Inspection on 25/04/06 for Beaufort Lodge

This inspection was carried out on 25th April 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 14/08/06

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 Unannounced Inspection 25th April 2006 09:52 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.V288346.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 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.V288346.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th October 2005 (Additional visit undertaken on 20th March 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.V288346.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 25th April 2006 between 09.52 and 15.30. A partial tour of the premises took place and care records were examined. The Manager, Deputy Manager and two staff members were spoken with. Six 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. No visitors were present during the inspection. What the service does well: What has improved since the last inspection? There have been a number of environmental improvements made to the home since the last inspection. Some bedrooms have been redecorated and new furniture purchased. Some parts of the home are cleaner and safer. Service users have been consulted with about how they would like to spend their days and information about daily activities has been made available to Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 6 them. There have been improvements to the care planning process. Some service users have a detailed care plan that describes how staff members should meet their needs, and that they have been involved in drawing up. Record keeping in some areas has improved. There has been further training in the safe handling of medication and this has improved practices within the home. The Manager now carries out weekly audits of medication systems, which has also resulted in improved practice. There has been staff training in a number of areas including pressure area care, fire safety and adult abuse. A number of staff members have been enrolled on NVQ in Care training programmes. The home has benefited from the consistency of having a Manager in place as staff members have been given support and guidance. 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 DS0000065236.V288346.R01.S.doc Version 5.1 Page 7 contacting your local CSCI office. Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 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.V288346.R01.S.doc Version 5.1 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, 4 and 6. There are appropriate procedures for ensuring that service users have their needs assessed prior to moving into the home and improvements have been made regarding consultation with service users. Service users therefore have their needs addressed and wishes respected. 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: The Manager said that a full assessment of need is undertaken for each service user prior to them moving into the home. A representative from the home visits privately funded service users in their own homes, or in hospital to carry out an assessment prior to them moving into the home. A Care Management assessment is obtained for service users who are funded by a local authority. The most recent service user to be admitted to the home, was an ‘emergency admission’ There was a needs assessment in place that had been obtained from the placing authority Care Management team on the day that the service Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 10 user was admitted to the home. This assessment included a social history, risk assessments and details about the service user’s personal care needs. All service users spoken with indicated that they were content with life in the home, and received the support they needed from the staff. One service user said of the staff “they are very good” Concerns were raised at the last two inspection of the home regarding the lack of information available to service users regarding the home’s activity programme. Details about activities were available on the home’s notice board and there was a list of forthcoming activities and events. The notice board detailed that ‘gentle exercise’ would be facilitated on the morning of this inspection. Three staff members were noted to be facilitating this exercise and a number of service users were noted to be participating, and enjoying the exercise activity. The Manager said that she had consulted with service users individually regarding their preferences for organised activities. Whilst this is positive, it is recommended that any consultation with service users be recorded in daily care notes, or service user meeting minutes in order to ensure that consultation is meaningful and acted upon. At the last inspection of the home it was recommended that the loud door alarm be changed so as to ensure that service users are not disturbed each time the front door is open, this has now happened. The home does not provide intermediate care. Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 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 continues to be shortfalls in the care planning process. This has potential for service user’s health, personal and social care needs not being meet. There have been improvements in the handling of medication in the home. Practices now promote the wellbeing of service users. There have been improvements in care practice, which now ensure that service users are treated with respect and have their dignity upheld. 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: Service users spoken with indicted that they had their needs met. One service user said, “I always have a bath and they keep my clothes nice” another service user said “they buy all my toiletries for me” There have been some improvements to the care planning process. Care plans for two service users were examined and these detailed clearly how staff members should support the service users with personal care, diet, mobility and continence. Moving Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 12 and handling risk assessments were in place in these care plans. One care plan had been signed by the service user. Documentation was available detailing that care plans had been reviewed by the Manager. However, there continues to be poor care planning for a number of service users. The home has recently begun to use a new format for care planning. There has been no training for staff members regarding the use of the new ‘Standex’ care plans. Care plans examined for some service users did not detail how staff should meet their needs. There was no information in any care plan examined about how the home would address the service user’s social interests, hobbies, religious or cultural needs. A number of care plans had not been reviewed recently. A number of repeat Requirements are made regarding care planning. Each service user must have a care plan that is drawn up, were possible, with their, or their representatives involvement, that details how their health, personal, and social care needs will be meet, and is reviewed at least monthly and updated to reflect changing needs. Concerns were raised at the last inspection of the home regarding failures to fully document any contact with health and social care professionals. Records were available detailing that the home regularly consults with health and care professionals, however, one service user has a sore that the Manager said is dressed on a regular basis by community nurses. There was limited information in this service user’s care notes detailing the action taken by the home in response to the identification of this sore. This is of particular concern as concerns have recently been raised regarding failures by the home to arrange treatment for a service user who had a pressure sore. Detailed records must be maintained of all interactions with health and social care professionals. A repeat Requirement is made regarding this issue. Improvements have been made regarding the recording of and reporting incidents and accidents in the home. Improvements have also been made in the handling of medication. Records indicate that the Manager now carries out weekly audits of the medication system. There was a list of all staff members who have been trained to handle medication safely and the Manager said that refresher training in medication is planned. Medication policies and procedures were reviewed in February 2006. Six Medication Administration Records examined. All were up to date and in general, in good order. However, some Medication Administration Records did not detail if the service user suffered from any allergies. The Manager said that there is a record in each service user’s file detailing any allergies suffered. It is recommended that there is a record on each Medication Administration Record detailing any allergy suffered by a service user. Medication was noted to be stored securely. Concerns were raised at the last inspection that the dignity of service users was not fully respected. No concerns were raised regarding the upholding of service user’s dignity during this inspection. Staff members were noted to Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 13 knock and wait for permission to enter service user’s bedrooms during this inspection. One service user said of the staff “They treat us well” Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 14 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. National Minimum Standards 13 and 14 were assessed as being met at the last two inspections of the home and as there have been no changes regarding these Standards in the home, it remains that they are considered met. In general, service users receive a varied, wholesome and nutritional diet that meets their preferences, and structured activities are provided, however, further consultation is required in order to ensure that the wishes of service users are fully respected regarding food and activities. Some food is not stored hygienically and this compromises the health and wellbeing of service users. 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: There was information displayed on the home’s notice board detailing a range of activities to be held in the home. A number of service users were involved in an exercise group during this inspection. The home has a small library and a number of service users have a television in their bedroom. Some service users have a newspaper delivered to the home. One service user had a care Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 15 plan that detailed that they would see a priest in the home on a weekly basis. A number of the staff team are currently receiving training in organising activities for older people. Care records indicate that a number of service users receive regular visits from their friends and family members. The Manager said that she consults with service users regarding their social and recreational needs during the admissions process. She also said that she has recently consulted with service users on an individual basis about how they would like to spend their days. It was recommended at the last inspection of the home that service user meetings be held, with minutes kept, in order to gain to views and preferences of the service user group. This recommendation is repeated. Any other consultation with service users about activities should be recorded. There is a varied menu and meals are served in a pleasant dining area. Staff members were observed to offer service users appropriate support during a mealtime. There was positive feedback from service users spoken with about food in the home. One service user said that food was “satisfactory” and that there was always a choice. There was a menu displayed in the dining room and the cook said that, as this is a small home, she has an opportunity to talk individually with service users about their preference in relation to food. Some service users are provided with a diabetic diet. There are no service users from ethnic minority groups living in the home currently, however, specific cultural diets could be catered for following consultation with the Manager. There was a good supply of fresh fruit and vegetables in the home. In general, food storage and preparation areas were clean and organised. However, it was disappointing to note that two chickens were stored in the freezer without being wrapped in a protective cover. All food must be covered appropriately before being stored in the freezer. A Requirement is made regarding this issue. Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 16 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. It is unclear whether improvements have yet been made regarding the home’s response to complaints as no complaints have been made to the home recently. There have been improvements in the procedures for reporting incidents that occur in the home, this ensures that the well being of service users is promoted and protected. 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: The home has a complaints policy and procedure and information about making a complaint is made available to service users and their representatives. Concerns were raised at the last inspection, as there had been a poor response from the home regarding a complaint made by a service user. There have been no recent complaints made to the home. However, this Standard is considered met as the Manager has demonstrated a good awareness of her responsibilities for responding to complaints and concerns raised by service users and their representatives. The Manager has also demonstrated an awareness of her responsibility for reporting incidents and accidents that occur in the home, to the relevant authorities. Correct procedures have been followed since concerns were raised regarding this issue at the last inspection of the home. Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 17 Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 18 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, 21, 22, 24, 25 and 26. Improvements to the environment have been made. However, there remain a number of serious 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: There have been a number of environmental improvements to the home since the last inspection including the redecoration of some bedrooms, the replacing of furniture and improved hygiene standards. A new dishwasher and oven have been purchased for the kitchen. The garden and grounds of the home continue to be well maintained. The London Fire and Emergency Planning Authority visited the home on 07/03/06. The home, in general, complies with fire regulations; however, Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 19 three requirements were made following this visit. There must be an automatic fire detection devise fitted in the first floor. Records of evacuation drills should include the date of the drill and the names of those who participate in it. External emergency lighting must be in good working order. Whilst it is clear that positive action has been taken towards ensuring that service users enjoy a well maintained and pleasant environment, there remain a number of issues that require action. There was a broken window blind that was repaired on the day of this inspection. Both bath seats were broken at the time of this inspection. The Manager said that this had been the case for six days, and service users had been unable to use the baths during this time. The Manager stressed that she had made arrangements for both seats to be repaired. The Manager is aware of the need to contact the Commission for Social Care Inspection should the home experiences problems in replacing or repairing these seats within one day of this inspection. The door of a bedroom on the ground floor was wedged open with a waste paper bin. Should doors must be propped open, this must be done with a devise that is in line with fire safety regulations only. A Requirement was made at the last inspection of the home regarding this issue and it is therefore concerning to note that the safety of both staff members and service users continues to be put at risk. Water from hand washbasins in some bedrooms was not close to 43 degrees. A number of bedrooms were viewed. These were homely, well decorated and had been personalised. One service user said that they liked their bedroom. Some bedrooms had a television or radio and one service user has a private phone line in their bedroom. All bedrooms seen had a working and accessible call bell. Action has been taken to repair the broken draw handles in one bedroom, identified at the last inspection, however, these draw handles remain broken. All areas of the home viewed were clean and hygienic. There was a cleaner on duty during this inspection. Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 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. National Minimum Standards 27 and 29 were assessed as being met at the last two inspections of the home and as there have been no changes regarding these Standards in the home, it remains that they are considered met. There have been some improvements in relation to staff training, however, there remains a need for staff members to develop the skills and knowledge necessary for fully meeting the assessed needs of service users. 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: A small number of care staff members have achieved NVQ Level 2 in Care. The Manager said that three staff members are scheduled to undertaken NVQ Level 2 in Care, one staff member is scheduled to undertake NVQ Level 3 in Care, and a senior staff member will undertake training at NVQ Level 4 in Care. 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. Progress with staff training in this area will be looked at during the next inspection of the home. There has been a great deal of progress with staff training since the new owners purchased the home. Records indicate that within the last six months Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 21 staff members have received training sessions in oral hygiene, infection control, first aid, fire safety, health and safety, protection of vulnerable adults, moving and handling, bereavement, epilepsy, dementia awareness and pressure area care. There were also records detailing that nail, foot, skin and continence care is planned. Some record keeping in the home is currently poor and there are poor arrangements for care planning. There continues to be a need to ensure that all staff members, including senior staff members, undergo training in recording keeping and it is essential that all staff members receive training in how to use the ‘Standex Format of Care Planning. One staff member spoken with said that they had attended a number of training sessions and there were records to back this up. However, there were no records detailing training for one staff member and the Manager was unable to provide evidence that this staff member had received induction training. There must be a written training and development programme in place that is in line with ‘Skills for Care specifications. Each staff member must have an individual staff training profile detailing all training undertaken. Each care staff member must undergo an induction programme that includes training in moving and handling, health and safety, infection control, food hygiene, and the protection of vulnerable adults. Records must be available detailing all training undertaken by staff members and when refresher training is planned. Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 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. A new Manager has been appointed which has resulted in staff members receiving improved support and guidance. However, there remain a number of concerns regarding care practices in the home that put into question the Registered Providers fitness for ensuring that the aims and objectives of the home are met. National Minimum Standard 35 was assessed as being met at previous inspections of the home and as there have been no changes regarding this Standard in the home, it remains that it is considered met. 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. Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 23 EVIDENCE: A new Manager has been appointed and she has demonstrated a commitment to meeting some of the Requirements set at the previous inspection. Staff members spoken with said that they had received good support from the new Manger. The Manager is a qualified nurse and has many years experience of working in a care home setting. This Standard is not considered met, as the Commission for Social Care Inspection has not yet received an application for registration from the Manager. There has been little progress in the development of a quality assurance programme. A Requirement made at the last three inspections of the home regarding the need to provide the results of an effective quality assurance system, to service users and their representatives is reiterated. There was no business, or development plan. This must also be implemented in line with Requirements made at the last two inspections of the home. Failures to address these repeat Requirements may result in enforcement action being taken. Policies and procedures are currently in the process of being reviewed. Since the last inspection a lock has been fitted to the boiler room door and this area no longer poses a risk to service users. There were records detailing that water temperatures, fridge and freezer, bath water and food temperatures are monitored regularly. There is a contract in place for the collection of clinical waste and records indicate that testing for legionella occurs. The home has up to date insurance. There is a contract in place for the testing of all fire safety equipment in the home and there are regular in-house fire alarm tests and fire drills. There are outstanding London Fire and Emergency Planning Authority safety Requirements (Refer to Standard 19 of this report) There were no records detailing that there has been gas safety, electrical installation safety and portable appliance safety tests in the home recently. These safety checks must occur. Some staff members have not been trained in safe working practices (Refer to Standard 30 of this report) Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X 3 3 X 3 2 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 1 Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 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 OP7 Regulation 13 (4)(c) 15 (1)(2)(b) (c) Requirement The Registered Providers must ensure that each service user has a written care plan in place that: 1. Details their individual needs in relation to health, personal and social care, and how staff members will address these needs. 2. Details any identified risks and how these risks can be reduced. 3. Includes an inventory of the service user’s possessions. 4. Includes a record of the service user, or their representative’s involvement in the care planning process, including their signature. Repeat Requirement. Timescale of 01/12/05 unmet. 2. OP7 15 (2)(b) The Registered Providers must DS0000065236.V288346.R01.S.doc Timescale for action 01/06/06 01/06/06 Page 26 Beaufort Lodge Version 5.1 ensure that care plans are reviewed at least once monthly, and updated to reflect changing needs. Records must be maintained of each review. Repeat Requirement. Timescale of 01/09/05 unmet The Registered Providers must ensure that clear records are maintained of any consultation with, or visit from a health or social care professional, regarding a service user. Repeat Requirement. Timescale of 01/12/05 unmet 4. OP15 16 (2)(j) The Registered Providers must 01/06/06 ensure that all food that is stored in the freezer is suitably wrapped so as to prevent cross contamination. 01/07/06 The Registered Providers must ensure that the requirements set following the most recent London Fire and Emergency Planning Authority are met: 1. There must be an automatic fire detection devise fitted in the first floor. 2. Records of evacuation drills should include the date of the drill and the names of those who participate in it. 3. External emergency lighting must be in good working order. The Registered Providers must ensure that doors are not propped open with any other DS0000065236.V288346.R01.S.doc 3. OP8 12(1)(a) 13(1)(b) 01/06/06 5. OP19 23 (4)(a) 6. OP19 23 (4)(a) 01/07/06 Beaufort Lodge Version 5.1 Page 27 devise than one that has been approved by the local fire safety officer. Repeat Requirement. Timescale of 01/12/05 unmet. The Registered Providers must ensure that all draws provided in bedrooms are in a good state of repair. Repeat Requirement. Timescale of 01/05/06 not met. 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. The Registered Providers must ensure that all staff members, including senior staff members, who currently work in the home, and any new staff members undergo training in: 1. Recording Keeping in Care Homes. 2. How to use the ‘Standex Format of Care Planning. 3. Protection of Vulnerable Adults (including identifying and reporting suspected abuse. Repeat Requirements. Timescale of 01/02/06 unmet. The Registered Provider must ensure that: 1. There is a, written, Training and Development Programme in place that is in line with ‘Skills for Care specifications. 2. There is individual staff Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 28 7. OP24 16 (2)(c) 01/06/06 8. OP25 13 (4)(a)(c) 01/06/06 9. OP30 12 (1)(a) 18 (1)(a)(c) (i) 01/06/06 10. OP30 12(1)(a) 18 (1)(a)(c) 01/06/06 training profiles detailing when each staff member has undertaken training, including induction training. Repeat Requirements. Timescale of 01/02/06 unmet. The Registered Provider must ensure that: 1. The results of satisfaction surveys are published and made available to service users. Repeat Requirement. Timescales of 01/03/05, 01/09/05 and 01/02/06 unmet 2. There is an annual development plan in place, which is available for inspection. Repeat Requirement. Timescale of 01/02/06 unmet. The Registered Provider must ensure that: 1. An up to date Landlords Gas Safety certificate is available for inspection. 2. An up to date electrical installation certificate is available for inspection. 3. Up to date records of portable appliance safety checks are available for inspection. 11. OP33 24 (1)(a)(b) (2)(3) 01/06/06 12. OP38 12 (1)(a) 13 (4)(a) 01/12/06 Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 29 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 OP4 Good Practice Recommendations The Registered Providers should ensure that any consultation with service users about activities be recorded in daily care notes, or in service user meeting minutes in order to ensure that consultation is meaningful and acted upon The Registered Providers should ensure that there is a record on each Medication Administration Record detailing any allergy suffered by a service user The Registered Providers should ensure that there is a menu displayed that details a choice. 2. 3. OP9 OP15 Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 30 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. Extracts may not be used or reproduced without the express permission of CSCI Beaufort Lodge DS0000065236.V288346.R01.S.doc Version 5.1 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!