Care Home: Beech Lodge Nursing & Residential Home

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What the care home does well The management and staff make the residents` visitors and relatives welcome, and there are frequent visitors to the home. Visitors said that the home has a very homely and welcoming feel to it. Health care awareness was evident, with the importance of any changes in health status and mental health, being continually monitored by appropriately trained, caring and diligent staff. Staff demonstrated great respect for residents, and residents were addressed in an appropriate manner. Discussions with staff were positive, and showed a clear determination that they belong to a committed team. Residents and visitors spoken with were very positive about the care that they and their relatives were receiving. There were also residents who were unable to communicate, the inspector noted that they appeared well cared for, and were happy in their surroundings. The home was clean, warm and comfortable. What has improved since the last inspection? A review of residents` care plans has resulted in them being more comprehensive and standardised. This makes them easier to read. More staff had been trained in regard to palliative care, and Dementia Awareness. A monthly exercise class has been added to the existing activities for residents. An ongoing programme of redecoration has continued at the home, with 6 bedrooms redecorated and carpeted in the past year, new chairs and new bedroom furniture have been purchased, and 6 windows have been replaced. The main lounge and the dining area have had new flooring and or carpeting, and work has started in regard to the replacement of tiles in the kitchen. 3 care staff had recently attained their NVQ level 2 awards, 5 care staff had enrolled on the NVQ level 2/level 3 awards. Domestic and Kitchen staff had completed their NVQ level 1 award, and are nearing completion of NVQ level 2. What the care home could do better: Care staff should receive regular supervision. Staff should receive update training in regard to the Protection of Vulnerable Adults (POVA) Due to the introduction of the Mental Capacity Act 2005, the care manager needs to look at staff`s awareness of the Act, the impact of the Act upon the service provided, and the use of Independent Mental Capacity Advocates where appropriate for residents. The variety and amount of activities offered to residents should be increased, and consideration given to the usage of the quiet lounge for this purpose. CARE HOMES FOR OLDER PEOPLE Beech Lodge Nursing & Residential Home Rakeway Road Cheadle Stoke-on-trent Staffordshire ST10 1RA Lead Inspector Pam Grace Unannounced Inspection 4th February 2008 13:00 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 Beech Lodge Nursing & Residential Home DS0000026939.V355717.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. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Lodge Nursing & Residential Home Address Rakeway Road Cheadle Stoke-on-trent Staffordshire ST10 1RA 01538 753676 F/P 01538 755054 blnh_676@yahoo.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) Minehome Limited Mrs Caroline Whiitaker Care Home 31 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (31), of places Physical disability (1), Physical disability over 65 years of age (31) Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. PD minimum age 60 years Date of last inspection 26th June 2006 Brief Description of the Service: Beech Lodge Nursing Home is situated in a rural location close to the market town of Cheadle in the Leek Moorlands area. The home is a 31-bedded establishment providing personal and nursing care to frail elderly persons over the age of 65 years and younger physically disabled persons over the age of 60 years. There is an adequate skill mix of staff including first level trained nurses and trained care staff, ancillary staff, administrative support and a handyman. The home provides links with specialist health care professionals including General Practitioners, district nurses, dentist, chiropodist, optician etc. Service users are accommodated in ground floor rooms (mainly single). A limited number of double rooms and en suite rooms are available. The establishment offers two lounges and a dining room for the benefit of service users. There are designated areas for smokers away from the main communal areas. The home can be accessed via private transport and has car-parking facilities at the front and another car park located next to the laundry building. It can also be accessed by bus and the train station is located in the nearby town of Cheadle. Staff organise a programme of activities, trips out and in-house entertainment for the benefit of the service users. Links with the community are encouraged and service users participate in local events. The home has a Statement of Purpose and Service User Guide which has been updated for the attention of prospective service users and their families. Visits to the home are welcome prior to admission. On 12/05/06 information from the care manager identified that the fees for the service ranged from £412 to £466 and additional charges were made for: hairdressing, escort to the hospital and newspapers and toiletries. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was undertaken by one inspector, over a period of approximately 8 hours. The Registered Care Manager Ms Caroline Whittaker RGN assisted the inspector throughout the inspection. The inspection had been planned with information gathered from the Commission for Social Care Inspection (CSCI) database, and the Annual Quality Assurance Assessment (AQAA) document that had been completed by the care manager. The key National Minimum Standards for Older People were identified for this inspection and the methods in which the information was gained for this report included case tracking, general observations, document reading, speaking with staff, residents and visiting relatives. A tour of the environment was also undertaken. At the end of the inspection, feedback was given to the care manager, outlining the overall findings of the inspection. Residents and relatives spoken with during the inspection visit were very positive about the care that they and or their relatives were receiving. There were also residents who were unable to communicate, the inspector noted that they appeared well cared for, and were happy in their surroundings. There had been two complaints made to the home, since the previous inspection, these had been dealt with in a timely way under the home’s complaints procedure by the care manager. One of the two complaints had been upheld, and the 2nd complaint had not been upheld. Both complaints were amicably resolved. Verbal feedback and comments received during the inspection visit were generally positive, and included, that “We are very pleased with the care given to our relative”, “We’ve never had a problem with anyone here, the staff are always helpful”. There were no requirements, and 3 recommendations made as a result of this unannounced inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? A review of residents’ care plans has resulted in them being more comprehensive and standardised. This makes them easier to read. More staff had been trained in regard to palliative care, and Dementia Awareness. A monthly exercise class has been added to the existing activities for residents. An ongoing programme of redecoration has continued at the home, with 6 bedrooms redecorated and carpeted in the past year, new chairs and new bedroom furniture have been purchased, and 6 windows have been replaced. The main lounge and the dining area have had new flooring and or carpeting, and work has started in regard to the replacement of tiles in the kitchen. 3 care staff had recently attained their NVQ level 2 awards, 5 care staff had enrolled on the NVQ level 2/level 3 awards. Domestic and Kitchen staff had completed their NVQ level 1 award, and are nearing completion of NVQ level 2. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beech Lodge Nursing & Residential Home DS0000026939.V355717.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 Beech Lodge Nursing & Residential Home DS0000026939.V355717.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): 1,2,3,5 and 6 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people who use this service and their representatives have the information needed to choose a home, which will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: A total of 3 residents were case tracked. This included examination of care plans, daily records, Medication, speaking with residents, relatives and staff, and visiting residents’ rooms. All care plan records seen showed evidence that pre-admission assessments had been undertaken prior to their moving into the home. These were either undertaken by the Local Authority, or by the care manager. The inspector spoke with relatives, who confirmed that they had received appropriate information about the home prior to visiting the home, and had Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 10 also had the opportunity to see the latest CSCI inspection report, which was available in the entrance to the home. Relatives spoken with confirmed that during their visits, the staff had made them feel very welcome. This had been on an unannounced basis, and the home was found to be very clean and tidy. Contracts seen in regard to the 3 residents case tracked, confirmed the services that were included and what charges would be made. In addition to this, the care manager confirmed that she sends out a letter to the resident, which shows the break down of charges and payments, which need to be made by the resident. An example of this was shown to the inspector. Residents who are self funding are invoiced as appropriate. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: In line with case tracking, care records evidenced that pre-admission assessments are being undertaken prior to moving in. Care plans evidenced that health needs were being met, and evidence of health professionals’ involvement and visits were seen. Care plans seen were clear and up to date, with relevant risk assessments in place. Relatives spoken with confirmed that their relative’s health needs were met on a daily basis. Medication was spot checked, was accounted for and stored correctly. The inspector discussed the use and application of prescribed topical creams for residents in relation to the signing of the Medication Administration Record. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 12 Controlled medication was checked with the Register, in accordance with amounts held. All amounts tallied. The medical fridge was in good working order, and temperatures were recorded. The residents were observed to be treated with respect and dignity at all times. Residents and relatives spoken with during the inspection visit confirmed this, and spoke highly of the staff team, and their hard work. One named resident’s care plan was discussed in detail. Particularly in regard to their being assisted to sit out for a short while each day. The inspector suggested that advice could be sought in relation to this from the Occupational Therapist. Beech Lodge Nursing & Residential Home DS0000026939.V355717.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 and 15 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are able to make choices about their life style, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual expectations. EVIDENCE: A limited range of activities was provided for residents living in the home. This included external entertainers visiting the home, trips out when weather permitted, to garden centres and other places of interest. In addition to this, staff made substantial efforts to provide interesting activities within the home to stimulate and provide enjoyment for the residents. Religious needs were also met with regular visits from Church representatives. Ideas for adding more opportunities, interest and variety to existing activities were discussed with staff members and with the care manager. Usage of the quiet lounge as a multi-purpose lounge and activities room was also discussed with the care manager and staff members. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 14 Staff were observed appropriately addressing and welcoming visitors to the home. The care manager confirmed that there was open visiting for family and friends. One relative told the inspector that ‘‘the home is really good, we can’t speak more highly of it, and we’ve have had no problems here.” Another relative visiting, commented that their sister “always has had very good care at Beech Lodge”. Throughout the inspection residents were observed making their own choices, residents said when asked, that they had plenty of food to eat, and that they were enjoying their usual nightcap before going to bed. When asked if they go to bed when they want to, residents confirmed that they could please themselves. Residents meetings are regularly held, and ideas are put forward in relation to the running of the home. Residents have a say in planning their menus, and in what activities are provided. During the inspection, a visit to the kitchen took place. The Cook confirmed that a recent environmental health inspection had taken place and the environmental health officer had not needed to make any recommendations. The kitchen was very clean and tidy, and all temperature recordings for fridges, freezers and food probes were within the required ranges and completed correctly. A cleaning schedule was in place, and included the signatures and dates of staff completing the work. Menus showed that a varied and nutritional diet was provided. The inspector noted that the kitchen door needs further work in order to fasten the existing fly screen securely. This had already been highlighted and requested by the care manager, and work is awaited as per the maintenance list. A varied and seasonal 4 weekly menu was in place. The home is non-smoking, and has a non-smoking policy. Staff needing to smoke would need to exit the building. There is currently an outside area designated for smoking. This was discussed in light of residents, and their needing to be outside in all weathers, as this area is uncovered. The inspector requested that the care manager look into ways of meeting the needs of residents who smoke. Beech Lodge Nursing & Residential Home DS0000026939.V355717.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 and 18 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: There was a clear and accessible complaints and protection of vulnerable adults procedure in place at the home. There had been two complaints dealt with by the care manager since the previous inspection. The care manager confirmed that she takes all concerns and complaints seriously and addresses them according to the procedure. Complaints were documented and recorded. The inspector discussed the two complaints that had been received by the home, since the previous inspection. One had been upheld, and one not upheld. However, both complaints had been amicably resolved. Residents and relatives spoken with said that they were more than happy with the service they received. They also confirmed that they would know whom to approach should they have any concerns or complaints. There is a clear complaints procedure on view in the entrance to the home. The complaints procedure is also contained within the Statement of Purpose. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 16 Staff spoken with confirmed that they were aware of the need to monitor the safety of residents and to protect them from any form of abuse. Protection of Vulnerable Adults (POVA) training is given to all new staff on induction, and the subject is covered during NVQ training. However, updates will need to be booked for all staff at the home. It is a recommendation of this report that all staff should receive refresher training in regard to Adult abuse and the Protection of Vulnerable Adults (POVA). The care manager and staff spoken with confirmed that staff had undergone appropriate recruitment checks prior to the commencement of their employment at the home. Checks had included POVA, CRB Police checks, as well as the provision of identification, and 2 references. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 17 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 and 26 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The inspector toured the building, spoke with residents, and with visiting relatives. The home was found to be clean and well presented. The main lounge had been decorated to a good standard, and new carpet and flooring had been fitted to the lounge and dining areas. An ongoing programme of redecoration has continued at the home, with 6 bedrooms redecorated and carpeted in the past year, new chairs and new bedroom furniture have been purchased, and 6 windows have been replaced. Work has also started in regard to the replacement of tiles in the kitchen. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 18 Bedrooms seen were personalised, well decorated, and had been adapted to suit the needs of the service users. Bumpers for bedrails were all present, and wheelchairs seen all had appropriate footplates, which were being used safely by staff when moving and transferring residents. Various aids and adaptations were in place including assisted baths, mobile hoists and other equipment used for moving and handling of service users. There was a nurse call bell in operation, which was seen and heard to be working at the time of the inspection. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Staff rotas were examined, and 4 members of staff were spoken with. Staff Rotas showed that existing staffing levels had been maintained. Discussions with staff were positive, and showed a clear determination that they belong to a committed team. Staff spoken with confirmed that they had received training in Dementia, Infection Control, Fire and First Aid. The care manager confirmed that all staff would be undertaking Moving and Handling in March 08, and the inspector noted that staff are yet to have Protection of Vulnerable Adult update training (POVA). This was subsequently discussed with the care manager, as the update training should have taken place in October last year. It is a recommendation of this report that staff should receive POVA update training. The care manager and staff spoken with confirmed that appropriate security checks had taken place prior to the commencement of their employment at the Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 20 home. This included POVA, CRB Police checks, the provision of 2 references, and confirmation of identification. Staff spoken with and records seen confirmed that care staff are not receiving regular supervision as per the National Minimum Standard. The inspector discussed this with the care manager during the visit, and made suggestions to improve upon the existing system used, and recommended that staff supervision is given as much priority as staff training. The AQAA document which is completed by the registered person, confirmed that out of 18 care staff, 10 had already achieved their NVQ level 2 or above, and a further 5 staff are currently undertaking the award. This means that the target of 50 has been achieved. Domestic and Kitchen staff had completed their NVQ level1 award, and are nearing the completion of NVQ level 2. The care manager has completed the Registered Managers Award since the previous inspection. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,34,36,37 and 38 - Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: During the inspection visit there were lots of very positive verbal comments made by residents, and also by relatives visiting the home. The home’s Statement of Purpose and Service User Guide was available for the inspector to view. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 22 Health and safety issues were inspected, and found to be in good order. Bed Bumpers were in place, and wheelchairs seen had appropriate footplates fitted, for the safety of residents. The care manager, and staff spoken with confirmed that all appropriate recruitment checks had taken place prior to their employment at the home. Including POVA, CRB Police checks, 2 references, and proof of identification. Staff spoken with confirmed that they had received training in Dementia, Prevention of Cross Infection, Fire, and First Aid. The care manager confirmed that all staff would be undertaking Moving and Handling training in March, and the inspector noted that staff are yet to have Protection of Vulnerable Adult update training (POVA). This was subsequently discussed with the care manager, as the update training should have taken place in October last year. It is a recommendation of this report that staff should receive POVA update training. Care staff spoken with confirmed that they are not receiving regular supervision as per the National Minimum Standard. The inspector made suggestions to improve upon the existing system used, and recommended that staff supervision is given as much priority as staff training. The care manager is very well qualified and experienced to oversee the running of the home. She is registered with the Commission for Social Care Inspection, and has also achieved the Registered Manager’s Award. Staff, residents and visiting relatives spoken to were complimentary about the care manager and confirmed that she was approachable and supportive. The care manager confirmed in the AQAA document, that the servicing of equipment in the home had been undertaken. The care manager confirmed that the monthly reports as per Regulation 26 were available for the inspector to view. Staff and service users spoken with during the inspection confirmed that the care manager is very approachable. She has an open management style, which is transparent, and includes the views of staff and service users. There had been two complaints received by the home since the previous inspection, one complaint had been upheld, and the 2nd complaint had not been upheld. Both complaints had been amicably resolved, and appropriately documented. Complaints are being dealt with appropriately, and in a timely way, using the home’s internal complaints procedure. Residents and their relatives are aware of how to make a complaint if they wish to. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 23 The care manager, staff, and residents spoken with confirmed that resident and staff meetings are being held. Quality Assurance was not inspected on this occasion, and will be monitored at the next inspection. Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 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 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X 3 3 2 3 3 Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 OP12 Good Practice Recommendations The variety and amount of activities offered to residents should be increased, and consideration given to the usage of the quiet lounge for this purpose. Staff should receive update training in regard to the Protection of Vulnerable Adults (POVA) Care staff should receive regular supervision. 2. 3. OP30 OP36 Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Beech Lodge Nursing & Residential Home DS0000026939.V355717.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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