Inspection on 15/06/07 for Beaufort Lodge

This inspection was carried out on 15th June 2007.

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

Other inspections for this house

Beaufort Lodge 14/08/06

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 Adrian Gordon Key Unannounced Inspection 11:00 15th June 2007 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.V341521.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.V341521.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 8549 8737 info@carehomesofdistinction.co.uk 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.V341521.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th August 2006 Brief Description of the Service: Beaufort Lodge provides care for twenty older people some of whom have dementia care needs. The home is owned and managed by Care Homes of Distinction Ltd. Beaufort Lodge is situated in a quiet residential street in Surbiton. Information about the service is available in the Statement of Purpose and Service User Guide. Fees for the home range from £500 to £575.00 per week. There are additional fees for hairdressing and chiropody. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over the course of one day by two inspectors. The inspection consisted of a tour of the premises, examination of records and observation of care practice. We met with a residents and visitors, four members of staff and the manager. Feedback questionnaires were received from four general practitioners associated with the home. What the service does well: What has improved since the last inspection? What they could do better: There remains a number of issues about the protection of residents and ensuring their safety. Recruitment checks must be improved in order to make sure residents are fully protected. More care must be taken in making sure the environment is safe by storing hazardous chemicals appropriately. Hot water temperatures must be carefully monitored to prevent scalding. Staff must be regularly trained in the Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 Page 6 protection of vulnerable adults. Resident finances must be recorded more accurately to prevent any financial errors. In addition care plans must be made more person centred so that residents have care provided according to individual need. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 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 Lodge DS0000065236.V341521.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents receive an assessment before admission which helps to confirm that it is a suitable placement. EVIDENCE: Beaufort Lodge does not provide intermediate care. Detailed needs assessments are in place for residents and these provide good information on different areas of need such as personal care and communication. Two recently admitted residents came from the home next door while it is being refurbished. It is owned by the same provider. They have different needs to the rest of the residents at Beaufort Lodge, however some of the staff from their home transferred with them. One of these residents is currently seeking a more suitable placement as the home is not fully set up to meet their needs. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements in the care planning system helps residents in having their needs met, However, the care plans still need to be improved further. EVIDENCE: Care plans hold good guidance about how to meet the needs of residents and are written in the first person. This includes information about personal hygiene, mobility, interests and cultural/religious interests. More must be done to make sure information is person centred and specific to each resident, including a detailed life plan. Information on social interests is limited and there was little information on sexuality. There was also some information that conflicted. For example, one resident had expressed a preference not to have a bath but there was then information about how to deal with aggressive behaviour when bathing them. Forms for the resident to sign agreeing their care plan were not complete. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 Page 10 There is good information about how to meet the health needs of residents. Evidence was seen that there is access to outside specialist such as an optician, chiropodist, dentist or doctor as required. Risk assessments are in place for moving and handling to make sure that this is carried out safely. Some residents were concerned that the laundry system was still causing problems. Comments were made about clothes going missing or being shrunk in the wash. This was a problem at the last key inspection and must be improved. The system in place for the administration of medication helps to protect residents. Medication Administration Record (MAR) sheets had no gaps and were accurate. Medication is stored appropriately. However, the record of medication which comes into the home was not always filled in and this makes it difficult to monitor exactly what is stored. Staff were seen to treat residents with respect and to talk to them in an appropriate way. If residents were in their bedrooms, staff knocked before entering. Staff offer drinks throughout the day but these are served in plastic beakers. It would be more dignified if residents are offered proper drinking glasses. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy a good range of activities which they can choose to take part in. EVIDENCE: An activity coordinator is employed to offer a range of suitable recreation for residents. This includes a current affairs group, quizzes, exercise and visiting entertainers. A newsletter gives a list of future events. Day trips are sometimes arranged, such as a trip to the seaside. A minibus is hired to take people out. Each activity is written up, including who took part and whether it was enjoyed. On the day of inspection the majority of people were in the lounge. Staff were seen to be chatting informally to residents, sometimes dancing with them and enjoying the music. The atmosphere was relaxed and pleasant. Residents were seen to be asked by staff before being supported to do anything. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 Page 12 One visitor said they are made to feel welcome and can visit at any time. They described the home as ‘excellent’ but felt that not enough outside activities are provided. A phone is available for residents to use if required. One person was seen to make use of this to speak to their doctor. The cook is familiar with all the residents and has a good understanding of their preferences. Each day she asks residents what they would like from the menu and provides an alternative if requested. The cook relates well with people that live there and was observed complimenting one resident on their appearance. Fresh fruit was seen in bowls on all the tables. Residents said they liked the food. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents feel safe and are aware of how to make a complaint. A lack of regular training in adult abuse awareness does not support staff in protecting residents. EVIDENCE: There are suitable procedures in place for dealing with complaints. These are available in the Service User Guide. Residents spoken to said they knew what to do if they had a complaint. The manager said that there had been no complaints since the last inspection. The service has internal policies and procedures for the Protection of Vulnerable Adults (POVA) and a copy of the local procedures was also seen to be available. There have been no recent allegations of abuse. Some staff have been on recent POVA training but not everyone has received this over the past year. This does not support staff in fully protecting residents. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a comfortable homely environment but more could be done to make the home a safe place. EVIDENCE: All parts of the home were found to be clean and tidy. The lounge and dining room are comfortably furnished and have a relaxed, homely feel. To the rear is a large garden area for residents to enjoy. A lift opens to the lounge and provides access to bedrooms upstairs. Bedrooms were seen to be comfortable furnished and made personal with pictures and ornaments. There is one double bedroom for a couple who live there. The rest of the bedrooms are single. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 Page 15 A risk to the safety of residents is that two cupboards used for storing hazardous chemicals were left unlocked. Toilet cleaner was also seen in one bathroom and this room did not have a lock that could be opened from the outside in case of an emergency. A new call bell system has been put in since the last key inspection. Each call bell is now tested every day to ensure that they are working properly. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff provide good support to residents. However, recruitment procedures do not fully protect people who live at the home. EVIDENCE: On the day of inspection the staffing levels were appropriate for the number of residents. This was confirmed by the rota. Staff were observed to relate well with residents and to offer support sensitively. Comments from residents about the staff include ‘I like the care I receive - staff are hardworking’ and in surveys sent out by the manager, all residents who replied said they felt safe and well cared for. Four recruitment records were examined. Three of these showed all the necessary recruitment checks had been carried out but there was no photograph. One record only contained one reference and no adequate evidence of right to work. A Criminal Records Bureau Disclosure showed a conviction but there was no record of any action taken with regard to this. The manager said this had been looked at and she was satisfied the person Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 Page 17 concerned was safe to employ. During the inspection she completed a written statement to go on file which confirmed her actions. Application forms include the question ‘Have you been convicted of an offence?’ but do not leave any space for a response. This must be amended. There is a good range of training available, including food hygiene, manual handling and NVQ2, however core skills training is not always refreshed every year. The opportunity to attend specialist training, for example dementia care, is quite limited which makes it difficult for staff to get up to date with current practice. However, information about good practice in dementia care was seen on the staff notice board. The training programme is out of date and does not include a programme for staff over the coming year. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management is making improvements to the service which enable residents to lead better lives. Health and safety must be more closely monitored so that there are no unnecessary risks. EVIDENCE: The manager has been at the home for two years but was only recently registered with the CSCI. She is a registered nurse and is currently undertaking the Registered Managers Award. She has a good understanding of the different needs of people who live at the home and has made a number of improvements to the service since the last inspection. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 Page 19 Residents and their relatives are sent questionnaires as part of the quality assurance process. The most recent survey was at the beginning of June 2007. Fifteen responses were received from residents. These gave a mostly satisfactory response about living at the home. An action plan must be put in place to summarise the survey and show how the service will respond to the comments made. The system for monitoring the use of residents finance must be improved. Receipts are not always clear and in some occasions it was difficult to see why money was paid out. Receipts are not clearly numbered. When residents are required to pay for hairdressing this is not always taken on the day, but paid out at a later time. This is not good practice and can lead to financial errors. Health and safety checks are all up to date and include a gas safety certificate in April 2007 and fire alarm system inspection in March 2007. Fire point testing is carried out regularly and a fire risk assessment is in place. Hot water temperatures are monitored regularly. However it is concerning that the temperature of the water in a bathroom was recorded as 73°C on 1st June 2007 and no action was taken. The water in the same bathroom on the day of inspection was also extremely hot. This is a serious risk to residents. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 3 X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 12(1) Requirement New residents must not be admitted unless assessments support that the placement is a suitable one. So that the needs of residents can be fully met, care plans must be person centred and include a life history. Information on sexuality must be more detailed. Care plan agreements must be completed and signed but the resident or a representative. In order to further protect residents, medication that comes into the home must be recorded. The laundry system must be improved to make sure that residents clothes are not misplaced or damaged. To promote the safety of residents all staff must receive training on the protection of vulnerable adults every year. To ensure there are no unnecessary risks to residents, cupboards used for storing chemicals must be locked and cleaning materials must not be left out. All bathrooms and DS0000065236.V341521.R01.S.doc Timescale for action 31/07/07 2 OP7 4(b), 12(1), 15 15/08/07 3 4 OP9 OP10 13(2) 16(2)(e) 15/07/07 15/07/07 5 OP17 13(6) 31/07/07 6 OP19 13(4) 31/07/07 Beaufort Lodge Version 5.2 Page 22 7 OP29 19, Schedule 2 8 OP30 18(c) 9 OP35 16(2)(l) 10 OP38 13(4) toilets must have locks which can be opened from the outside in an emergency. To ensure that recruitment protects residents, records must contain all the requirements of Schedule 2 and application forms must be amended to allow details of any previous offences. To ensure that staff have the necessary skills to carry out their roles, specialist training must be provided and all staff must have an up to date training profile. To make sure there are no financial errors in the handling of resident money receipts must give clear details and be numbered. Money owed for hairdressing must be paid out on the day and not left owing. For the safety of residents the hot water temperature must not exceed 43°C and the temperature of baths must be monitored with a thermometer. 31/07/07 31/07/07 31/07/07 15/07/07 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 OP10 Good Practice Recommendations To promote their dignity residents should be offered suitable glasses to drink from. Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beaufort Lodge DS0000065236.V341521.R01.S.doc Version 5.2 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. 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