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Inspection on 05/05/05 for Beaufort Hall Nursing Home

Also see our care home review for Beaufort Hall Nursing Home for more information

This inspection was carried out on 5th May 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

By the time of the last inspection, the acting manager had built up a sense of team spirit, had started setting up systems for clear guidance on care practice standards to staff, and had made improvements to the recording systems so that there were more detailed notes of the care each resident is receiving. Since then, she and the team have continued to develop these areas. Staff morale is now good, and the team has a clear sense of direction. Residents` care has also distinctly improved, and the records are much more informative than before. The areas most in need have been fully refurbished, and the overall standard of the premises is much higher. This program of redecoration is still underway. Safety issues have also been addressed, and the practice seen today indicated that potential hazards are being much better managed.

What the care home could do better:

No requirements or recommendations were made at this inspection, because the home is well on track for fully meeting the Regulations and the National Minimum Standards. Beaufort Hall has become the sort of home where residents can be safe and happy, and staff can be proud to be part of. If progress continues at its present rate, the home will soon be providing an outstanding service.

CARE HOMES FOR OLDER PEOPLE Beaufort Hall Nursing Home 28 & 30 Bimbeck Road Madeira Cove Weston Super Mare BS23 2BT Lead Inspector Catherine Hill Unannounced 5 May 2005 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 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. Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Beaufort Hall Address 28 & 30 Bimbeck Road Madeira Cove Weston Super Mare North Somerset BS23 2BT 0121 4462880 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Boyack Enterprises Ltd Care home with nursing 33 Category(ies) of Old Age - (33) registration, with number Pysical disability - over 65 - (6) of places Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 6 persons aged 65 years and over with physical disabilities. 2. May accommodate up to 33 persons aged 65 years and over requiring nursing care Date of last inspection 15 February 2005 Brief Description of the Service: Beaufort Hall Nursing Home is registered for 33 elderly people aged 50 years or over. The home is on Weston-Super-Mare seafront and occupies a prominent position overlooking Marine Lake. It is close to local amenities and the town centre. Beaufort Hall is a four-storey building and has a six-person passenger lift accessing all floors. There is a large dining room on the ground floor and two spacious lounges on the first floor, each of which has a small dining area. There are 25 single bedrooms and 4 doubles. Most bedrooms have en-suite toilets. Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted over approximately 4 1/2 hours during the middle part of the day. 15 people were in residence, and the owner was conducting his unannounced monthly visit. The manager and another trained nurse were on duty, along with three care staff and three catering services staff. One of the staff was taking residents one at a time to the local polling station to cast their vote. The inspector spoke with nine of the residents and with most of the staff on duty. What the service does well: What has improved since the last inspection? By the time of the last inspection, the acting manager had built up a sense of team spirit, had started setting up systems for clear guidance on care practice Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 6 standards to staff, and had made improvements to the recording systems so that there were more detailed notes of the care each resident is receiving. Since then, she and the team have continued to develop these areas. Staff morale is now good, and the team has a clear sense of direction. Residents care has also distinctly improved, and the records are much more informative than before. The areas most in need have been fully refurbished, and the overall standard of the premises is much higher. This program of redecoration is still underway. Safety issues have also been addressed, and the practice seen today indicated that potential hazards are being much better managed. 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. Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4 & 5 The homes admission procedure is much more explicit and helps to ensure that the experience of being admitted to the home is as smooth and pleasant as possible. EVIDENCE: The admission procedure has been revised and gives much clearer guidance to staff, so that they are better able to ensure the process is as smooth as possible for the new resident. Key workers are fully involved in all planned admissions so that they and the new resident can get to know each other from day one. The pre-admission assessment has been expanded to give more depth of information about the person, their needs and preferences. This means that the team is better able to prepare to meet the new person s needs. Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 9 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 standard(s) 7,8,9,&10 Residents care has greatly improved and the standard of care practice is consistently higher . EVIDENCE: One person commented how well she had been looked after during a recent illness, and staff gave detailed examples of the ways in which care practice has improved. Residents all looked well groomed, and staff had paid attention to the details. Call bells and other essentials had been placed within reach of less mobile residents. Care records are also much more detailed, and the daily notes are clearly cross-referenced to more detailed risk assessments. The charts for recording individual residents care are being completed on a much more regular basis than before, now that staff are getting used to using them. The home is now working in conjunction with the visiting GP to ensure that each person has a regular health check as a matter of course. The home is also liaising with the Primary Care Trust on doing a Falls Audit so that the reasons behind any recurring falls can be identified and action taken to minimise the Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 10 risk for the person. The acting manager has revised the home s medication procedure to reflect the requirements from the last inspection. This new procedure is exceptionally thorough and includes separate guidance on those residents who selfmedicate, as well as a clear information sheet for patients use. The supplying pharmacist is doing a thorough check of the home s medication systems every couple of months, and plans to review the organisation of the home s treatment room in the next year. Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 11 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 standard(s) 15 Residents get a good choice of menus. Meals are nourishing and varied. EVIDENCE: Residents have praised the menus at every recent inspection, and have always commented on the flexible and helpful attitude of catering staff. The cooks are not resting on their laurels, however, and a new four-weekly menu has been drawn up that includes a good range of alternatives to the main menu. Residents can still request other alternatives, but the main menus provide a good choice. There is also a wide choice of breakfast items. Vitamin supplements drinks are also being regularly provided. Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 12 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 standard(s) These standards were not assessed at this inspection. EVIDENCE: Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 13 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 standard(s) 19, 20, 23-26 The standard of decor and safety has greatly improved over the past year. EVIDENCE: The ground floor hallway, corridors and stairs had all been redecorated and recarpeted, creating a really fresh and welcoming first impression of the home. The pink lounge, which is first on the left from the front door, has also been recarpeted. It is planned to provide new furniture in this room next. Several more of the bedrooms have been refurbished since the last inspection. The inspector looked round most areas of the home today, and all of them smelt fresh and looked clean and tidy. Hazardous chemicals were all safely stored. A consultant has been asked to do the risk assessment on the premises that is required under health and safety legislation. The fire officer had just visited the home, and the manager is ordering the new fire exit signs and fire extinguisher signs he recommended. The new, more extensive fire system is now fully installed and covers all parts of the home, including the owners flat. All staff have recently had refresher training in what to do if there was a fire, and the fire equipment is being regularly checked to Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 14 ensure it is in good working order. Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 Staffing levels greatly exceed the minimum. Staff are getting a good range of training opportunities. Staff are getting clear direction in providing a residentcentred service. EVIDENCE: Staffing levels have been maintained, even though resident numbers have dropped recently. An excellent training programme had been drawn up and is already underway. All staff recently had manual handling training, and have been issued with certificates of attendance, as has the resident who joined in with this training. The local Continence Services Manager gave staff catheter training last month, and some of the nursing staff gave examples of the other professional training they have had recently. Several staff are doing three-month distance learning courses on infection control, nutrition and health, and basic food hygiene. Several others are doing NVQ training, two of the seniors are doing the NVQ Assessors course and a lot of staff are going to the short training sessions being laid on by the Primary Care Trust. The key worker system is up and running now. Each of the nursing staff is linked to a group of care staff and a group of residents, and is responsible for ensuring that each resident gets the exact care and support that person needs. Key working has been discussed in staff meetings, and some guidance for staff is also posted in the office. Staff are interacting with residents much more, and Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 16 the benefits of this are especially obvious among the more dependent residents, all of whom seemed much calmer and more engaged than on previous visits. Several of the more able residents commented on the kind and good-humoured approach of staff, and one person said they are all good. Another person said there is nothing they wouldnt do for you: the staff are an absolute treat. Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-33, 36-38 The acting manager has achieved remarkable changes in the few months she has been in post. Staff and residents are benefitting from clear guidance, and the team is being well supported to work consistently. EVIDENCE: The acting manager has been reviewing all the homes policies and procedures, in consultation with staff and with external professionals, to ensure that the guidance is up to date and encourages good practice. There is now also a file of the personal care procedures being used in the home, so that staff can check they are doing things properly. This file contains written risk assessments related to each procedure, and is cross-referenced to the home s other guidance manuals. Guidance for staff has vastly improved, and the staff met at todays inspection had a clear sense of direction and felt confident in their work. Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 18 There is a job description for the acting manager, and the owner is also drawing up guidelines on the division of tasks between his role and hers. As at the last inspection, staff were feeling really positive and enthusiastic about the changes the new manager has brought about. Staff liked the fact that they are getting clear instructions, plenty of relevant training, and are being involved in the decision-making. One person commented that the home used to be so isolated and was much happier that the team is now working so closely with external professionals. Staff felt well supported, and many of the longer term staff are feeling that their commitment to the home is now paying off. Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 x 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 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 3 3 3 x x 3 3 3 Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 20 Are there any outstanding requirements from the last inspection? 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 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 Good Practice Recommendations Beaufort Hall Nursing Home D53 - D02 S50501 Beaufort Nursing Home v222987 05.05.05 Stage4.doc Version 1.30 Page 21 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier Taunton TA1 4AL 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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