Inspection on 23/01/07 for Beresford Lodge

This inspection was carried out on 23rd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Beresford Lodge 22/01/09

Beresford Lodge 30/01/06

Beresford Lodge 12/08/05

Beresford Lodge 20/01/05

Beresford Lodge 13/09/04

Beresford Lodge 26/02/04

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 Beresford Lodge Beresford Road Seaton Sluice Whitley Bay NE26 4RJ Lead Inspector Karena M Reed Key Unannounced Inspection 23rd January 2007 1:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beresford Lodge DS0000000519.V314242.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. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beresford Lodge Address Beresford Road Seaton Sluice Whitley Bay NE26 4RJ 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) 0191 - 2377272 0191 2377272 mchawla88@aol.com Mr M Chawla Mrs Vivienne Lawson Care Home 26 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (20) of places Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 2006 Brief Description of the Service: Beresford Lodge is a home registered to provide personal care to twenty-six adults. Categories of registration include twenty places for older people over the age of sixty- five years and six places for people with memory loss over sixty-five years of age. The home does not provide nursing care. The home is situated in a residential area in the village of Seaton Sluice and is on a bus route. It is close to local shops, pubs and the nearby coast. The home consists of a large detached house with large gardens. All bedrooms are for single occupancy. Rooms are available on two floors of the building although three bedrooms to the front of the main house cannot be used due to restricted escape if there was a fire. There are two large lounges and a dining room overlooking gardens to the front and rear of the building. There are two assisted bathrooms and six lavatories. A Statement of Purpose and service user guide are available at the home for residents who are interested in coming to live at the home. The guides describe the services and facilities provided by the home and how staff are trained to meet service users’ care and support needs. CSCI Inspection reports are also available at the home detailing the quality of care provided by the home. Fees payable for living at the home at the time of inspection in January vary between £389 and £392. Additional charges are payable for hairdressing, private chiropody, personal toiletries and newspapers. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was unannounced and took place over three and a half hours. A partial tour of the premises took place and a sample of records were inspected which included: the Home’s Statement of Purpose and service user guide, 4 care plans, 2 residents contracts, 3 personal allowance records, the fire log, accident book, admission /discharge book, complaints record, staff communication book, staff meeting minutes, the medication system and four staff files. The deputy manager, one support worker and five residents were interviewed at the time of inspection. A questionnaire was also completed by the home before the inspection to provide information. Questionnaires were also sent to residents and other people involved with the home that may be able to comment about the running of the home. 11 resident questionnaires were returned. 9 residents and 4 staff were interviewed. Case tracking was carried out where certain service users and staff were spoken to and their records were examined. Residents said that: “Staff work well to meet needs.” “I am well looked after, happy and content.” “Staff keep me fully informed about the care given to my mother.” “Everyone is helpful and friendly.” “My mother was always involved in activities.” “Never needed to complain- tells you how well the staff work.” What the service does well: Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 6 The home respects the rights of the residents to remain at the home for as long as they can meet their needs. The home is well maintained and decorated with a very good standard of hygiene. There is commitment to staff training and staff are enthusiastic to receive this training to give them more insight into the different needs of residents. 98 of the staff team have completed or are studying for National Vocational Qualifications at levels 2 and 3. The home offers prospective residents whatever length of time they need to decide if they wish to live at the home. There is a selection of social activities and outings available if residents wish to become involved. There are detailed assessments describing the care and support needs of residents so staff can provide the necessary amounts of care and support.Detailed information is collected and given to prospective residents of the home. What has improved since the last inspection? The level of staff training continues to increase to ensure that staff are equipped with skills to meet the different needs of residents. The physical environment around the home continues to be improved for the benefit of residents. Carpets have been replaced in some bedrooms. Some of the windows have been replaced with double-glazing. The front and side door have been replaced. Lockable facilities have been replaced in bedrooms. A key pad has been fitted to the front door. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 7 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. Beresford Lodge DS0000000519.V314242.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 Beresford Lodge DS0000000519.V314242.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 1,3,4,5 Interesting and useful information is given to prospective residents about the home. The home collects enough information about the needs of prospective residents before they move in to help ensure staff are aware of the amount of care and support needs of the resident as they settle in. Staff receive a variety of training to give them the knowledge and insight to help understand the needs of residents and to provide the necessary levels of care and support to individual residents. Residents and their relatives are very welcome to visit the home to assess its suitability. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 10 EVIDENCE: The Home’s Statement of Purpose and service user guide were examined and they contained the necessary information as required by the Care Homes Regulations 2001. Records for four of the residents showed that when they were admitted to the home an assessment of their care needs had been carried out before their admission. The resident and relevant people who knew them were involved in the initial assessment. This information and the care manager’s assessment of the resident’s care needs were used to ensure all the needs of the resident could be met by staff. The records contained a range of information. The files had been audited to ensure information available was up to date. Staff receive training so that they know how to meet the specialist needs of the residents. Staff have received the necessary statutory training: Fire Training, Moving & Assisting, Food Hygiene, Safe Handling of Medication, First Aid, Protection of Vulnerable Adults and National Vocational Qualifications. Staff have also received training about; memory loss, equality and diversity, Future training planned includes updating Moving and Assisting and fire training, palliative care, continence awareness and supervisory management. Residents have the opportunity to visit the home as often as they need in order to decide if they want to live there. A resident may come for meals, have overnight stays and be introduced to other residents at the home at a pace suitable to the individual. Beresford Lodge DS0000000519.V314242.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 7,8,9,10 There are very good arrangements in place to ensure that residents’ health and social care needs are met. There is a system of reviewing the changing care needs of residents. Residents are well supported by staff and care plans show the amount of care and support that staff are providing to residents. There are very full arrangements in place to ensure residents health care needs are met. Staff receive training before they are able to administer medication to residents. Residents are treated with respect and their right to privacy is upheld. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 12 EVIDENCE: There are detailed assessments in the residents’ care plans. Personal support needs are well documented and give clear instructions to staff on how to support people in tasks such as washing, bathing, dressing, remaining mobile in order to help retain some independence. Care plans are amended and reviewed on a monthly basis by the resident’s key workers, (staff who have special responsibility for each resident). Residents and their families or representatives are involved in the process. Moving and handling assessments are in place. Technical aids and equipment is available for residents. Residents care records showed that they have access to external health care services. GPs and Community Nurses were regularly consulted for advice and treatment. Records show district nurses visit the home as required and residents are helped to use chiropody and optical services at least annually or as often as required. A random inspection of medication held within the home took place and everything was in order. A monitored dosage system is used by the home. A system is in place should residents be able to handle their own medication. Training records showed senior staff members receive training about medication before they are able to administer it to residents. Risk assessments are in place. Care records, conversation with staff and observation showed the privacy and dignity of residents are respected. All of those residents spoken to said that they were treated well by the staff and are well cared for. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A variety of activities and outings are available to residents. Residents maintain contact with family and friends as they wish. Staff help more dependent residents to exercise choice and control over their lives. The diet of residents is wholesome. EVIDENCE: A programme of activities is in place for residents this includes: videos, sing-along, manicurist, dominoes, aerobics, quizzes, crafts, hairdressing, “pie and pea suppers”, fish and chip suppers. Residents enjoy sitting in the large garden when the weather is suitable. Various seasonal parties are also Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 14 arranged, which are well supported by relatives and families. Residents were positive about the activities provided. Trips are arranged to the local pubs, theatre and Metro Centre. Written comments include: “My mother was always involved in activities.” Some residents have the opportunity to visit the local community with relatives or with staff. Staff ask each resident about their wishes, interests and choices. The cook talks with the residents to collect up to date ideas for making the menus and finding out about the food likes and dislikes of residents. At least two hot meals are provided daily and an alternative is available at teatime. Residents were very positive about the food: On the day of inspection, the tea served was shepherds pie and vegetables or sandwiches and scones. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 15 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): 16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure was available to remind people coming into the home of their right to complain. Residents are protected from abuse. EVIDENCE: There is a complaints procedure to inform people visiting the home of how they could complain if necessary. Residents have access to a complaints procedure that assists and supports them to bring any matters to the attention of staff outside of the home in case they felt uncomfortable bringing any complaints or concerns to the attention of staff within their home. The home keeps a record of complaints. One complaint has been received by the home since the last inspection and this has been resolved. Written comments include: “Never needed to complain- tells you how well the staff work.” Residents and their families are also asked at residents’ reviews if they have any complaints. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 16 Staff have received training about Protection of Vulnerable Adults and Prevention of Abuse. Staff have completed a Dementia Care course that has given them more insight into the needs of people with memory loss. Staff enjoyed the course and felt it provided them with more understanding about the care of people with different forms of dementia. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 17 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, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable and safe environment. There is a very good standard of hygiene around the home. EVIDENCE: There is a programme of redecoration and improvement around the home. Since the last inspection some bedrooms have been decorated. Some windows have been replaced with double-glazing and some bedroom carpets have been replaced. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 18 The ground floor bathroom walls were scuffed and marked. The bath panel was also marked and the paint was peeling at floor level. The home is clean, well decorated and very well maintained. The garden is well maintained and attractive. The home has enough sitting and dining space. Residents can see visitors in private in their own rooms. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are met by the numbers and skill mix of staff. Systems are in place to ensure residents are in safe hands. There are quite sound recruitment policy and practices in place to protect residents. Staff are trained to meet most of the care needs of residents. EVIDENCE: Examination of staff rotas and discussion with the person in charge and members of the staff team showed that the numbers of staff are as follows: 8.00am- 3.00pm 3.00 pm- 10.00pm 10.00pm- 8. 00 am Beresford Lodge 4 staff 3 staff 2 staff DS0000000519.V314242.R01.S.doc Version 5.2 Page 20 These numbers include the manager who works some supernumerary hours. The proprietor is also available and works at the home certain days of the week. There is a senior staff member on each shift. Other staff members are employed for duties such as food preparation, maintenance and cleaning. At least ten residents are now becoming more dependent due to memory loss, so staffing levels should continue to be reviewed to ensure the needs of residents can be met as individually as possible. Staff stated that they enjoyed working in the home and were observed to be kind, caring and respectful to residents. A stable committed staff team has been created. The necessary checks are being carried out prior to the workers being appointed. Two written references were available on the staff files examined from the most recent employers. An application form had been completed for each staff member. CRB checks are carried out before a person is appointed. There was no record to state when CRBs had been carried out or a way to remind management when they required renewing. A stable committed staff team has been created. Staff receive Skills for Care induction previously TOPSS. 98 of the care staff team have now achieved National Vocational Qualifications at level 2 some are also studying or have obtained level 3. Staff and their records showed that they also receive advice and /or training in other areas such as dementia care, health and safety, handling of medication, Vulnerable Adults Awareness, Health and Safety, Food Hygiene, First Aid, Infection Control and National Vocational Qualifications at different levels. Future training planned includes more NVQs and updating fire training and moving and assisting training. Written Comment cards: “Staff work well to meet needs.” Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 21 “I am well looked after, happy and content.” “Staff keep me fully informed about the care given to my mother.” “Everyone is helpful and friendly.” ” Good staff.” “Staff are really pleasant.” “Staff are very helpful.” Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 22 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): 31,32,33,35,37,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ live in a home that is well run and managed for the benefit of residents. Residents’ financial interests are safe guarded. The standard of record keeping is quite good. The health, safety and welfare of residents and staff are mostly promoted and protected. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 23 EVIDENCE: The registered manager has worked at the home for several years. She has completed a National Vocational Qualification at level 4 and has obtained her Registered Manager’s award. Discussion and observation maintain that she puts the needs of the residents first and promotes an ethos amongst staff of involving staff and residents in decision making within the home. Staff meetings do take place but the last meeting recorded was in the middle of 2006. The manager sends out questionnaires to residents and relatives annually to collect their views about the care provided by staff. This is to measure the quality of care provided by the home and to make improvements if necessary. The standard of record keeping is always good apart from staffing files looked at did not contain photographs of individual staff members, declaration of medical fitness and there was no proof of identity on staff files. Oxygen was being used in the home and there was no policy for its use or how to store it safely. Lockable facilities are available for residents to keep their own money if they wish. If a resident does not wish to keep control of their own money, the home is able to provide the facility to hold a small amount of money on behalf of the resident for everyday living. Individual records show the home has a suitable system for accounting any monies held on behalf of a resident. Documents detailing fire safety, risk assessments in the environment, water temperatures, maintenance contracts for equipment were all up to date. Staff training relating to health and safety was up to date and training being planned to renew any that required updating such as fire training and moving and assisting. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 24 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 3 x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 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 2 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 4 3 x 3 x 2 2 Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 25 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 2 Standard OP19 OP37 7,9,19 Schedule 2: 1,2,6 13(4)c Regulation 23(2)(d) Requirement The bathroom must be decorated. Staff files must contain proof of identity, photograph and declaration of medical fitness A policy for the use and storage of oxygen must be available. Timescale for action 01/05/07 01/05/07 3 OP38 01/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP27 OP32 OP37 Good Practice Recommendations To continue to review staffing levels. More regular staff meetings should be held. To establish a record of completed CRB checks to show when they require renewal. Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Beresford Lodge DS0000000519.V314242.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!