Inspection on 23/08/07 for Beaumont Lodge Nursing and Residential Home Limited

This inspection was carried out on 23rd August 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

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Beaumont Lodge Nursing and Residential Home Limited 19-21 Heatherley Road Camberley Surrey GU15 3LX Lead Inspector Sandra Holland Unannounced Inspection 23rd August 2007 10:10 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 Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.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. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaumont Lodge Nursing and Residential Home Limited 19-21 Heatherley Road Camberley Surrey GU15 3LX Address 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) 01276 23758 01276 709030 Beaumont Lodge Ltd Mrs Indira Coosmawtee Roopun Care Home 43 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (25), of places Sensory impairment (2) Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 43 beds can provide nursing care for elderly people from the age of 60 years. This is not applicable as this service has been newly registered as a limited company. Date of last inspection Brief Description of the Service: Beaumont Lodge is a large detached property situated in a quiet residential area of Camberley. The home can provide accommodation for up to 43 older people, any or all of whom, may require nursing care. Up to 12 older people who may have dementia and up to two people who may have a sensory impairment, may also be accommodated within the total number of 43 service users. The majority of bedrooms are for single occupancy, although a small number of double rooms are available. There are spacious communal areas and a large garden, most of the garden being to the front of the property. Car parking is also available to the front of the property. Fees at this service range from £ 565.00 per week to £ 725.00 per week. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection site visit was carried out by the Commission for Social Care Inspection (CSCI) under the Inspecting for Better Lives process. Mrs Sandra Holland, Regulatory Inspector carried out the site visit over six and a half hours, and was accompanied by Mrs Sandra Grainge, Locum Regulatory Inspector. Mrs Indira Roopun Registered Manager was present representing the service and the general manager also assisted with the inspection process. A full tour of the premises was carried out and a number of records and documents were sampled, including policies and procedures, residents’ individual files, medication records and staff recruitment and training files. A number of residents, visitors and staff were spoken with during the tour of the home. An Annual Quality Assurance Assessment (AQAA) was supplied to the home and this was completed and returned. Information provided in the AQAA will be referred to in this report. A number of CSCI feedback forms were supplied to residents, their relatives and friends, and to healthcare professionals involved in the support of residents. The results of the feedback forms are referred to at Standard 8, which relates to healthcare and at Standard 33 which relates to quality assurance. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. The inspectors would like to thank the residents, staff and management for their hospitality, time and assistance. What the service does well: Positive feedback was received from residents, their relatives and healthcare professionals about the standard of the care provided. Comments received included – “the care home staff are all very kind and caring and mostly help in any way they can. We are always kept informed of any situation that may arise”; “my relative seems to be reasonably happy and can think of no improvements”; Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 6 “I am happy with the care my relative receives at the home”; “Beaumont Lodge is by no means perfect, but on the whole my relative seems fairly contented there”; and when asked what the home does well, respondents said – “Everything” ; “Treats patients cheerfully and with tender care”; “very welcoming and listens to both my concerns and those of my relative” and “makes sure medical problems are seen to, monitors food and drink intake, provides activities and other stimulation and carries out annual reviews of care plan”. The home is attractively presented and well equipped and furnished to meet residents’ needs, whilst maintaining a homely style. All areas were clean, tidy and freshly aired. A good range of activities are offered to residents, both as a group and as individuals, if this is preferred. A choice of meals is provided and alternatives to this are offered to ensure residents are nourished, if the meal is not to the residents’ liking. What has improved since the last inspection? What they could do better: Liquid soap and paper towels must be provided in the laundry room, and liquid soap must be provided in the staff toilet, to prevent infection and the spread of infection. A record of staff induction must be maintained and must be kept in the home. Doors designed to close automatically if the fire alarm is activated must not be wedged or propped open. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 7 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. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of prospective residents are fully assessed before they are admitted to the home. EVIDENCE: The files of a number of residents were sampled including one of a recently admitted resident and it was positive to note that all the files which were seen contained a pre-admission assessment of the resident’s needs. Comprehensive pre-admission assessments were found in all the files inspected, and the file of the most recently admitted resident contained assessments including those relating to moving and handling, pressure area care, risk of falls, nutritional needs and medication requirements. Relatives of a resident who were visiting at the time of inspection, confirmed that an assessment was carried out prior to their relative’s admission. The Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 10 manager stated that she carries out the pre-admission assessments, or these are carried out by the general manager or one of the team leaders. Information supplied in the AQAA stated that if a resident receives financial support from a local authority, an assessment is carried out under the care management process. Where this is the case, a copy of the assessment is obtained by the home. The AQAA also advised that the first six weeks of admission are regarded as a trial period, which enables the resident to decide if the home is to their liking and enables the home to more fully assess the resident’s needs. The general manager advised that intermediate care is not provided at the home, so Standard 6 is not applicable. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed plans are available to guide staff to the care and support needs of residents. Residents healthcare needs are well met and medication is administered appropriately. EVIDENCE: As mentioned previously, the files of a number of residents were sampled. It was positive to note that the care plans which had been drawn up had used the information obtained in the pre-admission assessment as a baseline. Residents’ needs had been transferred to the care plan to provide clear instructions to care staff, the plans had been reviewed by nursing staff on a regular basis or when needs changed, and a daily record of the care given was also kept. The manager stated that qualified nurses carried out assessments and care staff were involved with daily recording of events and the care they had Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 12 provided. From speaking to care staff, it was clear they were aware of care plans and followed the guidance and instructions. It was clear that the plans of care are drawn up to meet individual’s needs. Residents who are unwell or who prefer to be quieter are given assistance to eat in their own room, and this was recorded in the care plan. Not all residents were able to comprehend or communicate any involvement in their care plans. The more able residents were aware of the document and residents’ relatives confirmed they were knowledgeable about the care being given to their relative. Most of the residents’ files contained a photograph of the resident for identification purposes, although no photo was held of the most recently admitted resident. The general manager said this was being obtained. From speaking to residents and visitors and from the feedback provided, it was clear that resident’s healthcare needs are well met. A number of healthcare professionals are involved in the support of residents, including general practitioners (GP’s), hospital specialists, optician and chiropodist. A visiting healthcare professional was spoken with during the inspection and they indicated that prompt and appropriate action was taken by staff at the home if a change was noted in the health of a resident. The administration of medication in the home appears to be effectively managed. Medication is supplied in “blister” packs, which contain individual doses of medications, the team leader advised. Medication and printed medication administration record (MAR) charts are supplied by a local pharmacy the general manager stated. Medication was seen to be stored appropriately in an allocated storage room and there is a medication fridge available for items requiring chilled storage. Other medication is stored and transported in a lockable trolley to each floor for administration. The team leader stated that no residents are currently administering their own medication, but storage facilities and a procedure are available if required. The MAR charts and pharmacy return records which were inspected were complete and up to date. A new pharmacy supplier has recently been contracted staff advised, which has provided a better service. The pharmacist carries out monitoring visits to the home to check and advise on all aspects of medication administration and supplies a report to the home of their findings. The lunchtime administration of medication was observed and found to be in order. Residents were observed to be treated kindly and with respect. An explanation of the medication being administered was given to the resident, along with assistance and a drink of water. The inspector was impressed with Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 13 the manner in which a team leader and member of care staff managed the situation of a resident who initially refused their necessary medication. Residents told the inspector that staff treat them with respect and kindness and that residents’ privacy is respected. Staff were noted to speak to residents in a respectful way and to knock on residents’ bedroom doors before entering, and this was observed to be usual practice during the inspection and tour of the building. Staff spoken to were aware of core values to be promoted when providing care, including those of privacy, dignity, respect, choice and independence and were seen to incorporate these into their support of residents. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A range of social and leisure activities are offered to residents and they are supported to maintain contact with their families and friends. A well-balanced and varied diet is provided. EVIDENCE: The general manager stated that a new activities co-ordinator has been appointed in the last three months and is proving popular with residents. This was evident on the day of inspection as there was an atmosphere of excitement in the home because residents were looking forward to a summer fete that was planned for the following weekend. Residents were busy preparing for the event by having their hair done and spoke of relatives being invited and expected. A detailed programme of activities is displayed and was seen to incorporate specifically allocated time to be spent with residents who require, or prefer, one to one support. This is allocated twice each day to enable the activities co-ordinator to support as many residents as possible. The range of activities on the programme included arts and crafts, music and movement, a quiz, letter writing, flower arranging, films, musical bingo and current affairs. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 15 Displays were seen in the home of projects carried out to interest residents and to record their reminiscences of their earlier lifestyles. A number of “pen pictures” in the entrance hall described the past lives and personal histories of residents, which give guidance and interest to staff as to the backgrounds of these individuals. The manager stated that these were displayed with the consent of the residents involved. Another display featured enlarged “postcards” which had been personalised with residents’ individual memories and pictures of places they had visited. It was noted that records are kept in residents’ care plans of the activities which residents take part in and time is allocated on the activity programme for the completion of these. The records enable the home to monitor which activities are preferred by residents and which activities individual residents respond better to. Most residents were pleased with activities on offer, but one resident who was spoken with in their room, stated that it was all too noisy and they chose to be in their own room. This choice was respected and the resident said that they enjoyed talking to individual staff, which was interesting because “they come from all over, but they all speak English”. Another resident spoke of making friends with the other residents with whom they shared the dining table for meals. The resident said they enjoy singing and this gift had been discovered and encouraged by staff. During the tour of the home it was clear that post for individual residents is delivered to each resident in their room and telephones have been installed for those residents who have requested it to enable them to keep in touch with their families and friends. Residents stated that visitors are frequent and are warmly welcomed in the home. A number of visitors were seen visiting the home during the inspection and those spoken with said they were very pleased with the home and the care provided and that they are kept informed about any changes affecting their relative. All residents were very complimentary about the food and the catering service. Observation at lunchtime showed that there was a choice of menu and staff were supportive and met individual requests as they occurred. One resident commented “ we have a menu to chose from in the evening of the day beforebut I can always change my mind” and another commented that “ I can be given too much not too little”. Lunch was served in dining room, which was furnished with small tables, attractively set with tablecloths, serviettes, glasses and tablemats. A selection of soft drinks or water were available to drink. Groups of friends were able to sit together, and those needing assistance were helped discretely. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 16 Plated meals were seen being served to residents in their own rooms, and it was noted that the food was hot, choices were given and staff were available to help. The meal had been adapted to suit the needs of residents, and some meals had been pureed if required. Staff advised that adapted cutlery was available to enable residents to manage their meals independently. One resident who had indicated on their feedback form that they wished to speak to an inspector, described the food as “wonderful” and thinks that staff are friendly. The cook stated that menus are reviewed on a seasonal basis and are designed to meet the assessed nutritional needs of residents. A four-week menu plan is followed and copies of these were provided at the inspection. These indicated that a well-balanced and varied diet is offered and the meal on the day of inspection was seen to match that on the menu plan. It was positive to note that a member of staff was heard to offer a nutritious supplementary drink to a resident when they declined to eat the meal that was offered. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Few complaints are received and these had been appropriately managed. Staff are aware of their role in the protection of residents. EVIDENCE: The home’s complaints procedure was noted on display in a number of areas of the home to ensure it was accessible to all who may wish to use it. This clearly stated the procedure to follow and included the timescales in which a response could be expected. Residents who were spoken with stated that they were aware of how to make a complaint, and the relatives of three residents confirmed that they had the information about how to make a complaint. All the visitors spoken with advised that they would speak to the manager in the first instance and felt sure that any dissatisfaction would be resolved in that way. It was positive to note that residents felt that they could raise any concerns with any member of staff and an older resident stated that they “ feel safe here”. The home’s complaints record was seen and only three complaints had been recorded in the last year and only one of these had been upheld. The manager stated that staff receive training about abuse during the induction to their role and this was recorded on the induction records seen. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 18 Staff spoken to advised that they would report any concerns about residents to the manager or the person in charge and would not hesitate to do so. In the event of a suspicion or allegation of abuse, the home would follow the Surrey Multi-Agency procedure for Safeguarding Adults, the deputy manager stated. An up to date copy of the procedure is kept in the home for staff to refer to if required. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A well maintained, comfortable and clean home is provided for residents to live in. EVIDENCE: A full tour of the premises was carried out and it was observed that an ongoing process of maintenance and improvement was in progress. Some areas of the upstairs corridors had been redecorated and others were being decorated at the time of inspection. All areas of the home appeared well maintained and had been furnished and equipped to meet the needs of residents, with attractive colour schemes and co-ordinating soft furnishings. Information in the AQAA indicated that adaptations had been made in the home, including grab rails and raised toilet seats, to support residents and encourage their independence. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 20 Residents’ individual rooms contained their favourite furniture, pictures, ornaments and possessions and the amount of space available was the only limitation to this, the general manager advised. One resident who spoke with an inspector gave permission for their bedroom to be seen. It was noted to be attractive, tidy, had been personalised with their own belongings and showed evidence of hobbies being undertaken. A new shaft lift has recently been installed and has greatly improved the access to all floors of the home for disabled people or those with limited mobility. The general manager stated that the lift was selected to ensure it was large enough to accommodate a stretcher, in case a resident is taken ill and needs to be transported by stretcher. Attractive grounds are available, with seating provided in sun and shade, and residents spoke of a summer fete which was to be held the following Saturday. All areas of the premises were noted to be very clean and odour free and carpet cleaning was taking place in an upstairs corridor at the time of inspection. A laundry room is situated near the lounge and is visible from the entrance to the lounge. Large capacity industrial washing and drying machines are provided in the laundry along with a wash hand basin. It was noted that no soap or paper towels were available in the laundry room for staff to use, to maintain hygiene and it is required that these are provided. The manager advised that specific laundry staff are not employed, as members of the care staff carry out laundry tasks. Sluice rooms are provided on each floor, are equipped with clinical waste bins and a contracted clinical waste collection and disposal service has been arranged. Staff advised that personal protective equipment including gloves and aprons are made available and used in the home to prevent infection and the spread of infection. Liquid soap, paper towels and waste paper bins were observed in most areas for staff hand washing, although as mentioned above none were seen in the laundry and only a bar of soap, which is not hygienic, was available in the staff toilet. A requirement has been made regarding Standard 26, that liquid soap and paper towels must be provided to prevent infection and the spread of infection. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A full team of trained and suitably recruited staff are employed to meet the needs of residents. EVIDENCE: From information supplied in the AQAA and records and documents seen at the inspection, it was clear that a full team of staff are employed to meet the needs of residents. The majority of the team are nursing and care staff, but they are supported by catering, housekeeping and maintenance staff. It was positive to note that residents commented that they felt there are enough staff to meet their needs, and this included at the weekend. Residents commented positively on the qualities of the staff, one hearing impaired resident uses lip reading and said that staff assist her and use signs. She also said she likes the “staff sense of humour “. Another resident stated that they were “Pleased to be in the home” and was seen to interact well with staff during the day. A number of staff have achieved or are undertaking a National Vocational Qualification (NVQ) in care to level 2 or above, the manager advised. When the staff undertaking their NVQ have achieved this, the home will have almost met the 50 of staff trained to this level, as recommended by the National Minimum Standards for Older people. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 22 Staff recruitment files were randomly sampled and these indicated that recruitment is carried out appropriately. The specified information and documents had been obtained, and the required checks had been carried out, including two written references and a Criminal Records Bureau (CRB) disclosure. It was noted that the nursing registration for one qualified nurse had recently become out of date. The manager understood that this had been updated, but had not obtained confirmation of this. It was agreed that confirmation would be obtained and forwarded to CSCI. Staff induction records are maintained, but when these were sampled, the induction record for a qualified nurse was not available. The manager stated that the nurse had taken the record home to complete, but these must be maintained and kept in the home. Individual staff training records are maintained and from these it was clear that staff receive training required by law, including fire safety, first aid and food hygiene and other training to develop their knowledge and skills, such as NVQ’s and infection control. The general manager stated that a schedule of staff training is maintained, to enable this to be easily monitored. As this did not include the most recent training undertaken by staff, it was agreed that this would be forwarded to CSCI. A detailed schedule was received by CSCI before this report was completed and this confirmed that staff had received training appropriate to their role. It was noted from the information provided in the AQAA and from speaking to those in the home, that both staff and residents were from a variety of cultural and ethnic backgrounds. Residents made positive comments as to the interest this created and encouraged staff to talk about their backgrounds. It was evident that residents appreciated the diversity of those supporting them. A requirement has been made that staff induction records must be maintained and kept in the home. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 23 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed, run in the best interests of residents and provides good outcomes for the people who live there. EVIDENCE: Information supplied in the AQAA confirmed that the registered manager is a qualified nurse with many years experience and has achieved the NVQ Registered Manager’s Award and NVQ level 4 in management and care. The outcomes for residents and the standard of record keeping in the home indicate that the home is being effectively managed. The general manager stated that a qualified nurse has been appointed as deputy manager since the last inspection, in order to provide management support. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 24 It was positive to note that the deputy manager and other qualified nurses who act as shift leaders, have also achieved the NVQ Registered Manager’s Award, to develop their knowledge and skills in the management of the home. The ownership of the home has been re-registered as a limited company since the last inspection, which was carried out under the previous registration. It was clear from the feedback received by CSCI that the home is run in the best interests of the residents who live there. CSCI feedback forms were completed and returned by two residents, five relatives or friends and two healthcare professionals. Residents and visitors have made a number of positive comments which have been included in the summary at the beginning of this report and the response from the healthcare professionals was included at Standard 8, which refers to healthcare. The general manager stated that the home had carried out its own quality survey within the last six months and an outside company had been employed to assist with this. The results of the survey were still being received the general manager advised, and had not yet been analysed. It was agreed that the results received so far would be reviewed and the outcomes would be forwarded to CSCI within two weeks. The results of the home’s quality assurance survey were received before this report was completed. The survey was detailed and it was positive to note that the questions asked of residents and their representatives, were linked to the key standards from the national Minimum Standards for Older People. The majority of responses indicated satisfaction with the standard of care and nursing provided. Each question also recorded any action required or planned by the home, but few changes were needed. Residents’ monies are not handled the general manager stated, as all residents have a representative to support them in dealing with their finances. Should the home have to pay for anything on a resident’s behalf, the expenditure would be invoiced to the resident or their representative so that the home could be reimbursed. It was observed that a number of fire doors, which were fitted with automatic closing devices, were wedged or propped open. These are designed to close automatically in the event of the fire alarm being activated. The doors kept open included residents’ bedroom doors. This practice is unsafe as it puts residents and others at risk of the spread of fire or smoke, as the doors will not close when the fire alarm is activated. The general manager removed the wedges and props and stated that he would remind staff that this must not occur. The general manager also stated that the a number of the fire doors would be checked as it was noticed that they did Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 25 not close fully to prevent the spread of smoke or fire, even when the wedges or props were removed. It was also recommended that the laundry door is kept closed to promote fire safety and to prevent residents having access. An automatic “dosing” system for the washing machine is used, but it was observed that the top of this was not sealed to prevent anyone from trying to consume it. The manager stated that a sealed top would be obtained from the suppliers. Fire safety records were seen and these recorded that fire drills and fire safety training had taken place. A very clear pictorial sign in the entrance hall and other points in the home, advised residents and others when the fire alarm was to be routinely checked. Other information supplied in the AQAA indicated that equipment and systems in the home are maintained and serviced appropriately to safeguard those living and working there. A requirement has been made that doors designed to close automatically when the fire alarm is activated must not be wedged or propped open. Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.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 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 4 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 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 2 Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? N/A 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 OP26 Regulation 13 (3) Requirement Arrangements must be made to prevent infection, toxic conditions and the spread of infection in the home. Specifically, liquid soap and paper towels must be provided in the laundry and liquid soap must be provided in the staff toilet. A record of the induction of staff must be maintained and must be kept in the home. Adequate arrangements must be made for detecting, containing and extinguishing fires. Specifically, doors designed to close automatically when the fire alarm is activated, must not be wedged or propped open. Timescale for action 21/09/07 2 OP30 17 (2) Schedule 4.6 (g) 23 (4) (c) (i) 21/09/07 3 OP38 21/09/07 Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beaumont Lodge Nursing and Residential Home Limited DS0000069641.V342642.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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. 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