Inspection on 07/11/05 for Beaufort House

This inspection was carried out on 7th November 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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beaufort House 04/09/06

Beaufort House 09/06/05

Beaufort House 14/10/04

Beaufort House 12/07/04

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Southfields

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

CARE HOME ADULTS 18-65 Beaufort House Beaufort House Chobham Road Knaphill Woking Surrey GU21 2TD Lead Inspector Pauline Long Announced Inspection 7th November 2005 13:30 Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 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 Beaufort House DS0000013563.V264750.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 Adults 18-65. 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 House DS0000013563.V264750.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beaufort House Address 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) Beaufort House Chobham Road Knaphill Woking Surrey GU21 2TD 01483 475536 Whitmore Vale Housing Association Miss Heidi Michelle Beech Care Home 7 Category(ies) of Learning disability (7), Physical disability (2) registration, with number of places Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 18 - 65 YEARS. Two of the 7 persons accommodated may be within the category PD in addittion to being within the category LD. Up to six named persons may be within the category LD(E). Date of last inspection 9th June 2005 Brief Description of the Service: Beaufort House is part of the Whitmore Vale Housing Association a charitable housing Society. It is situated in a residential area close to the centre of Knaphill Village on the outskirts of Woking. Beaufort House is registered to provide care and accommodation for 7 adults with complex daily needs and communication difficulties . The property has been converted from a private residence comprising seven bedrooms. One Bedroom has en suit shower and toilet facilities. There is a kitchen and large through dinning/lounge room. Off street parking is available at the front of the house and residents have the use of a well maintained and securely fenced garden . Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second Inspection of this home under the Care Standards Act 2000 and the CSCI year April 2005- March 2006 and was announced. The inspection was carried out by one inspector and lasted for three and half hours. CSCI would like to thank the residents, manager and staff for their hospitality and co-operation during the inspection. On the day the service had a welcoming atmosphere. All of the of the seven rooms at the home were occupied. The residents were at home at different times during the inspection and all were involved in the process. Discussions were had with the manager, care staff, residents and a visitor to the home. Documents sampled, included service users files, care plans, staff records, policies and procedures and the pre-inspection questionnaire. No comment cards were received at the CSCI office. A full tour of the home and garden took place. Feedback from the resident’s at home on the day was limited, in view of the their communication difficulties. What the service does well: This home presents a homely environment and atmosphere for the residents. The manager’s approach was open and inclusive. The care staff team is a stable one, and they demonstrated a good understanding of the residents care needs. This was reflected in the wellbeing of the residents who were at the home on the day. The home is committed to ensuring that the residents maintain contact with family/friends and the local community. There are various activities offered both in and outside the home. On the day, two of the seven residents had planned activities out side the home. A visitor to the home commented that, the home is excellent, the staff are well trained and always very welcoming. Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 House DS0000013563.V264750.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4 Arrangements are in place to ensure a full needs assessment takes place before any new admission. Service users needs are well met. Service users contracts are not routinely signed by either a service user or representative. EVIDENCE: In the first instance the home would receive a referral and a community care assessment from the Surrey County Council Social Care Team. Following the last inspection, the manager has recently completed a comprehensive assessment of needs on all of the service users. Two service user’s files were sampled. All aspects of daily living needs were assessed, indicating that the manager and care staff would be fully aware of individual residents care needs. Each prospective resident was offered the opportunity for visits to the home prior to a trial assessment period. These periods range from a lunchtime visit, to a weekend stay. A requirement has been made in respect of service users contracts. Please refer to page 23 of this report. Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 The manager and staff had a good understanding of the resident’s needs and choices, these were well met. On the day residents were involved in decisions, and were supported to take responsible risks. EVIDENCE: It was pleasing to note that the service users were encouraged to be involved in the inspection process, one resident was happy to show the inspector around the home and garden, he was particularly proud of the recent work they had completed in the garden. The care plans sampled had detailed needs assessments. On the day, residents was observed being supported and enabled to make choices safely. Risk assessments were in place and had been reviewed. Care plans included all aspects of personal support and health care needs. The relationships between the residents and staff at the home enabled help and support with some tasks residents found challenging. A resident was asked if Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 10 he wished to help to prepare the evening meal, he smiled, indicating that he was happy as he followed the member of staff into the kitchen. Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,13,15 The Manager and staff enable the residents to maintain fulfilling lifestyles in and outside the home. The home promotes contact with family, friends and the local community. EVIDENCE: One of the residents at Beaufort House is in paid employment. Other residents however go to individual day services. This enables them to have a degree of independence, and the opportunity to meet with other day service users. The home is committed to ensuring that the service users maintain their relationships with their family and friends. Some of the service users receive regular visitors and keep contact by phone. A visitor commented that the home was very welcoming and that they always encourage families to come in to the home. There were various flyers posted on notice boards, relating to possible future outings for example visits to the theatre and bowling. The manager, visitor and a resident discussed the future Christmas carol evening. The resident clapped her hands and smiled indicating that she was looking forward to the celebration. Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 12 Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21 The manager and staff have a good understanding of the service users support needs. This was evident from the positive interactions and relationships observed. The health needs of the residents are well met. Service users are are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Care plans included clear guidelines on any support each service user required with personal and health care. Physical and emotional needs of the service users were also detailed in the care plans and daily records, which included visits to the doctor, dietician, dentist and reviews of care. The home has a clear medication policies and procedures. None of the service users in the home administers their own medication. All of the care staff on duty were aware of the policies and procedures regarding medication. A new member of staff explained that he would not be permitted to administer medication until he had received medication training and was deemed competent. All of the medication record sheets were checked, and were found to be properly completed. Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The home has satisfactory policies and procedures in place for dealing with concerns, complaints and the protection of the service users. EVIDENCE: CSCI has received no complaints about this home since the last inspection. The homes statement of purpose and service user guides have been reviewed and amended to reflect the current details of the CSCI. The manager and staff were aware of and have attended the Surrey Multi Agency Abuse training. Discussions with a new member of staff included scenarios around abusive situations. It was very pleasing to note that he had a good understanding of the procedures. Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25,27,29 The standard of the environment within this home is good and meets the needs of the service users, providing an attractive, clean and homely place to live. EVIDENCE: The service users bedrooms were clean bright and tidy and there was evidence of many personal items. Rooms contained many sensory pieces of equipment for example, lava lamps, mirror balls, water features, one bedroom had a sensory projector. The home should be commended on the quality and quantity of sensory equipment provided. The bathrooms although well adapted for service users needs were domestic in design and quite pleasant. It was noted that some continence aids were stored in a bathroom cabinet, this was discussed with the manager, who agreed that this could be seen as communal use of these items and agreed to remove them. It was also noted that liquid soaps were kept in the communal bathrooms, no risk assessments had been carried out in this respect. Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 16 The main sitting room was bright, airy, uncluttered and clean. The standard of decoration in the hallways and communal rooms was satisfactory. On the day the overall cleanliness of the home was good and no malodours were noted. A requirement has been made in respect of the liquid soaps. Please refer to page 23 of this report. Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,35 The home employs an efficient staff team in sufficient numbers, who provide a good quality of care to the service users. Training opportunities in the home are good. EVIDENCE: There were 2 care staff, a deputy and manager on duty on the afternoon shift. The dependency levels of the residents on the day indicated that the present staffing ratio was adequate. Staff talked about their job roles, there was clarity and awareness of the different roles and responsibilities within the home. Training in the home is given a high priority, care staff stated that they are offered many opportunities to attend statutory training and other training in line with current good practice. One member of staff commented that he was looking forward to undertaking an NVQ qualification. A visitor to the home commented that the staff were well trained, and that they were very knowledge in respect of the service users needs. Since April 2005 some examples of the training programme have been provided: • • • Manual handling. First Aid. Health and Safety. DS0000013563.V264750.R01.S.doc Version 5.0 Page 18 Beaufort House • • • Fire Awareness. Food Hygiene. NVQ 2/3. Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38,40,41,42,43 Service users benefit from the ethos and management approach of the home. Health safety and welfare of service users is promoted, and service users views are listened to. Resident’s personal monies are safeguarded. EVIDENCE: The manager had a very open and inclusive style of management. From observation of her interactions with the service users and the staff, it was clear that there was an atmosphere of openness and respect. The staff expressed confidence that they could take any issue to the manager. All staff appeared confident in her presence and professional in their work. The home has clear policies and procedures, which are reviewed at regular intervals. Service users and staff may access these documents as they wish. Health and safety checks are routinely carried out at the home and clear records kept. All equipment in use on the day of inspection was properly maintained, water temperatures were checked in all rooms, and were found be satisfactory, apart from one of the upstairs bedrooms. The water in this room was found to be quite cool. The manager checked the temperature log, which Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 20 indicated that there had been a problem with the temperature. She stated that this would be dealt with straight away. Service users records regarding financial transactions were checked and found to be in good order. The homes financial policies and procedures were discussed with the staff on duty, they discussed scenarios around resident’s monies, it was pleasing to note that they were conversant with these. Through out the inspection, service records were sampled and were found to be well maintained. A requirement was made in respect of water temperatures. Please refer to page 23 of this report. Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 3 2 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X 3 X 3 X 3 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beaufort House Score x X 3 3 Standard No 37 38 39 40 41 42 43 Score X 3 X 3 3 2 X DS0000013563.V264750.R01.S.doc Version 5.0 Page 22 No 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 YA42 Regulation 12(1)(a) 4(a)(b)(c ) Requirement Timescale for action 07/12/05 2. YA42 12(1)(a) 13(3) 3. YA5 Schedule 4 (8) The registered person(s) must ensure that risk assessments are carried out in respect of the liquid soaps in the communal bathrooms and toilets. These assessments must be documented. The registered person(s) must 07/12/05 ensure that the water tap in the upstairs bedroom is checked and repaired as necessary to ensure the water reaches the right temperature. The registered person(s) must 07/01/06 ensure that all service users are provided with a contract of the care service provided and that these contracts are signed by the service user or their representative. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 23 No. 1. Refer to Standard YA6 Good Practice Recommendations The registered person(s) should consider as to whether or not it would be appropriate to keep details relating to personal care in the residents bedroom. Beaufort House DS0000013563.V264750.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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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