Inspection on 31/07/07 for Beaufort Lodge

This inspection was carried out on 31st July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 02/08/06

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 10/12 St Vincent`s Road Westcliff on Sea Essex SS0 7PR Lead Inspector Pauline Dean Unannounced Inspection 31st July 2007 09:45 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.V347484.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.V347484.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaufort Lodge Address 10/12 St Vincent`s Road Westcliff on Sea Essex SS0 7PR 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) 01702 353640 01702 353640 beaufortlodge@btconnect.com Mr Navneet Singh Johar Mrs Aunjali Johar Mrs Susan Anne Brown 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.V347484.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. 2nd August 2006 Date of last inspection Brief Description of the Service: Beaufort Lodge is registered for twenty one older people. 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. At the time of the site visit, the care home had only one functional bathroom located on the ground floor. It is understood that prior to recent building work to convert a double room into two single rooms the home had two bathrooms. Plans are in place to add a two-storey extension with two bedrooms and a second ground floor bathroom with specialist bath and shower attachment. Beaufort Lodge is situated within easy reach of the seafront and a local shop area at Westcliff on sea. The town centre and shopping centre of Southend on sea is a bus or train ride away. The home is close to rail and bus links. The current scale of charges as at the site visit was £385 to £550 per week. Hairdressing, chiropody, toiletries and newspapers are charged at cost. Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Beaufort Lodge took place on 31st July 2007 over a 7½-hour period. The inspection involved checking information received by Commission for Social Care Inspection (CSCI) since the last inspection in August 2006, looking at records and documents at Beaufort Lodge and talking to care staff and the people living at the home. This included the Annual Quality Assurance Assessment completed in June 2007 by the previous manager. The registered manager, Mrs Susan Brown was not available at this inspection. Mrs Sandy Hall, the Area Manager assisted at this inspection. At the site visit a tour of the premises was completed. Questionnaires were left with the Area Manager for distribution to all of the people living at Beaufort Lodge and seventeen surveys were completed and returned to the Commission by the people using the service, nine by relatives, carers and advocates and three surveys were completed by health professionals. During the inspection visit four people who live at Beaufort Lodge were spoken with. All were pleased with the service and happy about way they are supported and assisted by the staff. One person living at the care home said in the survey that staff were ‘helpful and kind people’. Four surveys completed by relatives said that ‘Staff are friendly and seem to care about the people who live here’, another said that ‘They (staff) provide the necessary support in a cheerful caring manner’ and a third said that staff were ‘Excellent. Twenty-four National Minimum Standards were inspected. This included all key standards. Six requirements and two recommendations were made as a result of this inspection, with all outcomes, excellent, good or adequate. What the service does well: The home continues to give a good choice of activities and entertainment in the care home. Consideration and thought is given to both the people living at Beaufort Lodge and their relatives. The home consults with them both as to the activities and entertainment offered and in the running of the home. The majority of people surveyed by Commission for Social Care Inspection (CSCI) had had a positive experience when they came to live at Beaufort Lodge. They said that they received sufficient information to enable them to make an informed choice as to whether the care home was for them. Beaufort Lodge DS0000063576.V347484.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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A comprehensive admissions process ensures that people who come to live at Beaufort Lodge are assured that their needs are met. Intermediate care is not offered at Beaufort Lodge. EVIDENCE: On the day of the site visit there were twenty people living at Beaufort Lodge. Mrs Sandy Hall, the Area Manager said that the primary care needs of the people living at Beaufort Lodge related to their old age, with twelve people having some form of memory loss and confusion. Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 9 The admission process was discussed and considered with Mrs Hall and paperwork was seen to support a comprehensive assessment and admission process. The pre-admission paperwork completed by the home detailed a wide range of physical and personal care needs such as mobility and dexterity, foot care, oral health and personal safety and risk. In addition, medication usage, continence management, meal assistance required, sight and hearing and communication are considered. Other topics given consideration are the person’s mental health, history of falls, social interests and hobbies etc. Full details were seen of in put from health professionals and details of family, Next of Kin and social worker was found on file. In addition the details of the individual’s background and social history are included in this documentation. This was evidenced in the three care plan files sampled, which ranged from a person entering the home in June 2007 to admissions in 2001 and 2004. These files had been reviewed and updated to reflect the current paperwork. Within the Annual Quality Assurance Assessment, it was said that relatives are involved as much as is possible in the pre-admission assessment. The acting manager, who had completed this form, said that the home encourages prospective residents and their relatives to visit the home before they move in. Surveys were sent to service users (people who use the care service), relatives, carers and advocates and health professionals. Seventeen surveys were completed by the people using the service, nine by relatives, carers and advocates and three surveys were completed health professionals. Of the seventeen surveys completed by the people living in the home, two said that they had not been given enough information about the home to make an informed decision to move into the home, one said they could not remember and fourteen said that they had been give sufficient information to make an informed choice to enter the home. No intermediate care is offered at Beaufort Lodge. Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Overall, care planning documents were comprehensive detailing health, personal and social care needs. Regular monthly reviews however need to be introduced to ensure that the people who use the service receive the care they wish and require. Overall, management of medication was well managed with the exception of Controlled Drugs storage. People who live at the home were treated with sensitivity and respect. EVIDENCE: Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 11 As stated previously in this report a detailed pre-admission assessment is conducted and from this a life history story entitled –‘Insight into Past Life’ is developed. A wide variety of questions were asked about the person’s family, their social life, their working life, their health, likes and dislikes, place of birth, family, friends etc. and this information was used to develop a care plan. Against each care plan entry entitled – ‘need/difficulty/ability/strength’ an objective was set and a course of action decided on and any changes in circumstances recorded. Evidence was seen in all three care plans of the action to be taken and any changes needed and required. One care plan was seen to have been reviewed after one month. This was the care plan of a person who entered the home in June 2007. The second care plan sampled had evidence of a review being conducted in July 2007 when some changes to the care had been recorded and made. A three monthly record sheet was seen and assessments and reviews covering toileting & aids, mobility, personal care & pressure area care had been completed. The third care plan inspected as part of this sample had been created in September 2004, with a Resident’s Profile added in January 2007. There was evidence of both the resident and family involvement in completing the life history story. A Plan of Care was seen and created August 2006 and again in March 2007 and whilst there was some evidence of ongoing reviews shortfalls were noted. The last review of the use of bedsides was recorded as having taken place in November 2006, when the continued use of bedsides was noted. Whilst we were told that bedsides continue to be used, they were not detailed in the care plan or risk assessments on the file. Overall the record keeping and documentation sampled and seen was both comprehensive and detailed, but the inconsistencies in the review processes and the lack of a photograph on one of the files sampled let this care practice down. Record keeping with regard to health care issues was seen to be in place. Records relating to weight, continence, visits by the chiropodist, hairdresser the GP were seen on the files sampled. These records detailed the reason for the visit and the action taken and the outcome such as a referral to a physiotherapist or a hospital consultant. Records were made in the health care record charts and in the daily evaluation notes when entries are made day and night. Risk assessments were in place relating to moving and handling and pressure area care and these were running alongside care plans. Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 12 Of the seventeen surveys completed by the people living in the home, fifteen said that they always received the medical support they needed and three had said that they usually receive the medical support the needed. One commented – ‘I haven’t called them much’ and one said that when they are unwell and ‘don’t feel able to get to the Surgery’ they are ‘told that Doctors will not make Home Visits.’ In contrast, all nine surveys completed by relatives, advocates and carers stated that they were either always or usually kept up to date with important health issues such as admission to hospital or an accident. Three surveys had been completed and returned from health professionals. A GP had stated that ‘to my knowledge’ the care service sought advice and act upon it to manage and improve individuals’ health care needs, a second completed by a Nurse Practitioner at a GPs surgery said that the home ‘Have always carried out any change of medication, bringing resident to the surgery with efficiency.’ A third survey completed by a Community Nurse said that on their visits – ‘Carers and senior managers are attentive and are always available to assist District Nurses.’ Medication is held in a medication trolley secured to the wall in the hall or in a separate medicines cupboard in the dining room. At the site visit records were seen of all staff who are trained to give medication, with a record kept of their name and initials for signing medication administered. Medication Administration Record (MAR) sheets are used for the auditing of medicines as they come into the home. Records were seen of fridge temperatures taken where medication is held and a senior carer said that the home’s pharmacist conducts a monthly audit of medication held at the home. Medication administration, record keeping and storage was sampled for the three people sampled in the case tracking. These were found to be in good order. A senior carer said that the home receives medication training from their pharmacist and all staff have completed a workbook training course – Safe Handling of Medication. At the time of the site visit, Beaufort Lodge had one person living at the home who required Tamazepam. This medication was held in a separate cupboard. The home needs to review this practice to ensure that Tamazepam is stored and managed as required, for as a Schedule 3 Controlled Drug, Tamazepam requires storage in a Controlled Drug cupboard. The home was however, following good practice recommendation for this medication was being recorded and administered through a Controlled Drug Register During the site visit, care staff were seen to be aware of the need to promote individual’s privacy and dignity. They were seen to knock on their bedroom doors and wait to be invited to enter. One of the surveys completed by a health professional commented that they ‘thought the individual’s privacy is respected.’ Beaufort Lodge DS0000063576.V347484.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The daily routine and activites in the home were flexible and optional, with people who live at Beaufort Lodge being encouraged to make choices with regard to their social, cultural, religious and leisure activities. Family contact and visiting arrangements were open and relaxed, with family links encouraged and promoted. Links with the local community are encouraged and promoted as wished by the individuals living at Beaufort Lodge. Beaufort Lodge provides a varied and nutritious menu for individuals to select from. EVIDENCE: Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 14 Beaufort Lodge continues to recognise the importance of providing occupations, activities and outings for the people who live at the home. The Area Manager said that consideration is given to the resident’s life history story when selecting and organising events. Themes are used for days and activities in the home and staff dress-up in line with the theme. Food and meals are planned along side these themes e.g. Italian theme and Italian food and evidence was seen of a themed days in photographs on display. Three people living at the home confirmed that there was a programme of activities on offer. They said that they enjoyed the quizzes, sing songs and visits from a pianist. Another person said that they enjoy the gardening and during the site visit they were seen busy watering and deadheading the flowers in the garden. Cream teas were also highlighted by two people who lived in the home. They said that they enjoyed them especially if there was entertainment. A resident’s notice board had details of planned entertainment on it. All seventeen completed surveys by the people living at Beaufort Lodge confirmed that activities are arranged by the home for them to take part in. Two said that they were made aware of the activities on offer, but they chose not to take part in. Within the survey work completed by relatives, advocates and carers there were positive comments regarding the entertainment and activities on offer in the care home. One said ‘It tries to make life as good as possible for the residents offering plenty of entertainment if they want to enjoy it.’ Another said the home ‘Tries to get the residents involved in activities’ … ‘Takes them to the theatre and lunches out’… ‘Organises garden parties and Birthday parties.’ A third comment received said of the care home that ‘They care. They also try to involve outside influences e.g. musical afternoons etc.’ Whilst a fourth and fifth relative commented that they were appreciative of the ‘hard work that goes into providing the additional entertainment/outings’ and they praised the staff for organising parties and outings and for ‘giving up a lot of their own time to do so.’ During the site visit there was an opportunity to speak with three visitors and all three said that the home made then very welcome. All three said that they visited the home regularly and they were able to take their relative out. They said that they were aware of the activities and entertainment offered in the home and their relative was able to choose whether they attended or not. In discussion with two people living at the home and with the three relatives, it was evident that some residents have been able to bring in personal possessions such as ornaments, photographs, small pieces of furniture and books and pictures. Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 15 At the site visit the home’s cook confirmed that two choices are on offered for the main meal of the day at lunchtime. In addition, however, other choices are offered. The cook said that the home is currently catering for two people who are diabetic and pureed meals are served as needed. In addition the likes and dislikes of individuals are considered in the menu planning. Records were seen of meals chosen and during the visit care staff were seen to go around the home assisting residents with making a selection for the following day’s main meal. In addition to nutritional record keeping weight charts are introduced if required. This was evidenced on the record keeping sampled. Food supplies in the home were ample and varied. The cook said that dried and tinned food is purchased fortnightly from a wholesaler; fresh vegetables and fruit twice weekly from a local supplier; fresh and frozen meat from a local butchers monthly; eggs are delivered weekly and other items are purchased from a local supermarket weekly. The home prides itself on the food offered in the home and both homemade and brought desserts and cakes are served in the home. Health and safety issues are considered in the kitchen with records kept of cooked meat temperature checks and fridge temperature checks three times a day. Survey work completed by the Commission resulted in eleven people who live in the home stating that they always liked the meals at the home, four said that they usually like the meals served and two said that they sometimes liked the meals served. Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who live at Beaufort Lodge can expect to have their concerns listened to for the home has both a complaints and adult protection procedures in place. EVIDENCE: Within the home’s quality assurance file the compliments and complaints process is detailed. The most recent complaint in November 2006 had been logged with details of the action taken and outcome following the investigation. The Area Manager said that the home’s quality assurance system is used to monitor complaints and the action taken and the outcome of complaints investigation are used as instigating training as required. Fifteen out of the seventeen surveys completed by the people living at Beaufort Lodge said that they did know how to make a complaint and eight Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 17 surveys completed by relatives said that also knew how to raise a complaint should they need to. At Beaufort Lodge a Protection of Vulnerable Adults (POVA) policy is in place and all staff have attended adult protection training. A staff training summary detailed nine staff as having attended this training in the last year. The Adult Protection and Prevention of Abuse Policy in place made reference to the Department of Health guidance - ‘No Secrets’ and local authority in put. This policy needs to be reviewed and updated to include the implementation of the Protection of Vulnerable Adults (POVA) register in July 2004. In addition, the home needs to review and revise this document to update this document and remove reference to Protection of Vulnerable Adults (POVA) referrals. This no longer exists and has been replaced by a Safeguarding Adult Unit. Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Overall, Beaufort Lodge provides a safe environment that is accessible to the people who live at the home. It is homely and meets individual’s needs. EVIDENCE: Beaufort Lodge presents as a homely, bright and light environment. At the front of the home there is some off road parking. Both the external decoration and maintenance are in good order. At the rear of the property there is an enclosed rear garden. There is ramp access from the rear lounge into the garden where garden furniture and shades are available. Two people spoken Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 19 to at the site visit said that they enjoy sitting in the garden under the trees and shade and they were seen in the garden in the morning. A tour of the premises was conducted at the site visit, when the majority of bedroom accommodation was viewed. The bedrooms were varied in both size and shape, with all but one being for single occupancy. Four of these rooms have en-suite facilities of a wash hand basin and a toilet. These bedrooms had been personalised with picture, photographs and small pieces of furniture. There was evidence of lockable drawers for storage and self-closing fitments had been fitted to the bedroom doors. Survey work conducted by the Commission asked the people who live in the care home if they found the environment clean. Eleven said that they always found it to be fresh and clean, three usually fresh and clean and one said that sometimes it was fresh and clean. Those that had responded negatively sited a problem with continence management in the home although this was not evident on the day of the site visit. A relative had also raised this concern, stating that it was particularly noticeable on entering the building, but once again this was not the case on the day of the site visit. Decoration and maintenance were also raised in a survey form completed by a relative. They had related that it had taken four months for their relative’s room to be decorated and even then it had not been finished with regard to the painting of a door and part of a wall. Following this site visit, the Commission has received a copy of a letter of noncompliance from the Essex County Fire & Rescue Service. This is with regard to the current arrangements for the emergency routes and exits. The external gate from the rear of the premises was padlocked shut. Urgent attention was required. Following the refurbishment of the home, Beaufort Lodge currently has only one bathroom, the second bathroom having been removed when a bedroom was enlarged. The Area Manager said that a planning application is to be made to add a second bathroom to new accommodation being added at the rear of the property. This two-storey extension will have two bedrooms and a ground floor bathroom with specialist bath and shower attachment. Currently the plans are with the home’s architect and the company is hoping to complete this work in the next few months. Beaufort Lodge is therefore, currently operating with only one bathroom as against previously having two bathrooms. Communal areas comprise of a front quiet lounge which had a television on and a rear lounge with a dining area. This area has a piano and they are used for entertainment and activities. Beaufort Lodge does not have a passenger lift, but has a stair chair lift to the first floor. Some resident bedrooms have steps inside their rooms and the Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 20 Area Manager said that assessments are completed to ensure that these people are able to mobilise around their room. The Area Manager said that thermostatic mixer valves had have been fitted to hot water taps and regular checks and records are kept on the hot water temperatures from these outlets. They were found to be around 39° C degrees. Beaufort Lodge has an in-house laundry. There is one washer and one dryer. Care staff confirmed laundry duties are completed by care staff, both night and day. Ironing is completed at night by care staff and clothes are left to hang to dry where possible. There are facilities for hand washing. Personal clothing was seen to be labelled clearly to assist with returning to the individual as they are laundered. Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff were roistered in sufficient numbers to ensure the people who live at Beaufort Lodge are safe and their individual needs are addressed. Beaufort Lodge has a good staff team and the people who live at the home are protected by the staff training programme. The people who live at the home are not protected by the home’s recruitment practice. EVIDENCE: The Area Manager said that staffing levels are calculated according to the assessed needs of the people living at Beaufort Lodge. Currently this has been calculated to give a Manager available throughout weekdays; four carers on duty in the morning; three carers on duty in the afternoon; two carers on duty in the evening and two awake night staff. Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 22 Within the survey work conducted by the Commission for Social Care Inspection (CSCI) amongst the people living at Beaufort Lodge, a question was asked –‘Are the staff available when you need them?’ Ten people living at the home had said that there were always staff available when they needed them; five said that staff were usually available and two said that sometimes staff were available. One person raised concerns regarding the staffing in the evening. They were concerned when the two staff on duty were upstairs attending to service users personal care needs and they and others were downstairs in the lounge areas. They said that they were unsure as to whether these residents would be able to use the call bell system to attract care staff. The Area Manager stated that all thirteen care staff have completed or are working on a National Vocational Qualification (NVQ) Level 2 in Care. A senior carer said that she had worked at the home for approximately seven years and has already completed a NVQ Level 2 in Care and is currently working on a NVQ Level 3 in Care. They said that they felt supported and encouraged in their training and once again been award the home had been awarded an Investor in People Award. This was confirmed by both management and staff at the site visit and was stated in the completed Annual Quality Assurance Assessment. At the site visit, the Regulation Inspector was unable to sample and inspect staff files, as the Area Manager was unable to unlock the secure storage. It was agreed that information, Criminal Record Bureau (CRB) clearance details, copies of application forms, references and staff induction records would be sent to the Commission. Details of the start date of each employee and their Criminal Record Bureau (CRB) clearance was sent but the paperwork submitted was incomplete for all three care staff. One application form was incomplete for only the years of employment had been added and not the month the employment had started or finished. A second application form had only one entry under the employment history and for a third carer no application form was received. Shortfalls were also noted in the copies of references sent to the Commission. One carer had only one reference; a second carer had two satisfactory references; whilst a third had a ‘To whom it may Concern’ reference. An induction training checklist for only one of the three carers had been sent to the Commission. The Area Manager said that statutory training needs were identified through supervision and this was confirmed by a carer. The home has been able to access free training from their local Primary Care Trust and training sessions in Fire Awareness, Health and Safety, Infection Control, Food Hygiene, Adult Abuse, Stoma Care, First Aid, Managing Dementia, Diabetics training and IT Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 23 training had all been offered this year. Training courses in Conflict Resolution, Depression in the Elderly and Supervision and Appraisal had been completed by the newly appointed registered manager. Certificates were not seen and inspected at the site visit. Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Beaufort Lodge benefits from clear management structure. People who use this service benefit from a developed quality assurance and quality monitoring system. People who use this service benefit, from safeguarding cash held in safe custody. Safe working practices are promoted through ongoing training. Health and safety certification and insurances promotes a safe working environment. Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 25 EVIDENCE: At the site visit the newly appointed registered manager was not present. The Area Manager for the company assisted with the inspection. It could be seen however, that a management structure within the home was in place and there were both competent and qualified staff working in the home. A Quality Assurance monitoring system was found to be in place. Quality Assurance surveys had been completed in 2007 by staff and an analysis of the findings completed in February 2007. A Quality Assurance monitoring questionnaire had been completed by the people living at Beaufort Lodge and questions relating to their welcome to the home, the information they received and the entertainment on offer had been considered. These had been further considered at their residents meetings and a quarterly newsletter had been developed to improve communications. Another form of communication is the comments book which is readily available for residents to add their comments and suggestions should they wish. Residents meetings were seen to be held every quarter. Minutes were seen to evidence this. At these meetings suggestions for outings and entertainment were considered. Relatives of the residents also have regular get-together evenings. The Area Manager said that team quizzes between the staff and the relatives are popular. The financial interests of the people living at Beaufort Lodge are safeguarded. The financial records and money held by the home for the three people who were part of case tracking exercise was sampled and inspected. All three were found to be in good order and the Regulation Inspector was informed that a monthly audit of these accounts is completed. As stated earlier in this report there was evidence of an ongoing programme of basic training courses to ensure that safe working practices are found within the home. Safety certifications were sampled and inspected at this inspection. These included certificates of inspection of Fire Extinguishers, Fire Alarm & Detectors & Emergency Lighting, the Emergency Lighting System Log and the Fire Alarm System weekly testing log. Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 X X X 3 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 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.V347484.R01.S.doc Version 5.2 Page 27 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(2)(b) (c) Schedule 3 (1)(b) Requirement People who use the service must be assured that their care plans must be reviewed by care staff at least once a month, updated to reflect changing needs and current health and personal care needs. People who use the service must be assured that Controlled Drugs including Tamazepam are stored in a secure Controlled Drug cupboard and are administered and disposed of through a Controlled Drug Register. This is a repeat requirement from the last inspection. Timescale of 31/10/06. 3. OP18 12(1)(a), 13(6) 24(4)(5) People who use the service must be assured that they are safeguarded by clear, accurate adult protection procedures. People who use the service must be assured that they are safe and the care home complies with the requirements of the Essex County Fire & Rescue Service. DS0000063576.V347484.R01.S.doc Timescale for action 02/11/07 2. OP9 13(2), Schedule 3(3)(i), 12(2)(3) 02/11/07 02/11/07 4. OP19 02/11/07 Beaufort Lodge Version 5.2 Page 28 This is with regard to emergency routes and exits. 5. OP21 23(2)(j) People who use the service must be assured that the provision of assisted bath and showers is returned to the same number of assisted baths for service users as they provided as at 31 March 2002. Minimum of two assisted baths/showers. People who use the service must be safeguarded by thorough recruitment practices and procedures. 30/11/07 6. OP29 19(4)(c) Schedule 2(5) 02/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 Good Practice Recommendations Each care plan file should have a photograph of the individual to make for easy recognition of the resident and their care plan. People who use the service should be assured that that there are sufficient care staff on duty to meet the assessed needs of the people living at the care home. This is with particular regard to the evening staffing levels. OP27 Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beaufort Lodge DS0000063576.V347484.R01.S.doc Version 5.2 Page 30 - 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!