Inspection on 02/08/06 for Beaufort Lodge

This inspection was carried out on 2nd August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 31/07/07

Beaufort Lodge 30/01/06

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Beaufort Lodge Beaufort Lodge 10/12 St Vincent`s Road Westcliff on Sea Essex SS0 7PR Lead Inspector Christine Bennett Key Unannounced Inspection 09:00 2nd August 2006 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 DS0000063576.V301245.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 DS0000063576.V301245.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaufort Lodge Address Beaufort Lodge 10/12 St Vincent`s Road Westcliff on Sea Essex SS0 7PR 01702 353640 01702 353640 beaufortlodge@btconnect.com 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) Mr Navneet Singh Johar Mrs Aunjali Johar Manager post vacant Care Home 21 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (21) of places Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Total number of service users for which personal care can be provided must not exceed twenty one. Personal care to be provided for up to four older people aged over 65 years who have dementia. 30th January 2006 Date of last inspection Brief Description of the Service: Beaufort Lodge is registered for twenty one older people, four of whom might additionally suffer with dementia. The accommodation is on two levels with a stair lift to enable access to both floors. It has two lounges, one with a dining area, eleven single bedrooms and five shared bedrooms. It has a large enclosed garden and there is limited parking to the front of the property. It is situated in a residential area close to the shopping centre at Southend on Sea, the seafront and also nearby to bus and train routes. The home has an updated Statement of Purpose, Service User Guide and a copy of the last inspection report in the entrance hall. The current scale of charges as at July 2006 is between £400 - £475 per week. Extras charged are for hairdressing, chiropody and newspapers. Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key site visit was unannounced and took place on 13th July 2006 over a nine hour period. At this inspection all the key standards and the progress since the last inspection were assessed. A pre inspection questionnaire had been completed by the home prior to this visit. 10 surveys were sent to residents, of which 6 were returned, 10 to relatives, of which 7 were returned, and 5 to health professionals, of which 5 were returned. The acting manager was available throughout the day to assist with the inspection process. A tour of the premises took place and a random selection of records and policies were examined. Time was spent with the residents, observing care practices, and conversation took place with most of them and any visitors to the home. Staff were also given the opportunity to speak with the inspector. Feedback was given to the registered manager at the end of the site visit. What the service does well: The home makes sure that they can look after residents properly by visiting each one in their own home and inviting them and their relatives to the home to see if they like it. One resident said, “the home was very nice, clean and welcoming” and another who had been unable to visit said, “my son and daughter in law told me how lovely it was.” The home has an established staff team who know all the residents well. This means that they understand what their needs are and their likes and dislikes. The residents and relatives were all happy with the care and comments made were, “my mother gets fantastic care”, “the staff look after me very well” and “at my age I have more needs now and there is always someone to tend to me”. There is a good choice of activities going on in the home and the relatives are included in some of them. One resident said, “There are always activities that I very much enjoy but only take part if or when I feel like it”. The home consults with the residents and relatives about the running of the home and their views are listened to. Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. Beaufort Lodge DS0000063576.V301245.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 DS0000063576.V301245.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): 1,3,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The pre admission assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: The Statement of Purpose and Service User Guide have been updated in April 2006 to reflect the service that the home can offer to future residents. These are displayed in the hall, along with the last inspection report. Surveys received from residents described a pre admission procedure whereby they or their family had visited the home. The manager said they are welcome to spend time in the home and share a meal with the other residents before they decide if it is the right place for them. Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 10 The registered provider or the area manager had also visited them in their own home to take a detailed history to make sure that the home could meet their needs. The manager was happy with this arrangement as both these people are in the home frequently and can make a good assessment. A review is held approximately one month after admission to make sure everybody is happy with the arrangement. Two care plans looked at had detailed pre admission forms. Five of the six surveys returned commented that they had received enough information before moving into the home. One resident commented, “When I was shown round the home, it was clean and I was very much welcomed.” Intermediate care is not provided by the home. Beaufort Lodge DS0000063576.V301245.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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents’ health needs are well met with good multidisciplinary working taking place. EVIDENCE: The home is in the process of introducing new care plans. The manager thinks they will be easier to use, and is planning training for staff to make sure they understand how to use them. Care plans were seen for two residents and generally these had the information needed to allow staff to give the best care. A good life history had been recorded, allowing the staff to have a good insight into the person, and not just their care needs. There was evidence that relatives had been involved in the care plans. The home liaises well with other professionals and all the residents’ surveys felt that they receive the medical support they need. The optician visits twice a year, the chiropodist 6 weekly and the dentist visits when required. One Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 12 resident commented, “the doctor is called when necessary” and the chiropodist commented, “the home is well run and efficient, any requirements I have are dealt with quickly and efficiently”. The residents were satisfied with the care that they are getting and the relatives were equally complimentary. Two visitors said that they come at all different times to the home and they are always happy with their relative’s care, saying “the staff are wonderful”. Other comments made were, “I am completely satisfied with the way I am looked after” and “anytime I want anything it is got for me, or even if I want a chat, the girls are there”. Medication was generally well handled by the home and was stored appropriately. The manager said that the home has a good relationship with the pharmacist and he visits the home monthly. There were minor errors noted that were bought to the attention of the manager at the site visit. Staff who administer medication are having refresher training in August 2006. Residents felt their privacy and dignity are respected in the home. There are privacy screens in shared rooms and staff always knock before entering. The residents have the option of locking their own rooms and have lockable storage within the room. One resident has their own telephone and one resident receives communion in her room. Beaufort Lodge DS0000063576.V301245.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): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to the service. A range of activities within the home and community provide stimulation and interest for people living in the home. EVIDENCE: The home recognises the importance of providing occupation for residents. One of the senior members of staff takes responsibility for organising events and fund raising. She spoke of the support she receives from the residents and their relatives. A relative said, “Mum enjoys the entertainment, although she doesn’t remember afterwards. We are invited to functions held at the home such as Christmas parties, garden parties and evening quizzes”. A relative also commented, “very friendly staff and we are made very welcome at all times”. Residents comments included, “it’s very varied with games and singing to a pianist”, “they always have activities there if I want to join in” and “the girls always find a way for me to join in”. At the site visit a pianist visited the home in the afternoon and some of the residents enjoyed singing along with him. The home has a comments book for residents and relatives. This included a thank you to say how much they had enjoyed the cream tea and relatives thanking the staff for getting their relative ready for a special occasion and the interest shown by staff afterwards. Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 14 The home operates a four weekly menu and the residents discuss different food preferences at the residents’ meetings. One resident said, “I am very happy with the menu” and another said, “ there is always something on the menu that I like, and if not the staff will always cater to my needs”. Visitors are able to come to the home for a meal. A member of staff confirmed that residents can get up and have their breakfast when they choose, and can come downstairs in their dressing gown and slippers if they choose. Lunch and tea were seen at the site visit and the residents were sitting in the dining area and seemed to be enjoying their meal in an unhurried way. Beaufort Lodge DS0000063576.V301245.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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by the home’s complaint procedure and staff knowledge of POVA. EVIDENCE: There have been no complaints to the home in the last year. The surveys revealed that all residents who responded would know who to talk to if they were unhappy and most knew how to complain. There is a copy of the complaint’s procedure in each bedroom. The policies relating to abuse and “whistleblowing” have been updated in April 2006. The manager has attended POVA training relating to her responsibility as a manager and all staff are up to date with POVA training. All staff spoken with had a good knowledge of different types of abuse and how to report it. There have been no allegations of abuse at the home. Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 16 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): 19,25,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of mixer valves on the hot water system could potentially put the residents at risk of scalding. Other areas of the home have improved and are clean and hygienic EVIDENCE: A tour of the premises was conducted with the registered provider. A maintenance person is now employed, and carries out regular checks on the home. Any work that needs to be done, is recorded in the maintenance book. The home and garden are generally well maintained and the resident’s comments in the surveys included, “There is never any unpleasant smell, only fresh and pleasant odours” and “the home always smells sweet”. One relative commented, “Clean but sometimes smells of urine”. There are still some areas that need to be addressed in the home to offer protection to the residents. This includes the fitting of mixer valves to individual sinks to ensure that hot water is delivered at a safe temperature. Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 17 Some wedges are still being used in doors and the registered provider acknowledged that magnetic fire doors need to be fitted in these areas. Individual bedrooms were clean and tidy with their own personal items to make them seem more homely. One relative spoke about her mother saying, “she feels that this is her home which is very important” and residents comments were, “I am happy to be here, they make me feel at home” and “this is my home”. The manager confirmed that there are still areas in the home awaiting refurbishment, and this will start in September 2006. She has compiled a list of furniture to be upgraded. Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 18 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staffing levels and skills are appropriate for the needs of the residents. EVIDENCE: The home is fully staffed and staff are not working excessive hours. Residents had indicated that another member of staff was needed in the evenings and the manager had increased the staff numbers accordingly. She felt it had not been beneficial and it was discussed at a residents’ meeting. The outcome was that the residents said it had not made any difference and the staff numbers reverted back. The manager is keeping it under review. Resident’s surveys generally felt there are enough staff to meet their needs. Comments made were, “there is always someone about”, and “they are there when I need them”. One resident wrote, “More staff would be nice but they do the best they can”. Staff spoke of a good staff team and there was a friendly atmosphere around the home. The manager has completed NVQ level 4 in care and management. Seven care staff have achieved NVQ level 2 and two new members of staff have applied to commence this training. Three care staff are in the process of doing NVQ level 3 and two have applied to commence NVQ level 4. Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 19 The home was able to evidence extensive training that is taking place for staff in the autumn. This includes infection control, pressure area care, vital signs, dementia, continence, falls prevention, nutritional needs and fire training. One member of staff was able to discuss the special needs of a resident who has dementia and had extensive knowledge around this subject. The staff file was checked for a member of staff who had been recruited since the last inspection. There was no evidence to state that a POVA 1st check had been done and the CRB was obtained after her commencement date. Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 20 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): 31,33,35,36,37,38 Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The manager provides stability to the home and provides leadership and direction to staff to promote the health, safety and welfare of the residents. EVIDENCE: The manager has been in post for approximately one year, although she has worked in the home for many years. She has recently completed NVQ level 4 in care and management. The registered provider has an application form to register as the manager with CSCI. Staff were positive about her managerial role and said that she is approachable and listens to people’s views. One member of staff felt reassured that she did not share confidential information Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 21 The home has carried out it’s own quality assurance programme consulting with residents and relatives and stakeholders of the service. Evidence was seen of regular staff and residents’ meetings. This information has been collated and an action plan produced and will be made available to the residents and CSCI. Money held by the home on the residents’ behalf was checked and agreed with their individual records. It is held securely by the home. Staff supervision is in place and evidence was seen on staff files. A member of staff confirmed that she had received supervision on a regular basis. The home has been inspected by the fire department in July 2006, and a small number of requirements need to be met. Night staff must have fire training made available to them. The home endeavours to maintain a safe and secure environment for the residents with a programme of regular maintenance checks. Concerns identified in relation to the health and safety of residents are the temperature at which hot water is being delivered and the lack of automatic closures on fire doors. Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 22 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 3 X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X 2 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13 (2) Requirement The registered person must make arrangements for safe administration of medication in the home The registered person must comply with the requirements of the fire service. This refers to removing wedges in doors and fitting magnetic closures. Timescale for action 31/10/06 2. OP19 12(1) 31/10/06 3. OP25 13 (4)(C) 4. OP29 Schedule 2 The registered person must 31/10/06 ensure all areas of the home are free from risks to residents. This refers to the temperature that hot water is delivered. This is a repeat requirement The registered person must 31/10/06 operate a thorough recruitment policy. This refers to the absence of a POVA 1st on a file where the CRB was received after the commencement of employment. Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 24 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 OP31 Good Practice Recommendations The registered provider should submit an application to CSCI to register the acting manager. Beaufort Lodge DS0000063576.V301245.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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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