Inspection on 30/01/06 for Beaufort Lodge

This inspection was carried out on 30th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beaufort Lodge 31/07/07

Beaufort Lodge 02/08/06

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 Unannounced Inspection 30th January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beaufort Lodge DS0000063576.V284229.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 DS0000063576.V284229.R01.S.doc Version 5.1 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.V284229.R01.S.doc Version 5.1 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. 12th July 2005 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. Beaufort Lodge DS0000063576.V284229.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 30th January 2006, and lasted for 7 hours 45 minutes. The inspection process included discussion with the registered provider and the acting manager, three members of staff and three relatives who were visiting the home during the inspection. A tour of the premises was undertaken with the registered provider, and a sample of records and policies were viewed. Time was spent during the day amongst the residents of the home and seven were spoken with individually. The inspector would like to thank everybody who was involved in the inspection process. What the service does well: What has improved since the last inspection? The registered provider is in the process of making significant changes to the home to improve the lives of both the residents and the staff. Since the last inspection, the lounge chairs have been renewed, a new tumble drier, kitchen equipment, a new emergency lighting system and a new cleaning /hygiene system have been installed. Residents said that the food has improved and the standard of food seen at the inspection was very good. Residents’ meetings are now held monthly and changes are made in the home according to their wishes. The acting manager described that at a recent meeting, they requested swede to be added to the menu, and this has now been done. The registered provider has now produced an up to date Statement of Purpose and Service User Guide, to ensure people know what the home offers, and can decide if it will be able to meet their needs. Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 6 The area manager is completing a monthly report on the home and sending a copy to the Commission for Social Care 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 contacting your local CSCI office. Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Although these standards were not looked at during this inspection, the inspector viewed a new Statement of Purpose and Service User Guide which the provider has recently produced, to enable prospective residents to know if their care needs can be met by the home. Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 Minor shortfalls in the completion of care plans and medication could mean that the needs of residents are not fully met. EVIDENCE: Residents spoken with were very complimentary about the staff and felt that their care needs were being met. They described the care staff as “very patient” and three relatives said that they were pleased with the quality of the care being given to the residents. During the inspection, staff were seen to interact with the residents respectfully and there was a pleasant atmosphere in the home. Individual care plans are kept for residents, along with a nutritional record and an activities record. The care plans were inspected for two residents, and there were shortfalls in the recording of information for a new resident. These included basic care needs and risk assessments and management of any risks identified. Staff had a very good knowledge of individual residents and were able to identify any care needs and confirmed that they have a verbal handover between shifts. Medication was generally seen to be well handled by the home. Recordings and stock balanced on MAR sheets selected at random. There were minor shortfalls in the recording in the Controlled Drug book and some liquid Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 10 medication was out of date in the fridge. Liquid medication and eye drops need to be dated on opening, to ensure they are not used past their expiry date. Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15 Daily routines are flexible and the home promotes residents to remain independent and supports them to maintain control over their lives. Food is supplied in sufficient quantity and quality to provide a well balanced diet for individual needs. EVIDENCE: Residents and relatives both confirmed there is always “lots going on” in the home. They were very positive about some of the activities that had happened recently, including outings, parties and games held within the home. The activities co-ordinator said she is supported by the residents and their families both in fundraising and in time spent participating in the activities. A notice is displayed of any forthcoming outing and residents have the choice if they want to join in and an individual record is kept. On the day of inspection, approximately twelve residents were playing a quiz game, and there was lots of chatter and laughter. The home operates a four weekly menu and a member of the care staff goes to residents on the previous day to ask them their choice of food for the following day. Menus are also discussed at residents’ meetings and there is also a comments book, where residents can record any views. The dining area is very attractive, with cloths and flowers on the table and good quality china and cutlery in use. One visitor to the home confirmed that she has stayed to lunch twice recently and said that it was very nice, with “the lightest sponge pudding I have ever Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 12 had”. Another relative said that her mother is happy with the food and has put on weight since being in the home. Residents said that the food has improved and there is lots of variety. Comments made were “Sunday roast is lovely”, “meals are much nicer now” and “I always enjoy the sweet course but today was extra good, if I hadn’t been so full I would have done an Oliver Twist and asked for more.” Nutritional charts are kept but it was suggested to the acting manager that she might develop these to include amounts eaten by residents with higher dependencies. Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 The home has a satisfactory complaints procedure. Some staff are not aware of the issues relating to the protection of vulnerable adults, which could put the residents at risk. EVIDENCE: There have been no complaints since the last inspection. Each resident has a copy of the complaints procedure in their bedroom and the home has a complaints policy and a complaints book. Both residents and relatives confirmed that they felt able to discuss any concerns with the management of the home and that they would be sorted out. The acting manager had a good knowledge of abuse but in her new role needs to have a clearer understanding of the reporting of abuse. She recognises this and will access some appropriate training. One member of staff who commenced employment in the home in October 2005, did not recognise the term “Whistleblowing” and needed prompting on different forms of abuse. New members of staff must have POVA training to ensure the continued protection of the residents. However eleven members of the sixteen staff team have had POVA training in the last year. Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25, 26 The home is clean, comfortable and homely, making it a pleasant place to live. It is generally well maintained making it a safe place to live. EVIDENCE: A tour of the premises was conducted with the registered provider. Since the last inspection, the lounge chairs, the emergency lighting system and some kitchen equipment have been replaced. There has also been the installation of a new cleaning/hygiene system, which will benefit the home. There are still some areas that need to be addressed, mainly the fitting of mixer valves to individual sinks to ensure that hot water is delivered at a safe temperature and access by residents to the radiator thermostat in their bedrooms. These and other minor issues were discussed with the registered provider at the inspection. The home has a maintenance person who regularly checks the home for any shortfalls, and there is a maintenance book to record any work to be done. The garden area is well maintained and residents spoke of their pleasure to look out of the lounge window at the wildlife in the winter. Residents and visitors confirmed that the home is always clean and tidy and there are never any unpleasant odours. Clothes were seen to be stored tidily Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 15 in wardrobes and drawers and residents’ clothes were clean and ironed. One new member of staff said she enjoyed working in the home as it is “cosy”. Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 Staff are employed in sufficient numbers, and have the skills to meet residents’ needs. EVIDENCE: The home is fully staffed and no member of staff is working excessive hours. Generally staff and residents felt there are enough staff on duty to meet residents’ needs. However one resident said that sometimes in the evening the staff are busy on the first floor, leaving the downstairs lounges unattended. This was discussed with the acting manager at the inspection, who agreed that the deployment of staff should be addressed to ensure that one member of staff is downstairs at all times. Staffing levels appeared to allow time for staff to spend time with residents, and residents said that the staff are always kind and never impatient. The files of two new staff members were checked and these contained evidence of CRB/POVA checks being carried out prior to commencement of employment. There were minor shortfalls on the records, which were discussed with the acting manager at the inspection. The staff team are very committed to training and one member of staff has NVQ level 3, eight have achieved NVQ level 2 and three are presently working on NVQ level3. The home is to be commended and this ensures the residents are in safe hands. Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 17 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, 38 The home has clear leadership to ensure the consistency of care for the residents. EVIDENCE: The acting manager has worked at the home for nineteen years and commenced her NVQ level 4 in care and management in September 2005. She has recently undertaken the role of manager of the home and an application form has been sent to the registered provider for her to be registered with CSCI. Residents, relatives and staff were positive about this position and felt that the home is being well run under her management. Evidence was seen of regular meetings with staff and residents and the home has recently completed an annual questionnaire for relatives and stakeholders. This information now needs to be collated and analysed and an action plan formulated and given to residents and CSCI. Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 18 Four residents handle their own finances, the home does not act as power of attorney for any residents. Money held by the home on the residents’ behalf was checked and agreed with their individual records. The health and welfare of the residents is protected by up to date maintenance of the home. This includes gas and electricity servicing, window restrictors to upstairs windows, maintenance of equipment and security of the premises. Food was seen to be stored appropriately in the fridge and records relating to fire safety were examined. All the senior care staff are qualified first aiders and one member of staff is undertaking training to be a moving and handling assessor. Evidence was seen of forthcoming first aid and moving and handling training sessions, asking staff which session they wish to attend. COSHH training was given to staff in January 2006 by the home’s new supplier. The relevant risk assessments now need updating. The acting manager said that the Health and Safety policy is under review. Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 19 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 X X 3 2 3 STAFFING Standard No Score 27 3 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 20 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 15 Requirement Timescale for action 31/03/06 2 OP9 13 (2) 3 OP18 13 (6) 4 OP25 13 (4)(C) The registered person must prepare a plan as to how a resident’s needs will be met. This refers to all areas as detailed in standard 3 and any individual special needs, involving the resident/relatives This is a repeat requirement The registered person must 31/03/06 make arrangements for safe administration of medication in the home The registered manager must 31/03/06 make arrangements for the acting manager and new members of staff to receive training relating to the protection of vulnerable adults The registered person must 30/04/06 ensure all areas of the home are free from risks to residents. This refers to the temperature that hot water is delivered. Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard OP7 OP24 OP27 OP29 OP31 OP33 Good Practice Recommendations The acting manager should develop nutritional plans to record the amount eaten and use them for residents who have been risk assessed to need them. The registered person should offer lockable storage to all residents in their bedroom, and record in their care plans if they do not require it. The acting manager should arrange the deployment of staff to ensure residents are not left unattended. The acting manager should obtain two references and get telephone verification where necessary. A ten year working history should be recorded. The registered provider should submit an application to CSCI to register the acting manager. The registered person and acting manager should develop a plan and submit to CSCI based on information acquired from the quality assurance process. Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Beaufort Lodge DS0000063576.V284229.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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