persons must ensure that the bathroom, toilet and en-suite floorings are replaced via the refurbishment programme. Timescale of 05/06/05 not met. The registered persons must ensure that the flooring in bedroom 38A en suite, toilet 13A and 8 A are replaced as a matter of urgency. Timescale of 01/05/06 not met. The registered persons must ensure that in rooms occupied by residents’ suitable bedding, furniture, curtains and floor coverings are provided. There must be suitable adjustable beds provided for residents receiving nursing care. The registered persons must ensure that liquid soap and paper towels are available in residents’ bedrooms. The commode shelving must be replaced in the downstairs sluice. Timescale of 01/09/05 and 30/04/06 not met. The registered persons must ensure that the adapted bath seat is cleaned after use and the plastic non-slip mats are replaced. The registered persons must ensure staff progress with NVQ level 2 or equivalent training to ensure 50 of care staff are trained to meet residents needs. The registered persons must ensure that all staff have two written references. The registered persons must ensure that all staff have DS0000000419.V289550.R01.S.doc 31/10/06 31/10/06 01/08/06 01/07/06 30/06/06 30/09/06 01/07/06 01/10/06 Page 28 Bewick Lodge Version 5.1 18. OP31 9 19. OP33 24 20. OP35 12,20 21. OP38 13,23 ongoing training in safe working practices and specialist-training toe meet the residents assessed needs. The registered person must ensure that there are clear lines of accountability internally and externally and the care home is conducted as to promote the health and welfare of residents. The registered persons must establish and maintain a system for reviewing and improving the quality of care including the quality nursing care with records kept. The registered persons must ensure that residents personal allowances have interest accrued to their accounts. Timescale of 01/04/04 not met. The registered persons must ensure that advice is sought from the Fire Officer regarding the use of door closures. Maintenance checks must be recorded and statutory training be brought up to date. The new wardrobes must be fixed to bedroom walls to prevent toppling accidents. 01/07/06 30/06/06 30/06/06 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations The home should provide a safe; secure garden area for residents to freely use. Bewick Lodge DS0000000419.V289550.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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