Inspection on 14/08/06 for Beaufort Lodge

This inspection was carried out on 14th August 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 Lodge 15/06/07

Beaufort Lodge 25/04/06

Beaufort Lodge 20/10/05

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Beaufort Lodge 38 Beaufort Road Kingston Upon Thames Surrey KT1 2TQ Lead Inspector Diane Thackrah Key Unannounced Inspection 14th August 2006 10:00 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 Beaufort Lodge DS0000065236.V301865.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. Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaufort Lodge Address 38 Beaufort Road Kingston Upon Thames Surrey KT1 2TQ 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) 020 8546 2073 020 8390 9253 CHD (Care Homes) Ltd Care Home 20 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (7) of places Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2006 Brief Description of the Service: Beaufort Lodge provides care for twenty older people. The home is owned and managed by Care Homes of Distinction LTD, who have recently taken over the home. This organisation also own and manage ten other care homes. Beaufort Lodge is situated in a residential street close to the centre of Surbiton. Accommodation is provided over three floors. There is a lounge/dining area on the ground floor and a conservatory, which is the homes smoking area. There is a well maintained garden to the rear of the property. A copy of the home’s Statement of Purpose and Service User Guide can be obtained on request from the Registered Provider’s, as can a copy of the most recent Commission for Social Care Inspection, inspection report. At the time of writing, fees for the home range between £356 - 550. There are no additional charges. Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 14th August 2006 between 10.00 and 15.30. A partial tour of the premises took place and care records were examined. The Manager, Registered Provider and two staff members were spoken with. Four service users also gave their views on the home. Some service users living in the home do not have the mental capacity to share their views regarding their care. Observations of care practices and interactions with staff members occurred in order to make judgements about the care that these service users received. Four visitors were also spoken with. What the service does well: What has improved since the last inspection? A number of the Requirements set at the last inspection of the home have been addressed. There has been improved practice for care planning and for ensuring that service users and their representatives are involved in this process. Care plans are now reviewed and updated appropriately. Staff members have received training in care planning and record keeping and the success of this is evident. Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 6 There have been a number of environmental improvements including the redecoration and refurbishing of a number of bedrooms and new appliances for the kitchen. Practices for fire safety have improved. There have been improved arrangements for consulting with service users and their representatives and for running the home in a way that reflects the needs and wishes of service users. What they could do better: The home is failing to meet National Minimum Standards in a number of areas and this is of concern. There has been an ongoing failure by the Registered Provider’s to address some Requirements set by the Commission for Social Care Inspection, and as a result, enforcement action may be taken against the home. In general, the arrangements for carrying out needs assessments and for care planning are good, however, the home has failed to ensure this good practice for all service users. It is therefore unclear whether all service users have their needs met by the home. Concerns were raised during this inspection due to one incident were a staff member spoke to a service user in an inappropriate manor. There is a need for improved practice regarding the reporting of suspected abuse. There remain a number of concerns regarding health and safety and cleanliness in the home. It is also concerning that there are poor arrangements for staff induction and providing new staff members with training in safe working practices. One staff member has been employed to work in the home without having the necessary pre recruitment checks carried out. Some concerns have been raised about service user’s bedrooms not providing a homely environment. There are concerns about the Registered Provider’s commitment to providing a service that is based on the wishes and best interests of service users as there has been an ongoing failure to produce a development plan for the home. Please contact the provider for advice of actions taken in response to this Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beaufort Lodge DS0000065236.V301865.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 Beaufort Lodge DS0000065236.V301865.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. In general, there are good arrangements for planning for the care of service users prior to them moving into the home. However, it is unfortunate that one service user has been admitted to the home without having their needs assessed and it is therefore unclear whether this service user’s needs are being fully met. The home does not provide intermediate care. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There was a detailed needs assessment in place in four of the most recently admitted service user’s files. There was documentation detailing that a representative from the home had visited service users in their homes to assess their needs, and had consulted with the placing authority. There were Care Management needs assessments, and a nursing needs assessment in two of the files seen. However, there was documentation detailing that one service Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 10 user had not had their needs assessed adequately prior to moving into the home. There was a brief needs assessment that had been prepared by the service user’s placing authority. This provided some information about the service user’s personal care and health needs. It did not provide comprehensive information about the service user’s needs, and, it had not been obtained prior to the service user moving into the home. No service user should move into the home without having their needs assessed and been assured that these needs will be met. Written assessments of need must be carried out by a trained representative from the home, in conjunction with the service user, and/or their representative for privately funded service users. For individuals referred through Care Management arrangements, the Registered Providers must obtain the Care Management assessment of needs. It is unfortunate that, despite there being good systems in place for ensuring that the needs of prospective service users are assessed prior to them moving into the home, the home has failed to ensure that they could meet the needs of one individual before they moved into the home. A Requirement has been made regarding this issue. Beaufort Lodge DS0000065236.V301865.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. There have been large improvements in this area, and, in general, there are good arrangements for ensuring that service users have their health, personal and social care needs met. However, there remain some poor practice issues that put into question the quality of care provision in the home. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: It was positive to note that there have been improvements with the care planning system. The majority of the staff team have received training in the use of the ‘Standex’ care planning system, record keeping and care planning. Five service user’s care plans were examined. Four of these were in good order, had been generated from a comprehensive needs assessment, contained good detail about how staff members should address the health, personal, and social care needs of the service users, included an inventory of the service user’s possessions, had been drawn up in consultation with the service user, and signed by the service user, contained information about how significant risks could be reduced, and, had been reviewed and updated on a Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 12 monthly basis. However, a Requirement made about poor care planning at the last two inspections of the home is repeated. There was a care plan for the most recent service users that had not been fully completed despite the service user living in the home for four weeks. There was a lack of information about how this service user’s personal care needs should be addressed by the staff members, and there was no moving and handling risk assessment. It is acknowledged that there has been a vast improvement with the care planning process in the home; however, further improvements must be made to ensure that all service users have a written care plan. A failure to ensure this may result in enforcement action being taken by the Commission. A Requirement made at the last inspection about poor record keeping in relation to service user’s health and social care has been met. There were records in each of the five service user’s files examined detailing the contact they had had with a variety of health and social care professionals. Comments have been received regarding poor arrangements in the home for returning the correct items of clothing to service users from the laundry, and for ironing clothing. The Manager said that she was aware of these problems and had taken action to address them. This situation should be monitored. Medication was not examined in detail during this inspection, however, the last inspection of the home found medication to be generally handled safely. A recommendation made at the last inspection of the home has been addressed. Ten Medication Administration Records examined detailed information about any allergies suffered by the service users. Medication Administration Records were in good order and medication was noted to be stored and handled safely. There were records in place detailing the medication that entered and left the home. A care staff member said that they had not yet been trained in handling medication, and only those staff members who were trained, could administer medication to service users. Some positive interactions between service users and staff members were observed during this inspection. Staff members were noted, in general, to treat service users with respect, knock on bedroom doors before entering and seek to views of service users. A visitor said that some of the staff members were “wonderful” and “caring” However, it was concerning to observe one staff member refer to a service user as a “naughty girl” due to them not finishing their lunch. This is an inappropriate way in which to speak to an adult. A Requirement is made regarding this issue. Beaufort Lodge DS0000065236.V301865.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. There are good arrangements in place for ensuring that service users have access to social and leisure activities and for keeping in touch with their friends and family members. Meals are healthy and varied. Service users are therefore able to enjoy a lifestyle in accordance with their wishes. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users were listening to gentle music in the main lounge when this inspection commenced. Some service users had a newspaper and there was a good supply of books, including large print. There was information about service user’s social and recreational interests, and religious wishes in four of the care plans examined. There were also minutes of a recent meeting in the home that detailed that service users had been consulted with about the type of social activities to be facilitated in the home. One service user said that they had enjoyed a BBQ at the home the previous week that their relatives had attended this. Another service user said that there had recently been a day trip arranged by the home that they had enjoyed. Some service users had a television or music equipment in their bedroom. Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 14 Two visitors spoken with said that they were happy with the arrangements for visiting the home. One visitor said that they visited the home every day and were made to feel welcome by the staff members. Service users can see their visitors in private in their bedroom, or in the garden. One service user was visited by a relative and a Care Manager on the day of this inspection and had access to a staff meeting room in order to have a private discussion. The majority of service users spoken with said that they enjoyed the food in the home. Other service users appeared to be enjoying the meal. One service user said that they did not like the food in the home. It was noted however, that this service user was offered an alternative from the menu choices. The menu board displayed in the dining room detailed a choice of meal and desert. A meal of mashed potato, vegetables, poached fish and parsley sauce was served for lunch during this inspection. Meals were presented attractively and appeared nutritious. A meal was sampled and this was enjoyable. Staff members were available throughout the meal and offered appropriate support. There is a pleasant dining room and tables had been set attractively. There were records detailing that service users had been consulted with regarding their dietary preferences. Records also indicated that the home had been in consultation with the local Speech and Language Therapy Service in order to provide one service user with a specialist diet in line with their health care needs. All food storage areas were noted to be clean and in good order and food was stored hygienically. Beaufort Lodge DS0000065236.V301865.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. There is a system in place for the effective handling of complaints and service users and their relatives are encouraged to raise any concerns they have. Service users therefore know that their concerns will be acted upon. Arrangements are in place for handling allegations and instances of abuse however these must be improved to ensure that users will be protected from harm. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There are policies and procedures in place for dealing with complaints. Information is made available in the Service User Guide about how a compliant, concern or suggestion should be made, and how this will be handled. This information also includes details about how a concern may be raised with the Commission for Social Care Inspection. Feedback from four relatives indicated that they had been made aware of the home’s complaints policies and procedures. The Manager said that no complaints have been made about the home since the last inspection The home has a copy of the Royal Borough of Kingston Council’s vulnerable adult protection procedures. One service user has recently reported money go missing from their bedroom. The Manager has reported this issue to the police, who have yet to investigate this. She has also reported this to the Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 16 Commission for Social Care Inspection under Regulation 37. However, it is also necessary that this incident is reported to the local Adult Protection Coordinator, in line with local and national policies and procedures for responding to suspicion or evidence of abuse. A Requirement is made regarding this issue. Beaufort Lodge DS0000065236.V301865.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25 and 26. Improvements to the environment have been made. However, there remain a number of matters of concern which put people at risk of harm and do not provide safe and comfortable surroundings in which to live. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A number of bedrooms in the home have been redecorated and refurnished to a good standard. There have been improvements in the kitchen including the provision of a new oven, fridge, extractor fan and dish washer. The grounds of the home were tidy and safe and there is a very pleasant and well maintained garden that provides a number of seating areas. Requirements were made at the last inspection of the home regarding the need for improved fire safety arrangements in the home, in line with Requirements made by the London Fire and Emergency Planning Authority. It Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 18 was positive to note that all of these Requirements have now been met. However, there was an emergency light fitted to the first floor fire escape that prevented the fire door being opened fully. This light was removed before the end of this inspection and the fire door was seen to open fully. The Registered Providers are reminded that all fire escapes must be kept free from obstructions at all times. There are a number of hoists in the home and there was documentation detailing that these are safety checked on a regular basis. Records indicated that staff members from the home have been in consultation with local health care professionals regarding the provision of pressure relieving mattresses and cushions. There is a passenger lift in the home that is serviced regularly. All bedrooms seen had a call bell. The majority of these were working; however, the call bell in a ground floor bedroom was not working. This is of concern as previous inspections of the home has highlighted that service users have not had access to call bells. A Requirement is made regarding this issue. A Requirement was made at the last two inspection of the home regarding the need to ensure that draws provided in one service user’s bedroom did not have broken handles. This Requirement has now been met. A number of bedrooms seen had new, good quality furniture and carpets. The majority of bedrooms seen were homely and had been personalised by the service user. One service user said that they had been able to bring items of their own furniture to the home. One bedroom seen however, was not homely in appearance and contained only a small amount of the service user’s personal possessions. The Manager said that this was due to the service user being in the home on a temporary basis. It is strongly recommended that, were a service user does not bring items to personalise their bedroom, the Registered Providers ensure that the bedroom has some homely touches such as plants, a clock or pictures. There was a wardrobe in a bedroom on the ground floor that and a large hand written notice reminding staff members not to store linen in the wardrobe. This notice added an institutional feel to the bedroom. The Manager said that this had been put up by a care staff member and she removed it on the day of this inspection. It is also strongly recommended that the Registered Providers ensure that staff members avoid practices such as this. One service user said that they had been provided with a lockable box in which to store their valuables, and had been offered to use of the home’s safe. This service user also said that they had been given a key for their bedroom. However, the lock on this service user’s door did not ensure accessibility for staff members in the case of an emergency. A Requirement is made regarding the need for this lock to be changed. A Repeat Requirement is made regarding the need to ensure that water close to 43 degrees is provided in all bedrooms. Two bedrooms did not have hot water at the time of this inspection. There has been an ongoing failure by the Registered Providers to ensure that all service users are provided with hot water in their rooms. The Registered Provider said that there are plans to Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 19 replace the home’s boiler, but this would take up to two months. This is too long a period in which service users should go without hot water in their bedrooms. Alternative arrangements must be made for the provision of hot water until the boiler is replaced. It was positive to note however, that the Manager now carries out regular checks on hot water temperatures in the home. The home was generally clean and hygienic; however, there were some areas in which hygiene standards were not adequate: 1. There were stains on the walls in the lounge, one service user’s bedroom and ground floor corridors. 2. There were dirty sheets and a dirty blanket on a poorly made bed in one service user’s bedroom. 3. There was a smell of urine on the first floor corridor. Requirements are made regarding these issues. Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Staff members are provided in sufficient numbers; however, the procedures for the recruitment of staff are not robust and do not provide the safeguards to offer protection to people living in the home. There has been some improvements with the staff training and development programme, however, it remains that staff members are not provided with the training necessary for fully meeting the needs of service users. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The number of care staff members in the home at the time of this inspection, and detailed in staffing rotas appears to be adequate, and in line with the needs of the current service user group. Four relatives surveyed said that they believed that there are sufficient staff members on duty in the home. There has been no progress regarding the need for staff members to be trained at NVQ Level 2 in Care. A small number of care staff members have achieved NVQ Level 2 in Care; however, the home does not currently comply with National Minimum Standard 28, which requires that at least 50 of the care staff team have an NVQ Level 2 in Care. The Manager said that only one new staff member has commenced work in the home since the last inspection. Documentation for this staff member was Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 21 examined. It was concerning to note that a Criminal Records Bureau and Protection of Vulnerable Adults list check had not been carried out by the home for this staff member. The home had obtained and old Criminal Records Bureau and Protection of Vulnerable Adults list check, and all other information required by Regulation. Criminal Records Bureau checks are not portable. No staff member should be employed to work in the home until a new, satisfactory, Criminal Records Bureau and Protection of Vulnerable Adults list check have been applied for, and obtained. A Requirement is made regarding this issue. It was further concerning to note that there were no records detailing that this staff member had undergone induction training. A discussion with the staff member backed this up. The home’s training coordinator said that a new training and development system would be introduced in the home in September 2006 and provided documentation to demonstrate this. It is positive to note that arrangements are in place for providing future staff members with adequate training and induction. Also, that there has been a number of training sessions provided to staff members since the last inspection of the home. However, all new staff members must undergo induction training that is in line with ‘Skills for Care’ specifications. This has been an ongoing area of concern and a failure to address this may result in enforcement action being taken by the Commission for Social Care Inspection. Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. There has been an improvement with the management of the home which has resulted in some practices that reflect the wishes of the service users; however there remains a need for improvements to the quality assurance processes in order to ensure that the home is run in the best interests of service users. In general, there are adequate arrangements for ensuring health and safety. However, there remain some concerns regarding health and safety in the home, which potentially places the wellbeing of service users at risk. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: It was evident that the Manager has worked hard to meet a number of the Requirements made at the last inspection and to improve practices in the home. There remains a need for the Manager to make an application to Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 23 become registered with the Commission for Social Care Inspection and this must be done within the agreed timescale in order to avoid possible enforcement action by the Commission. There have been improvements to the quality assurance process in the home. There was documentation detailing that service users and their representatives had been surveyed about their views on the home, with the results being published. There was also documented evidence detailing that positive action has been taken by the Manager to address issues raised by the survey. Feedback from some service users and visitor was that they were able to raise any issues of concern, informally with staff members. There were minutes of a recent service user meeting detailing that service users had been consulted with about daily living issues in the home. There were also records detailing that the Manager has devised systems for in-house health and safety checks. It is of concern that the Registered Provider’s have failed to produce and annual development plan, despite Requirements being made regarding this at the last two inspections of the home. An action plan must be produced, based on a system of planning, action and review, reflecting aims and outcomes for service users. The action plan must detail how the Registered Providers intend to address the Requirements set out in this report. The Manager said that family members, in general, retain control over service user’s finances. Small amounts of money are kept in the homes safe for some service users for purchases such as toiletries and hairdressing. Records are maintained of the money held by the home on behalf of service users and any transactions. There was an up to date Landlords Gas Safety certificate, in line with a Requirement made at the last inspection of the home. Documentation was not available detailing that the home’s electrical system or portable electrical appliances have been safety checked. A number of Requirements have been made relating to poor health and safety arrangements throughout this report. Beaufort Lodge DS0000065236.V301865.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 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 2 3 X X 2 X 2 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 (1) (a)(b) (c)(d) Requirement Timescale for action 01/09/06 2. OP7 13 (4)(c) 15 (1) The Registered Providers must not admit a service user to the home, unless they have carried out, or obtained, a full assessment of the service user’s needs. A written copy of the needs assessment must be maintained in the home and available for inspection. 01/09/06 The Registered Providers must ensure that each service user has a written care plan in place that details their individual needs in relation to health, personal and social care, any significant risks, and how staff members will address these needs. Repeat Requirement. Timescales of 01/12/05 and 01/06/06 unmet. The Registered Providers must ensure that: 1. Service users are treated with respect, and have their dignity upheld at all times. 2. The staff member responsible for speaking to a service user in an inappropriate manner 3 OP10 12 (4)(a) 18 (1)(c)(i) 01/09/06 Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 26 receives training in dignity and respect. 4. OP18 12 (1)(a) 13 (6) The Registered Providers must ensure that any suspicion or evidence of abuse is reported to the local Adult Protection Coordinator without delay. The Registered Providers must ensure that call systems with an accessible alarm are available in every bedroom and bathroom. The Registered Providers must ensure that any bedroom door, to which a service user has a key, has a lock that can be opened by staff members at any time in the case of an emergency. The Registered Providers must ensure that water that is close to 43 degrees can be obtained from hot water taps in all bedrooms and bathrooms. Repeat Requirement. Timescale of 01/06/06 unmet. The Registered Providers must ensure that stains on the walls in the lounge, one service user’s bedroom and ground floor corridors are removed. The Registered Providers must ensure that service users are not provided with beds that have dirty sheets, dirty blankets and are poorly made. The Registered Providers must ensure that there is not a smell of urine on the first floor corridor. The Registered Providers must ensure that a new, satisfactory, Criminal Records Bureau and Protection of Vulnerable Adults list check have been applied for, and obtained in respect of any new staff member employed to DS0000065236.V301865.R01.S.doc 01/09/06 5 OP22 12 (1)(a) 23 (1)(a) 12 (1)(a) 23 (1)(a) 01/09/06 OP24 6. 01/10/06 7. OP25 13 (4)(a)(c) 01/09/06 8. OP26 23 (2)(d) 01/10/06 9. OP26 12 (1)(A) 23 (2)(d) 01/10/06 10. OP26 23 (2)(d) 01/10/06 11. OP29 19 (1)(a) Schedule 2 01/09/06 Beaufort Lodge Version 5.2 Page 27 11. OP30 12(1)(a) 18 (1)(a)(c) work in the home. The Registered Provider must ensure that there is individual staff training profile detailing when each new staff member has undertaken training, including induction training. 01/10/06 11. OP33 24 (1)(a)(b) (2)(3) Repeat Requirement. Timescale of 01/02/06 and 01/06/09 unmet. The Registered Provider must 01/10/06 ensure that there is an annual development plan in place, which is available for inspection. Repeat Requirement. Timescales of 01/02/06 and 01/06/06 unmet. The Registered Provider must ensure that: 1. An up to date electrical installation certificate is available for inspection. 2. Up-to-date records of portable appliance safety checks are available for inspection. 12. OP38 12 (1)(a) 13 (4)(a) 01/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP24 Good Practice Recommendations It is strongly recommended that, were a service user does not bring items to personalise their bedroom, the Registered Providers ensure that the bedrooms has some homely touches such as plants, a clock or pictures. It is strongly recommended that the Registered Providers ensure that bedrooms do not contain large signs that add an institutional feel. DS0000065236.V301865.R01.S.doc Version 5.2 Page 28 2. OP24 Beaufort Lodge Beaufort Lodge DS0000065236.V301865.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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