Inspection on 31/01/06 for Beaufort House Care Home

This inspection was carried out on 31st 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

Beaufort House Care Home 22/09/07

Beaufort House Care Home 11/01/07

Beaufort House Care Home 07/06/06

Beaufort House Care Home 17/08/05

Beaufort House Care Home 15/03/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Beaufort House Care Home High Street Hawkesbury Upton South Glos GL9 1AU Lead Inspector Glenda Simons Unannounced Inspection 31st January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beaufort House Care Home Address High Street Hawkesbury Upton South Glos GL9 1AU 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) 01454 238589 01454 238589 Beaufort Care Ltd Mrs Carol Ann Bird Care Home 28 Category(ies) of Dementia - over 65 years of age (6), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (21) Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th August 2005 Brief Description of the Service: Beaufort House is situated in an attractive village location where there are shops, community facilities and a bus service. The home is situated approximately 4 miles from Wotton-Under-Edge and 8 miles from Chipping Sodbury. Bristol and Bath are within easy commuting distance. The property is a large mature house that has been extended. Accommodation is arranged on three floors. There is a passenger lift. Rooms consist of 26 single bedrooms and one double room. 17 bedrooms have en-suite toilet facilities. The home is set in attractive, well maintained gardens with lawns and a patio area. The gardens are accessible to all service users and have been made safe. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Only a few residents were able to express their views, as many of the residents in Beaufort House have mental health needs. Time was spent with the manager who is responsible for the day to day running of the service. The registered manager (who is a part owner of the business) was not present. The inspector interviewed four care staff, one was also undertaking cooking duties today due to holiday cover, also discussions were held with the laundry assistant. General observations were made when staff were assisting residents with their needs. A range of records were viewed by the inspector including policies and procedures used within the home. The inspector wishes to thank all staff present at the time of the inspection for enabling this process to be completed. What the service does well: What has improved since the last inspection? It would appear that the new owners and present manager work together well, and are continually reviewing systems and have a business plan in place for making improvements to the home. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 6 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 Care Home DS0000061734.V280098.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 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 the following standard(s): Residents have their needs assessed before moving into the home, either on a permanent basis or for respite care, by the manager. EVIDENCE: Four resident files were viewed to see how care needs are assessed. Assessments were in place and were reviewed and dated on a regular basis. Some residents had a care management care assessment/plan in place if financed by Social Services. The files contained records on plan of care, residents history, residents personal care, residents sensory care, risk assessments relating to resident, weight management charts and a daily record sheet. The home has had two respite placements in the last year, and only deal with respite care if there are any vacancies. Both service users visited the home with relatives before their stay and the manager assessed their needs. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 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 the following standard(s): 7, 9,10, and 11 Records that are regularly reviewed demonstrate that residents’ health and personal care needs are met EVIDENCE: Residents’ plans of care appear to meet identified need and show action required to meet those needs. Health care needs records are kept, and reviewed monthly. The medication procedure for the handling of resident’s medication is in place, but staff need to adhere to the homes’ policies. Records of four residents were viewed. Care plans showed information relating to the residents health, personal and social care needs. A record of bathing of residents was viewed, showing when individual residents were bathed. A daily record sheet was viewed which recorded events such as: referral to Psychiatrist re medication review, health care/personal care issues, and district nurse and Doctor visits. Risk assessments were found when a risk had been identified, and showed how staff should manage the risk. For example one resident is responsible for taking her own medication, a risk assessment was in place to identify the risk and policies put in place, such as resident locks medication away in her drawer in bedroom. Also when her medication is Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 10 delivered to home, staff count tablets, sign and date on medication administration records. The home uses a monitored dosage system. At the time of the inspection, keys to the medication cupboard were in an open box above the cupboard which is sited in dining room, but I was informed that they are normally kept in a locked cupboard within office, as is legally required at all times. The manager deals with re-ordering of medication, and senior care staff are responsible for supervising medication procedures. However, at the time of the inspection, when checking with a member of staff, one residents medication, it would appear had been given, but not signed for on the medication administration record. Five residents medication records were examined. Photographs of residents were found on medication files, this helps identification of a resident and is good practice. A chiropodist visits every six weeks Staff were observed assisting residents in a respectful manner, giving all residents individual attention. Clothing that residents were wearing was clean and tidy. A few residents who were able to comment said that they choose their own clothing, but because of mental health needs, some residents were assisted in this task. One family member of a resident said that ‘the home encourages her father to do things for himself’ and that his personal care needs are met. A discussion was held with the manager regarding caring for the dying. The manager explained that family and friends are involved and supported throughout this time, all staff are made aware of the situation, and treat the resident and family with care, sensitivity and respect. The manager herself attends residents’ funerals on behalf of Beaufort House. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 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 the following standard(s): 12,13 and 15 Residents are provided with a range of activities however records in the home fail to demonstrate this. The home provides residents with a healthy diet. EVIDENCE: During the inspection several residents were having their nails painted and hands massaged, residents clearly appeared to enjoy this activity and found it reassuring and calming. Music was being played in the lounge during the afternoon. One resident commented that she enjoyed her knitting, and she also likes to clean her own room. A resident’s daughter told me that family were invited to a Christmas party at the home, and how much everyone enjoyed themselves. One resident goes out shopping once a week with a relative. Twice a month the church visits the home and holds a service. Beaufort House is next door to a village school and often the school choir visit and perform for the residents, also the residents are invited to dress rehearsals for the school play. Twice monthly two people visit and arrange a sing-along with residents. The manager told me that residents really enjoy the music quiz and have fun guessing the name of the song played. The home has a selection of videos and residents who can join in enjoy exercising to music. A ball game is often played in the lounge supervised by staff trying to encourage residents Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 12 to participate. Some residents appear happy to sit down quietly in their rooms and watch some television. Residents are encouraged to maintain contact with family and friends by invitations to functions held at Beaufort House, such as Christmas party and garden parties in the summer. A hairdresser visits the home every Thursday. On speaking with the Manager, about all the activities that Beaufort House offers, she is keen to start recording all the activities, which will help to promote the home and make auditing activities easier for management purposes. During the inspection, a cooked lunch and tea were prepared for residents. Most residents were assisted to sit at tables in the dining area, and seem to enjoy the social event. The meal served at lunch was spaghetti bolognaise followed by a fruit crumble and custard. The meal was well presented and looked appealing. Some residents were assisted with their food; this was done sensitively by the staff and showed respect for resident’s dignity. Some residents were assisted to eat in their bedrooms by individual staff and a few preferred to eat in the lounge, again with assistance. A jacket potatoe and cheese was served for tea, with a selection of homemade cakes and tea to drink. Residents appeared to enjoy their food, and commented ‘that the food here is good’, ‘food is beautiful here’, and another resident said ‘ its all right’. The kitchen was visited and was clean and tidy. Colour coded boards were stored in an appropriate rack. The pantry was full of dry foods, and very well stocked with good brand names and a good selection of fresh food available. The fridge and freezers temperature were recorded daily in a log record. Food in the fridge was covered and dated to reduce risk of serving out of date food to residents. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 13 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 and 18 Residents have access to a complaint process and steps have been taken to protect them by training most staff in protection of vulnerable adults from abuse. EVIDENCE: A copy of the home’s complaints procedure is included in the residents’ care files and a copy is on display in the home. One resident said that if she had any concerns she would speak to the manager, and felt confident that the issue would be addressed and she would be listened to. The complaints and compliments book was viewed, however the format of the complaints book should be clearer, which must show action and outcome of the complaint. Two care staff interviewed said that they had attended training on the prevention of vulnerable adults at South Gloucestershire Council. All staff interviewed said if they had any issues or concerns regarding abuse they would speak to the manager. The prevention of vulnerable adults training is being extended to all staff. The Policies and Procedures file was seen. The policy on Abuse and Prevention of vulnerable adults was last reviewed on 17/02/05; all staff are required to sign after reading policies. It was noted that a copy of the joint policy and procedure for prevention of vulnerable adults from abuse written by South Gloucestershire Council was present for reference. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 14 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 and 26 The environment is suitable to meet the needs of residents currently living at the home and is clean and satisfactorily maintained. EVIDENCE: The home is set in its own landscaped gardens in a quiet area off the main road of Hawkesbury Upton, near to a school, church, community village hall, and public houses. The property is a forty-minute drive away from the City of Bristol where there are shops, services and amenities. The home is also a short drive away from nearby M4 and M5 motorway access. The inspector walked around the inside of the home and viewed all the communal living areas and most of the resident’s bedrooms. The standard of fixtures and fittings are satisfactory and were domestic in style. There is evidence of wear and tear of a carpet in one resident’s room, and another resident had her own rugs in her bedroom, which were curling at edges, this is dangerous to residents, visitors and staff and should be addressed. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 15 The environment was clean, tidy and satisfactorily maintained. The owners have in place an operational business plan for redecoration and refurbishment of the premises. This clearly shows that new equipment has been purchased and there is also a maintenance programme. The gardens to the rear of house were viewed and the grounds were kept neat and tidy and safe. Two side gates to the property were locked to ensure residents’ safety from road. The laundry is situated in the cellar of the main house. A new washing machine and dryer was purchased last year. A member of staff is responsible for the laundry and general housekeeping. At the time of inspection, some deep cleaning to the rear ground floor was being undertaken, and generally the carpets were clean and fresh, only in some areas odours occurred, in particular the front hall carpet, which the manager informed me is being replaced. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 16 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, 29 and 30 Adequate staff are deployed to meet the needs of service users. The home operates a satisfactory recruitment procedure, but needs to confirm that all staff have a Criminal Records check and can provide supporting evidence. EVIDENCE: Due to the high level of mental health needs of residents sufficient staff were seen on duty, giving time to individual residents who needed more assistance and support. A good range of skill mixes, including laundry assistant, care workers (including one male worker), senior care worker, cook and cleaning staff. Five staff files were examined, showing contracts of employment, references and training records. However, two staff files showed that CRB checks were carried out on a date, but no registration number or copies were seen. The home has recruited staff from Poland, using an independent agency. A file was seen showing individual CV’s, local checks, and references. One staff member who was interviewed had received a range of training, such as Induction, to Topps standards, medication with the Chemist, Protection of Vulnerable Adults at South Gloucestershire Council, Manual handling (in-house) by the Manager who is a Trainer, Ist Aid, and has just started National Vocational Qualification Level 2 in care. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 17 Another staff member interviewed has already obtained National Qualification Level 2 and is now undertaking Level 3. She has completed a manual-handling course, and is programmed to do dementia care training next week, and palliative care next month. She commented to me that ‘this is the first home I’ve worked for that has offered me so many training courses’. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 18 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): 33, 36 and 38 The management of the home ensure regular supervision of staff, monitoring of the quality of service provision and monitors the procedures for health and safety. EVIDENCE: Questionnaires were seen which had been sent to resident’s family. The questionnaires are sent out on a regular basis. The information received is analysed and discussed as part of the regular staff meetings. Feedback of the surveys is printed in the Beaufort News, which is circulated four times a year to residents and their families. The staff meeting book was seen and showed that meetings take place on a regular basis, and minutes of the meeting are recorded. The minutes showed that there was evidence of adopting new systems in place to meet the care standards. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 19 The Owners visit the home on a weekly basis and attend staff meetings. The Owners report was viewed, which is undertaken monthly and looks at staff rotas, menus discussed at food meetings, talking to residents about quality issues including food, talking to staff on duty, and reviewing the medication system. The Manager who is at present responsible for the day to day running of the home told me that she receives supervision herself from the owners (one is the current registered manager) and that she can contact the owners at any time to get support and advice. The manager informed me that she is responsible for staff supervision this is planned for every 6 – 8 weeks however there are occasions when the time between supervision is slightly longer due to sickness and holiday. Staff interviewed said that they did receive supervision and found it very helpful, and said that if they have any concerns would raise issues with the Manager who was approachable and would try and get things sorted out. Training issues are identified and the manager has started to set up personal development files, and would like to introduce reflective practices after training. A philosophy of care policy and bill of rights is displayed in the home. The manager trains staff in manual handling techniques ensuring that staff know how to transfer residents safely and avoid injury to themselves. The fire safety log book was examined and showed that weekly tests by staff are recorded and dated, fire fighting equipment is recorded monthly and there is a record of staff training which was dated 10/10/05. The home has a HSE accident book which is used to record accidents. Risk assessments were seen on individual resident files; also several risk assessments were displayed on a notice board including fire safety and action, and supervision of residents in the lounge on the first floor. A missing persons procedure was also on display in the home. The home has a file called ‘important events book’, which shows inspections made by the Lift Company, and also Avon fire and rescue. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 3 X 2 Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 21 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. 2. Standard 38.7 9.1 Regulation 37 13.2 Timescale for action All incidents that occur within the 01/02/06 home must be reported to CSCI. The registered person ensures 01/02/06 that staff adhere to medication policy and procedures when administering medication. Suitable provision for storage 31/03/06 purposes must be made available. The registered person shall make 31/03/06 arrangements to train all care staff in POVA. To ensure that the carpets 31/03/06 outlined in the report are in a good state of repair and do not create a health and safety issue. Requirement 3. 4. 5. 22.7 18.1 24.1 23 (2)(L) 13 (6) 23 (2) (b) Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 22 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. 2. 3. Refer to Standard 12.3 16.3 29.3 Good Practice Recommendations An Activities Book should be introduced to record all the activities and social events held at the home. The Complaints Book format should be reviewed, a clearer format is required, showing the outcome and action taken. The records of Staff who were employed before the new owners took over do not show the CRB reference numbers. In future it is recommended that this number should be quoted and dated on staff records. Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Beaufort House Care Home DS0000061734.V280098.R01.S.doc Version 5.1 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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