Inspection on 01/11/07 for Beauley Lodge

This inspection was carried out on 1st November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beauley Lodge 08/11/06

Beauley Lodge 22/11/05

Beauley Lodge 13/06/05

Beauley Lodge 03/02/05

Beauley Lodge 14/07/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Beauley Lodge Lumley New Road Woodstone Village Houghton Le Spring Tyne and Wear DH4 6DN Lead Inspector Mrs Sue Lowther Key Unannounced Inspection 09:30 1st November 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beauley Lodge DS0000007454.V353058.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. Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beauley Lodge Address Lumley New Road Woodstone Village Houghton Le Spring Tyne and Wear DH4 6DN 0191 3857182 0191 3859213 beauley.lodge@fshc.co.uk www.fshc.co.uk Tamaris Healthcare (England) Ltd 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) Irene Louise Simm Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Old age, registration, with number not falling within any other category (36) of places Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home - Code PC To service users of the following gender: Either Whose primary need on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP, maximum number 36 2. Dementia - Code DE(E), over 65 years of age, maximum number 36 The maximum number of service users who can be accommodated is: 36 8th November 2006 Date of last inspection Brief Description of the Service: Beauley Lodge is a well-established care home for older people, some of who suffer from dementia. It is provided by the Four Seasons Health Care Group. All bedrooms are singles, located on the ground floor. There is an inner garden/patio area that is secluded and sheltered from the wind. There are planted borders and sheltered seating in this garden, plus easy access to and from the home. There are a good number of lounges that may be used for various activities, plus a spacious dining room. The home is committed to the values and principles underpinning good care practice, such as the importance of privacy, dignity and choice in daily life. The home aims to promote residents’ quality of life through its philosophy and practice of care. The fees charged are between £365 and £417 weekly. This does not include hairdressing, toiletries, chiropody and newspapers. Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 1st November 2007. During the inspection time was spent talking to people using the service, staff, relatives and management. A number of records were looked at and the grounds and building itself were inspected. The home was also asked to complete a self-assessment, which provided the inspector with information prior to the site visit. Several of the people who live in the home, staff and visitors returned questionnaires about the home. Information gathered throughout the inspection may be included within the inspection report. The inspection focussed on key standard outcomes for people who live in the home and to check whether requirements from the previous report had been met. What the service does well: What has improved since the last inspection? The manager has been registered with the CSCI since the last inspection. All of the staff have worked very hard since the last inspection and improvements have been made in several areas. The recording in care plans is clearer and staff have written guidance on how to meet the diverse and individual needs of the people who live in the home. Risk assessments are contained in care plans and give good clear directives to staff on how to risk manage people in their care. There was evidence to confirm that people have been consulted with regard to their care plans and agree with them. All of the people who live in the home now have a contract so that they understand the service that they can expect to receive. The home now obtains the signature of people who have Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 6 deductions made from their personal allowance to participate in the bonus ball. This confirms that they have agreed to this arrangement. Several areas of the home have been redecorated and refurbished. 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. Beauley Lodge DS0000007454.V353058.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 Beauley Lodge DS0000007454.V353058.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): 2 and 3. The home does not provide intermediate care. Therefore assessment of standard 6 is not required. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. Admissions are well managed and people are provided with information about the home before moving in. EVIDENCE: The home provides a statement of purpose and service user guide, setting out its aims and objectives, the range of facilities and services it offers to people. This enables people to make fully informed choices about whether the home can meet their indivdual needs. The administrator said that all of the people who live in the home now have contacts. Some of these were seen during the inspection and were found to be in order. Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 9 People are only admitted after a full assessment of need is carried out by an appropriately trained person. This is usually the registered manager. This is to make sure that the home can meet the care needs of the people who go to live there. The family of one person who had recently gone to live in the home confirmed that they had looked around the home and had been supplied with all of the information they needed to make a decision about whether or not their relative would like to live there. Beauley Lodge DS0000007454.V353058.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. People’s health care needs are well managed by the home. Systems to administer medication are safe and people living at the home say that they are treated well and that the standard of care is good. EVIDENCE: All of the people who live in the home have care plans so that staff know how to look after people on an individual basis. The manager said that since the last inspection staff had received training in person centred care. The care plans seen were greatly improved and now provide staff with much more information. There was evidence within some of the plans to confirm that people had been consulted with regard to their care. Records examined showed that people receive visits from other healthcare professionals. These include district nurses, doctors, and care managers. One person who lives in the home said “When I need the doctor the staff call him straight away. I have had to see him a few times lately as I haven’t been very Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 11 well”. Another said “The staff make sure that I see the optician and dentist when I need to. I have just got new glasses”. Medication is administered by senior care staff who have been trained. The home has a comprehensive medication policy. Accurate records of all medicines received, administered and those leaving the home are maintained. The drug fridge was checked. The manager said that a new fridge had been ordered. People spoken to said that staff always treat them with dignity and respect. One of the relatives said “Everything at this home is really fine. I have already booked my place for when I need it. The staff are lovely and caring and treat people with dignity and respect. My relative always said that once she needed care this would be the home for her”. One of the people who lives in the home said “The staff are nice and always knock on the door. They are always pleasant and polite”. Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 12 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. The home provides a range of activities with input from the people that live there. Relatives are made welcome and encouraged to visit the home. People living at the home said that they were able to make choices within all aspects of daily living. There is a varied menu and people likes and dislikes are well catered for. EVIDENCE: The home have a very enthusiastic activities coordinator. One person said “ We all appreciate the lady who does activities. We really enjoy them”. Routines of daily living and activities are flexible and varied to suit individual expectations, preferences and capabilities. Personal choice is promoted at all times. People’s interests are recorded, there is a daily activity programme which is flexible. The activities organiser said that she tends to work with people in small groups or on a one to one basis. The range of activities includes hair and beauty therapy, board games, musical exercises, arts and crafts. Birthday parties, pie and peas suppers and outings. The home have a sensory garden. The lavender grown in the garden is used to make lavender bags which are then sold and the proceeds are put into the amenity fund. This fund is then Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 13 used for the benefit of the people who live in the home. On relative said “The manager and staff have a pie and peas night for the families which go down well. We have had some good nights there and they have made some money for the residents”. Another said “We are happy that activities are now ongoing and that people are now having trips out into the community”. People can have visitors at any time and private visiting areas are available. People’s spiritual needs are respected. People are encouraged to make choices and decisions wherever possible and this was observed throughout the day. One person said “I can get up and go to bed when I want. I can also have a bath or shower when I want”. Meals are varied, appealing, nutritious and based on individuals choice. The choice of menu is recorded daily but remains flexible. Special dietary needs are catered for and people are assisted to eat if necessary. One person who lives in the home said “The food is good. We get a choice and there is definitely plenty”. Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 14 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. Complaints and adult protection matters are supported by clear guidance and training. EVIDENCE: The home has a complaints procedure in place, which is displayed throughout the home. There were no complaints recorded since the last inspection. People who live in the home said that they would know how to make a complaint. One person said, “I have never had any problems but if I did I would ask to see the manager. I know she would put things right as soon as she could. She is a good manager, she gets involved, and doesn’t just sit in the office”. Staff said that if they have a problem they feel that they can approach the manager and she tries her best to sort it out. Staff are trained to recognise and prevent abuse of the people who live in the home. The home has a clear adult protection procedure which links with the local authority procedure for safeguarding adults. The home also has an active whistleblowing policy. All staff spoken with said that they would have no hesitation in whistle blowing (telling someone) if there was a problem. One member of staff said, “If I saw something I did not like I would say. I am here for the residents”. Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 15 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 and 26. ‘People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. The home is clean, well maintained and furnished and decorated to a good standard. EVIDENCE: Parts of the home have been refurbished to provide a good environment for the people who live there. Some of the areas were being redecorated on the day of the inspection. Many of the bedrooms have been personalised to individual choice and taste. One person who lives in the home said “ I like my bedroom. It has just been redecorated and I chose some of the colours”. Another said “The manager has offered to redecorate my room but I do not want to. I like it the way it is”. There are a variety of lounge/dining areas for people to enjoy. The building complies with local fire and environmental health regulations. Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 16 The premises were clean, hygenic and free from any odours. Policies for the control of infection are in place and adequate handwashing facilities are available. Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 17 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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service’. Staffing numbers support people’s needs. The home has a commitment to staff training and recruitment practices protect people living in the home. EVIDENCE: The home had staff files in place, which provided evidence that the appointment of new members of staff is made through proper recruitment processes. This includes the vetting of staff through the use of Criminal Record Bureau (CRB) checks, Protection of Vulnerable Adult checks (POVA) and written references. The manager said that new members of staff may be invited to start their induction training before the written references are received. In those circumstances the staff member would have no direct contact with the people who live in the home. It is recommended that where this is the case a clear record is kept with regard to the whereabouts and the activity undertaken by the staff member. The staffing rotas were examined during the inspection. Staff felt that there were generally plenty of staff on duty to meet the needs of the people who live in the home. One person who lives in the home said, “You just have to buzz and the staff are there. There are always plenty of staff around”. Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 18 Training has recently taken place in fire safety, safe handling of medicines, person centred care, moving and handling and first aid. A large number of care staff are trained to NVQ level 2. Certificates to confirm this were seen in staff files. Staff confirmed that there is plenty of training available. Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 19 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. We have made this judgement using a range of evidence, including a visit to this service’. The home is well managed and relatives and people using the service are regularly consulted about the service they receive. Financial arrangements are good and health and safety systems and practices protect people. EVIDENCE: The manager has several years experience in working with older people. Since the last inspection she has been registered with the CSCI. However she should undertake an appropriate management course and an NVQ level four in care. Staff, the people who live in the home and visitors were extremely complimentary about the manager. One recently appointed member of staff said “The manager is brilliant. She is very supportive and I get the level of Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 20 supervision that I need. I feel very comfortable in approaching her if I have a problem or query”. There clear lines of accountability within the home. Staff, relatives and those living at Beauley Lodge are actively involved in the decision making process of the home. The home has an annual plan for quality assurance which includes, meetings with people using the service, relatives and staff. These are held monthly and information from these are included in quality monitoring. The area manager completes a regulation 26 visit monthly. This is an audit which covers all aspects of the environment and the care delivered. The manager said that during this audit the area manager speaks to staff, the people who live in the home and visitors about their views. Any suggestions made are considered and improvements made where possible. The administrator is responsible for the record keeping with regard to people’s financial interests. Personal finances are kept in the home for people who request this. Two signatures are obtained and receipts are kept to ensure peoples’ financial interests are safeguarded. The company carry out an audit on a regular basis. Since the last inspection the administratror has obtained signatures from people who contribute to the bonus ball. This confirms that they have agreed to this. Health and safety systems were looked at. Safe working practices are maintained in line with current regulations and appropriate risk assessments are available. All safety checks for maintenance are carried out by external contractors as designated by law. All accidents are recorded and reported appropriately. Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 21 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP31 Regulation 9 Requirement The registerd manager must undertake an appropriate management course and an NVQ level four in care. Timescale for action 31/03/09 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 OP29 Good Practice Recommendations When a newly recruited staff member is invited to undertake training before written references are received, a clear record should kept with regard to the whereabouts and the activity undertaken by the staff member. Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Beauley Lodge DS0000007454.V353058.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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