Inspection on 13/06/05 for Beauley Lodge

This inspection was carried out on 13th June 2005.

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 01/11/07

Beauley Lodge 08/11/06

Beauley Lodge 22/11/05

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 Fencehouses Durham DH4 6DN Lead Inspector Stephen Ellis Unannounced 13th June 2005 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 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 B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Beauley Lodge Address Lumley New Road Fencehouses Durham DH4 6DN 0191 3857182 0191 3859123 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Tamaris Healthcare (England) Limited (wholly owned subsidiary of Four Seasons) Vacant CRH 36 Category(ies) of DE(E) (36) registration, with number OP (36) of places Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 3rd February 2005 Brief Description of the Service: Beauley Lodge is a well-established care home for older people with or without dementia. It is operated 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 and conservatory.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 service users’ quality of life through its philosophy and practice of care. Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours. The inspector looked around the building and spoke to 13 service users, 2 relatives and 4 staff. He inspected a number of records that are required to be kept. What the service does well: 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. Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 6 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 Standards Statutory Requirements Identified During the Inspection Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 7 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 standard(s) 3 All service users have had a full assessment of their needs, prior to their admission, and have been assured that the home will meet those needs. EVIDENCE: Service users and relatives said that they were happy with the services and facilities provided, especially the care, and felt that the home was able to help them appropriately. Three care plans that were examined showed attention to detail and covered all of the important areas to do with health and personal care. They showed that people’s care needs had been thoroughly assessed. Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 8 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 standard(s) 7, 8, 9 and 10 Good arrangements are in place for service users’ health and personal care. Service users are treated with respect and their right to privacy is upheld. EVIDENCE: Service users and relatives said that they felt the health and personal care needs of service users were well met. Relatives added that they could talk to the management and staff about any concerns. Both service users and relatives felt their views were taken seriously and they were treated courteously, with respect shown for their individuality and privacy. Care plans and case files showed that service users’ needs were recorded in sufficient detail to be useful documents to guide care practice. For example, service users’ medical information and health care needs were summarised in each document, along with detailed plans of care. The medicines room was clean and well organized. Care staff have been having training in the safe handling of medicines. Management is implementing the recommendations of a pharmaceutical audit earlier this year. Senior staff are supervising less experienced care staff to ensure that they will be competent at all times when dealing with service users’ medicines. Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 9 Care staff expressed confidence in their understanding of service users’ needs and their ability to provide for them. For example, they said they had the necessary equipment within the home (e.g. aids and adaptations) plus access to primary health care teams and specialist services when required. Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 12 to 15 There are good arrangements for daily life and social activities. EVIDENCE: Service users said that they could choose how they spent their time; for example, when they got up and when they went to bed and whether they stayed in their room. Staff would ask them about what clothes they would like to wear and what activities they would like to do, if any. Staff confirmed that they always try to respect service users’ individual choices and preferences. The activities coordinator organized a varied programme of social and recreational activities and service users said that they had enjoyed taking part in them. For example, service users had been involved in planting sunflower seeds in the garden (sometimes having someone else do it for them) and in recent parties celebrating the Royal Wedding and V.E. day. One resident enjoyed playing a keyboard in one of the lounges; another service user had one to one sessions with the activities coordinator each day. Several service users had enjoyed outings in a minibus (e.g. to South Shields). The home has been successfully involved in fundraising activities and has enjoyed the support of local people in the process. Relatives said they were free to visit at any time and were made welcome. Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 11 All service users who were spoken to said they liked the meals and beverages supplied. Catering staff provided a varied and appetising menu, including a choice of meal at each mealtime. There was evidence of ‘home baking’. Records were kept of meals served. The kitchen was clean and well organized. Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16 Service users and their representatives are confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: All service users and relatives spoken to said that they were confident about telling the staff or manager about any concern or complaint. They believed their concerns or complaints would be taken seriously and acted upon to bring about improvements. They described the manager and staff as being approachable, friendly and helpful. All complaints are logged in a complaints book, giving details of the complaint and the action taken by the home to deal with the matter, including a record of outcome for the complainant. Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19 Service users live in a safe, well-maintained environment. Action is required to take professional advice and upgrade fire extinguishers as required. EVIDENCE: An inspection of maintenance records showed the home is being systematically checked for any faults and appropriate repairs or replacements are made. Service users and relatives said they were satisfied with the standard of accommodation and facilities provided. A tour of the building showed that the home is being well maintained, with evidence of redecoration in places (e.g. reception area). A recent entry in the maintenance record revealed a fault with one of the fire extinguisher hoses. The manager said that the old hoses were going to be replaced with modern fire extinguishers. The advice of the fire service should be obtained about the timing of the replacement and any consequence for fire safety, so that a thorough risk assessment can be made. Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 The numbers of staff on duty throughout the day and night, and the skill mix and competence of staff, are appropriate for the assessed needs of service users. EVIDENCE: Service users and relatives said that the care and support of staff was good and service users felt that they were well looked after. They were supported to make choices and to act independently where appropriate. More dependent service users received a more intensive input from care staff and activities coordinator. Staff commented that sufficient care hours were provided to allow them to care effectively for service users. They confirmed that they had been having appropriate training, including moving and handling and safe handling of medicines. Many members of care staff have been involved with NVQ training and assessment at either levels 2 or 3. Staff felt competent to carry out their required duties. Senior staff members supported and mentored less experienced staff (e.g. with medicines and moving and handling). New members of staff undergo comprehensive induction and foundation training, in accordance with an assessment of their training needs. The staff rosters showed that there are 4 members of care staff on duty 08.00 to 14.00 and 3 members of care staff at all other times, including the night (20.00 to 08.00). Within these numbers, there is always a designated senior care assistant on each shift. In addition, there is a part time activities Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 15 coordinator (25 hours) plus an administrator, a maintenance man and a manager (all full time). Catering and domestic personnel are deployed in sufficient numbers to meet the needs of the home. Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 36 The home is run in the best interests of service users. EVIDENCE: Service users and relatives said they had confidence in the management and staff. They were supportive, caring and approachable. Several service users said that they could discuss any of their concerns with staff and knew that they would be taken seriously and treated with respect. The manager said that she was planning to hold a meeting of residents and relatives next month and hoped this would become a regular feature for consultation and quality assurance. Informal arrangements for staff supervision are being made formal, with suitable records to be kept, so that each member of staff will receive six supervision sessions each year, one of which will be the annual appraisal. Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x 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 3 x x x x x x x STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x 3 x x 2 x x Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 18 No Are there any outstanding requirements from the last inspection? 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 19 Regulation 23 Requirement Advice should be sought from the Fire Authority about the number, location and type of fire extinguishers in the home, and appropriate action should be taken promptly. Care staff should receive formal supervision at least 6 times per year. Timescale for action 01/07/05 2. 36 18 01/09/05 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 12 Good Practice Recommendations Life story work with service users would be desirable, as discussed at the inspection. This could be raised with service users and relatives at their next meeting. Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection No 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Beauley Lodge B54 S7454 Beauley Lodge V223778 130605 Stage 4.doc Version 1.30 Page 20 - 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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