Inspection on 04/01/06 for Bewick Lodge

This inspection was carried out on 4th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bewick Lodge 11/03/08

Bewick Lodge 15/01/07

Bewick Lodge 15/05/06

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 Unannounced Inspection 09:30 4th and 23 January 2006 rd 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.V258955.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. Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 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.V258955.R01.S.doc Version 5.0 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). 20th June 2005 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.V258955.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over two days. On the first day the Infection Control Nurse from the Health Protection Agency accompanied the Lead Inspector. That report will be sent to the home and the Commission for Social Care Inspection (CSCI) separately. Another Inspector from the same office assisted the Lead Inspector on the second day. His observations and report are incorporated into the main body of this report. The manager was not available on the first day of the inspection and following an initial inspection of the home it was decided to stop the inspection and discuss the issues found with the homes Regional Manager. Following discussions with her it was agreed that she would conduct a full audit of the home in regards to general housekeeping and cleanliness. Since the announced inspection in June 2005 an additional unannounced visit and two complaint visits have been made. The registered person has responded to all letters and other communications within timescales. On both days a tour of the building took place, records inspected, staff and one relative were spoken to. During the inspection process two complaints regarding the service were received and these are currently under investigation by the Company and CSCI. What the service does well: What has improved since the last inspection? There is now a registered manager of the home and he is endeavouring to put right the outstanding issues that have been problematic over a period of time. Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 Page 6 The contracts for residents for residents are now available and are being introduced. The problems with the admission documentation and care planning have been resolved and advice is now sought from other professionals to ensure residents assessed needs are met. Records about specialist diets and recording of resident’s food likes and dislikes have improved residents individual dietary needs. Improvements have taken place with medication recording so that audits are possible. Statutory training and some specialist training has taken place with records being available. Staff are now receiving regular supervision and appraisals have started. Recruitment and selection procedures are detailed and organised. Some repair and replacement of floorings and furniture has taken place. Fire risk assessments, fire and moving and handling training are now up to date. Several of the outstanding requirements from previous reports have been met. There was an improvement in all areas on the second inspection day in regards to general housekeeping, odour control and health and safety matters. What they could do better: The personal care of residents needs to improve to ensure all of their hygiene needs are met and their dignity maintained. The qualified nursing staff must ensure that the recordings of medications are clear and the controlled drug cupboard light needs to be repaired for safety reasons. Improvements about the recreation and leisure events need to be started so that all residents have their preferences and choices taken into account. The number of staff deployed at mealtimes needs to be reviewed to enable residents enjoy their meals in pleasant settings. Suitable numbers of domestic staff need to be employed over a seven day period to ensure the home is clean and hygienic at all times. Regular audit of the home are needed to ensure all fittings and fixtures are safe, clean and well maintained. Furniture, bedding and linen, which are soiled and torn, need to be regularly replaced as part of an ongoing programme. A planned refurbishment and decoration programme needs to be produced with records and timescales for completion kept. All staff must be supervised on a daily basis and they must follow infection control procedures at all times. Safe storage of clinical waste is needed and suitable hand washing facilities provided in all staff and resident areas. The provision of suitable bathing and showering facilities must be reviewed to ensure all residents’ needs are met. Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 Page 7 The manager needs to develop the staff team and the care provision within the home and implement a quality assurance programme. Training for staff to NVQ level 2 must continue to ensure all the residents care needs can be met. The home must consult with the Fire Officer regarding the use of suitable fire door closures as the practice of using chocks and small items of furniture to hold doors open is not supported and places people at risk. The in house maintenance records need to be completed as required and be dated and signed. Progress needs to continue to meet the requirements of this and previous inspection reports within the specified timescales. 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.V258955.R01.S.doc Version 5.0 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.V258955.R01.S.doc Version 5.0 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): 2,3. The Statement of Terms and Conditions (or contract) ensures the rights and obligations are clear for residents and the provider. The admission assessments ensure the residents needs can be met. EVIDENCE: Since the last inspection the home has produced terms and conditions of residency for those residents who are self funding. Residents who are funded by the local authority are provided with contracts. The care plans show evidence that admission care plans are produced by care managers and the senior staff carries out admission assessments. These documents form the basis of the care planning for residents living in the home. Bewick Lodge DS0000000419.V258955.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. The care planning systems provide staff with the information they need to meet residents’ needs. The health needs of residents are compromised by the lack of support given in regard to personal care. The policies and procedures for the safe administration of medicines are not being followed placing residents at risk of harm. EVIDENCE: Each resident has a plan of care that is based on a recognised nursing model, which covers all aspects of daily living. The care plans inspected showed that risk assessments for dependency, moving and handling, falls, continence, mental health status, nutrition, pressure sores (Waterlow scoring) and use of bedrails were available. The home manager has recently audited the care plans and any deficiency highlighted. They were up to date, regularly reviewed and signed by the author. All residents have access to all NHS facilities. There was evidence of advice being sought from specialists regarding pressure sore care, continence care and nutrition. Residents likes and dislikes regarding food preferences are recorded which enables their dietary care needs to be met. Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 Page 11 Several of the residents had not had their haircut for some time, food debris was left on their faces and clothing and fingernails were long and grimy. The staff are able to deal with residents who exhibit challenging behaviours evidence is available to show that appropriate referrals are made to psychiatrists when necessary. The home has policies and procedures in place for staff to follow to ensure the safe administration of medicines. A random audit of the Controlled Drugs was satisfactory. There were gaps in recording on the Medicine Administration Records and not all handwritten directions had two signatures. Record of all medicines received, returned, or disposed of are now maintained. The treatment room was generally untidy and disorganised with many items out of date. The Controlled Drug cupboard warning light still has not been repaired. The home is currently supplying suitable identification for the Medicine Administration Records. Bewick Lodge DS0000000419.V258955.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): 12,15 Social activities are not organised and do not provide stimulation and interest for the residents who live in the home. The home provides a varied four weekly menu. Improvements to the service are needed to ensure residents are able to exercise choice and control over what they eat. EVIDENCE: Since the last inspection the home has been without a designated activities organiser. This has had an effect on the social and recreational needs of residents within the home. Previously all activities undertaken were recorded and specified if they enjoyed it or otherwise. There is currently little evidence to support that planned activities take place on a daily basis either on individual or group basis. On both days of the inspection residents were seen to be sitting watching television or wandering aimlessly around the home. The qualified and care staff were focusing on the complex mental health care needs of residents and caring for those who were very poorly. The home has a four weekly menu, which offers choices and variety for each meal. Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 Page 13 The home has a dining room on each floor. Downstairs the dining room is adjacent to the kitchen and upstairs there is a kitchenette adjacent to the dining room. Both inspectors observed the lunchtime meal, which was of ample portion size, hot and nicely presented. In one dining room it was observed that residents had a long wait to be served, residents’ chairs not pushed fully into tables, causing needless stretching and food spillage. In place of napkins plastic aprons were used. These were loosely tied, allowing food to drop beneath apron onto clothing. Residents were not offered a choice for dessert. Residents who needed assistance with their meal were assisted in episodes, with carers attending to other things in between (one carer sat to feed, one stood). There was no one supervising or checking what residents were eating. The dining room tables downstairs were set with tablecloths and cutlery. The dining tables upstairs had no tablecloths, cutlery, or condiments provided prior to the meal being served. Again residents were assisted with their meals in episodes, the meal presentation for two residents was poor. The meal was served in a dessert dish and presented to the resident who did not come to the table for the meal. Another resident was assisted with the meal sitting in a semi prone position, which made eating and drinking difficult. The upstairs unit had six residents who need full assistance with eating and drinking and others who need supervision to ensure they are eating and drinking enough. Again there was no one actually supervising the dining room or checking what residents were eating. The staff had a nice approach with gentle prompting to eat, offering assistance in a quiet manner and ensuring the mealtime was unhurried. The main kitchen is shared with the adjoining home. This was found to be clean and well organised. Appropriate food and fridge temperatures are recorded, menu choices are kept for four to five months, menus are displayed and there are lists of special diets and of individuals’ preferences for portion size. The cook displayed a good knowledge of nutritional ‘build-up’ diets. Bewick Lodge DS0000000419.V258955.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): 16,18 The complaints policies are comprehensive with some evidence now available that views are listened to and acted upon. Staff have knowledge and understanding of Adult Protection issues, which protects service uses from risk of abuse. EVIDENCE: The home has comprehensive policies and procedures in place, which give details of how and to whom to complain should a resident or their representative wish to do so. On the first inspection day the complaints records could not be located as the manager was not available. On subsequent visits to was established that not all concerns and complaints were being accurately recorded and actioned within a 28-day timescale. On the last inspection day the recording systems had been reviewed and appropriate documentation was in place. The home has had four complaints referred to the Commission for Social Care Inspection since the last inspection .Two of these complaints are currently being investigated. The home has policies and procedures in place for staff to follow regarding Protection of Vulnerable Adults. Since the last inspection there is evidence that Abuse training for staff has commenced with records kept. Bewick Lodge DS0000000419.V258955.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): 19,2021,22,24, 26. There is now some investment in the home, which is improving the environment for residents living there. There are a number of outstanding requirements, which have the potential to place residents at risk. There are infection control and health and safety issues, which place residents’ staff and visitors at risk of harm. EVIDENCE: The home is purpose built over two floors and set in extensive well-maintained gardens which residents came only access when supervised by staff. There is no provision of a safe secure area for residents who have mental health problems to freely access. On the first inspection day the home was generally untidy, smelly and disorganised. Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 Page 16 The lounges and dining rooms on both floors were pleasantly furnished and decorated. The flooring in the upstairs communal areas has been replaced since the last inspection. There is general damage to paintwork and doors in the corridors and the carpets were dirty and stained. All of the radiators were generally dusty, dirty and stained with old food debris and liquid spillage. The plastic on the radiator guards was missing in places and the guards were dirty. There are bathrooms and toilets close to all communal areas and bedrooms with eighteen bedrooms having an en-suite facility. There are no disabled showering facilities in the home. Bathroom 2A houses a domestic style bath, which cannot be used, by the residents and this room is used for storage. Bathroom 5A the enamel has been scraped off the bath by the assisted bath chair. Other bathrooms and toilet floorings were showing signs of wear and tear, although there was evidence that some refurbishment had taken place. An inspection of the bedrooms on the first day found that many of the carpets were stained, mattresses were ripped and stained with body fluids, and bedding was of poor quality and the furniture dirty and stained. Several of the bedrooms and en-suite were smelly and dirty. The bedrails and protective bumpers were dirty and marked with body fluids. The sluices were dirty, with the sluice hopper and bedpans stained with body fluids. In one sluice there was only a bag provided for the clinical waste and in other areas the bins were not foot operated. There was evidence that it was everyday practice to use “communal continence knickers, socks, tights and Sudocrem. As the manager was unavailable to discuss the problems the Regional Manager was requested to visit the home. The problems about the environment and concerns about infection control were discussed with her and it was agreed that an internal audit would take place and the issues identified addressed. It was agreed that the inspection would be aborted and would be completed at a later date. The Infection Control Nurse from the Health Protection Agency will write her report based on the evidence found on the first inspection day. A return unannounced visit to complete the inspection was completed nineteen days later. Many of the problems regarding the cleanliness of the home had been resolved and a refurbishment and replacement programme had been put in place. New bedding and furniture has been ordered and the home was generally cleaner and odour free. The manager confirmed that furniture and bedding was being replaced and a cleaning schedule had been started. Both sluices were clean and the practice of using communal clothing and creams had stopped. The mattresses that were stained had been replaced and bedrooms were fresher and tidy. Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 Page 17 On the second inspection day the following was found: Emergency call cords do not reach skirting level nor are easy to clean. All light cords are neither easily accessible nor easy to clean. Radiator guards remain dirty, with plastic missing. The paintwork on doors and skirting boards are damaged. Bedroom furniture is marked with some drawers in dressing tables being ill fitting and broken. Several of the bedrooms have an odour problem. Clinical wastes are not disposed of securely nor are all bins foot operated. Liquid soap and paper towels are not readily available in all resident areas. There is no suitable shelving to store commode pots in the sluices. Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The staffing levels are adequate, however the deployment of staff at meal times is not sufficient to meet the needs of the residents. The lack of designated domestic staff could have a detrimental effect on residents care needs. The standard of recruitment and selection is satisfactory and protects resident from harm. Further training is needed to ensure all residents assessed and specialist needs are met. EVIDENCE: The home always has a First Level Registered Mental Nurse on duty throughout a twenty-four hour period. The home is staffed as follows: 2 Registered Mental Nurses 8am to 8pm 1 Registered Mental Nurse 8pm to 8am 4 care staff 8am to 8pm 3 care staff 8pm to 8am There are laundry, domestic, administrative and maintenance staff employed. There have been difficulties with recruitment of domestic staff. There have been numerous occasions when there has been only one domestic on duty for the whole home. This has caused problems with the general housekeeping in the home. Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 Page 19 The activities organiser has been off sick for some time and this also has had an impact on the daily lives of the residents. The manager confirmed that recruitment had been successful and an organiser was due to start later in the month. All of the kitchen staff are shared with the adjoining home. The NVQ level 2 training is currently on hold. There are two staff with NVQ level 3 and 2 staff with NVQ level 2. 50 of care staff do not hold this qualification. A sample of staff files showed that the recruitment and selection procedures are being followed. There was evidence of two references, Criminal Record Bureau checks, medical clearance, terms and conditions of employment and proof of identity. Since the last inspection the training files have been reviewed and brought up to date. There is evidence that the staff have completed training in Food Hygiene, Moving and Handling, Fire Prevention, First Aid and a qualified nurse is the Infection Control liaison. Training for wound care has been sourced and booked. Staff training for the Protection of Vulnerable Adults has started. Evidence of other training for staff includes Dementia Care, Palliative Care, Customer Care and Drug Awareness. Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 The manager needs to produce a clear development plan for the home, which can be effectively communicated to the residents, staff and all other interested parties. The systems for consultation and quality monitoring are poor with little evidence to support the resident and representative views are sought or acted upon. 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. 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 Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 Page 21 residents with mental health problems. He has completed the Registered Manager’s Award and is awaiting verification. The manager is relatively new in post and is endeavouring to address the outstanding issues in the home and build a supportive team. There is no effective quality assurance or quality monitoring systems in the home. The views of residents and their representatives have not been sought through satisfaction questionnaires or from discussion. Relatives and resident meetings are not regularly held. Residents’ personal allowances are held in a central non-interest 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 cross references receipts and regularly audits the accounts. Supervision and appraisal of staff takes place with suitable records kept. The staff have received training in safe working practices including moving and handling and fire training. The fire risk assessment has been updated for the current year. Risk assessments for the use of bedrails are available in residents care plans. Accident recording are up to date and detailed with monthly analysis carried out. The in house maintenance records were available although the weekly checks were not up to date. Contract maintenance certificates were available and up to date. Many of the bedroom doors were held open with wooden chocks and small items of furniture. Bewick Lodge DS0000000419.V258955.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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 2 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 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 3 X 2 Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 Page 23 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 OP8 Regulation 12,13, Requirement The home must ensure that staff maintains the personal and oral hygiene of each resident with records kept. The Controlled Drug cupboard warning light requires repair. Handwritten directions on the Medicine Administration Records (MAR) require two witness signatures. All residents require suitable identification on the MAR Sheets. TIMESCALE 20/06/05 NOT MET. The home 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. The home must ensure that meals are taken in a congenial DS0000000419.V258955.R01.S.doc Timescale for action 30/04/06 2. OP9 13 30/04/06 3. OP12 12,14,15, 16 30/04/06 4. OP15 15,16 30/04/06 Bewick Lodge Version 5.0 Page 24 5. OP19 23 6. OP20 23 7. OP21 23 8. OP21 23 9. OP22 23 10. OP24 23 11. OP24 16,23 setting and at flexible times as may reasonably be required by the residents. The premises must be kept in sound construction and in a good state of repair internally. A programme of maintenance and renewal of the fabric and decoration of the home must be produced and implemented with records kept. The home must repair and repaint damaged paintwork on doors and skirting boards and clean all radiators and radiator guards and replace plastic on the guards. TIMESCALE 01/12/05 NOT MET. The bathroom, toilet and ensuite floorings require replacement via a refurbishment programme. TIMESCALE 05/06/05 NOT MET. The home must ensure that the bath is repaired in bathroom 5. The flooring in bedroom 38A ensuite, toilet 13A and 8A require replacing. The home must provide sufficient aids, hoists, assisted toilets bathing and showering facilities as may be required to meet the assessed needs of individual residents. The home must ensure that broken ill fitting bedroom furniture is replaced. TIMESCALE 01/12/06 NOT MET. The home 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 DS0000000419.V258955.R01.S.doc 30/04/06 30/09/06 31/03/06 01/05/06 30/09/06 01/08/06 01/08/06 Bewick Lodge Version 5.0 Page 25 12. OP26 13,23 13. OP27 18 14. OP28 18 15. OP33 24 residents receiving nursing care. The home must ensure that the staff follow the policies and procedures for the control of infection including the safe handling and disposal of clinical waste. Suitable foot operated waste bins must be provided. A secure clinical waste storage area must be provided Liquid soap and paper towels must be available in sluices, treatment room and residents bedrooms. The commode shelving must be replaced. The sluices must be cleaned on a regular basis. The light cords must be sheathed to enable daily cleaning and be accessible. The bed rail protectors require regular cleaning. The home must implement a cleaning schedule and audit all areas on a regular basis. TIMESCALE 01/09/05 NOT MET. The home must ensure that the deployment of care staff at mealtimes is appropriate to meet residents’ needs. The home must ensure there are sufficient domestic on duty to maintain the home in a clean and hygienic state, free from dirt and offensive odours. The home must progress with NVQ level 2 or equivalent training to ensure 50 of care staff are trained to meet residents needs. The home must establish and maintain a system for reviewing and improving the quality of care including the quality nursing care with records kept. DS0000000419.V258955.R01.S.doc 30/04/06 30/04/06 30/09/06 30/06/06 Bewick Lodge Version 5.0 Page 26 16. OP35 20 17. OP38 12,13,23 All residents’ personal finances must be banked individually, so that interests to their accounts can be accrued. TIMESCALE 01/04/04 NOT MET The emergency call cords must reach skirting level. Advice must be sought from the Fire Officer regarding the use of door closures. All maintenance records require signing and are updated. TIMESCALE 01/09/05 NOT MET. 31/03/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations The home should provide a safe; secure garden area for residents to freely use. Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Bewick Lodge DS0000000419.V258955.R01.S.doc Version 5.0 Page 28 - 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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