Inspection on 16/11/06 for Beverley Lodge

This inspection was carried out on 16th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beverley Lodge 29/10/08

Beverley Lodge 14/01/08

Beverley Lodge 19/12/05

Beverley Lodge 28/09/05

Beverley Lodge 20/01/05

Beverley Lodge 14/09/04

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

CARE HOMES FOR OLDER PEOPLE Beverley Lodge 122 Grove Road Sutton Surrey SM1 2DD Lead Inspector Deborah Yapicioz Key Unannounced Inspection 16th November 2006 13:15 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 Beverley Lodge DS0000019077.V308230.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. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beverley Lodge Address 122 Grove Road Sutton Surrey SM1 2DD 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) 020 8643 4128 020 8643 0673 zeenatnanji@aol.com Mr Nanji Mrs Z Nanji Mrs Doreen Margaret Hynes Care Home 19 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0) of places Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A maximum of eight service users may be in the DE(E) category. Date of last inspection 19th December 2005 Brief Description of the Service: Beverley Lodge is a residential care home for older people providing nursing care. The home is close to local amenities and public transport systems. Beverly Lodge is a large, detached, domestic style house. The home has recently undergone a programme of improvement and now provides fourteen single bedrooms and two double bedrooms. There is also a lift. The home has a single large lounge, which is also used as a dining area. This area was extended previously. The home has the usual facilities including toilets, bathrooms/ showers, laundry, sluice, kitchen and office. There is large garden to the rear and off street parking facilities to the front. The garden can be accessed by wheelchair users via a ramp. The home is well maintained and has a friendly atmosphere. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on the afternoon of 16th November 2006. The home was inspected under the National Minimum Standards Care Homes for Older People. A tour of the premises was undertaken and several residents and members of staff were spoken with. A sample of care plans and the medication records were also viewed. Records relating to the health and safety of residents were assessed and recruitment practices and staff training were monitored. The inspector would like to thank the service users, the staff team and Mrs Hynes for their help in facilitating the inspection. Overall the inspection confirmed that the home continues to provide a good standard of care to the people living there. What the service does well: What has improved since the last inspection? An aroma therapist has recently started visiting the home and one of the service users said how much she enjoyed having aromatherapy. The home manager explained that she is in the process of reviewing the care plan format used by the home and has looked at varied options. The manager Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 6 is aiming to have a more person centred plan which will include some life history information. The home has recently completed a quality monitoring exercise. Questionnaires were sent to service users, staff members and relatives. The home manager informed the inspector that the comments received were mainly positive with a few requests from the service users. One of the comments received from service users was regarding the television in the lounge area. As a result a new bigger television was purchased and put into the lounge. 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. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5, Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home provides good information and introduction opportunities for prospective service users and their families to make an informed choice about moving to the home. A needs assessment is always completed to ensure that service users needs can be met at the home. EVIDENCE: Beverly Lodge has a comprehensive statement of purpose and a separate service user guide in place, which contained all the information required under the Care Standards Act. The home manager confirmed that both documents are reviewed regularly. A copy of the homes most recent inspection report was available in the home on request. A needs assessment is requested from the referring care manager and the home management team also completes the in-house assessment to ensure that the home is suitable and the service users needs can be met. The service users files looked at during the inspection all contained assessments completed before the service users moved into the home. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 9 The home manager stated that any cultural or religious needs are identified at the referral stage and the way the home can meet those needs are built into the care plan. Records seen indicated that residents are invited to view the home and to stay for a trial period before a final decision is made for the placement to be long term. Most residents have involved relatives who also participate in this process. Each of the service users has a personal contract, specifying the terms and conditions of their occupancy that included periods of notice, fees charged, and the cost of ‘extras’ not covered by the basic cost of the placement. This home does not offer intermediate care therefore standard six does not apply. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users have individual care plans, which include consultation with service users. Care plans are regularly updated to ensure the service users changing needs are met. Residents’ medication is well managed to ensure good health. EVIDENCE: During the inspection staff were observed to be treating service users in a pleasant, friendly manner. Service users spoken to during the inspection felt that the staff team are nice to them and treated them well. The homes induction process covers treating the service users with dignity and respect and protecting their right to privacy. Details of advocacy services for older people where on display in the home. The home has a system in place for updating care plans. The service user plans carry on from the original plan drawn up by the care manager and other involved professionals. The plans include risk assessments and any medical appointments or visits from other professionals. Details of any cultural or religious beliefs are also included in the plans. A sample of plans was inspected. These indicated that residents’ individual needs were identified, action was taken to meet these and they were reviewed regularly. The home manager explained that she is in the process of reviewing Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 11 the care plan format used by the home and has looked at varied options. The manager is aiming to have a more person centred plan which will include some life history information. The home operates a risk management strategy. Service users at the home have individual risk assessments depending on their needs. The service users are all registered with a local General Practitioner The service users preferred term of address is recorded on their file and used by the staff team. The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. The records showed that all medication administered had been correctly recorded on Medicine Administration Record Sheets. Photographs of the service users were attached to the mars sheets. Service users who are prone to pressure sores had the necessary equipment for the promotion of tissue viability and prevention or treatment such as airbeds, soft cushions and heavy-duty foam cushions. Pressure sore risk assessments (Waterlow) are carried out and copies were seen on file. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. 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. The service users at the home are offered the opportunity to engage in various activities that satisfy their social, cultural, religious and recreational interests and needs. The home has an open visitors policy to ensure family links are maintained. Dietary needs are catered for with meals that are nutritionally well balanced and clearly based on the service users food and drink preferences, providing them with daily variation and healthy eating options. EVIDENCE: On the day of the inspection the homes daily activities and the lunchtime meal choices were all conspicuously displayed on the homes notice boards. Information about the homes recreational activities were on easy to read posters attached to the homes notice boards around the home. The home has organised a Christmas party, which friends and family members are invited to. The service users are also hoping to go on a trip to see the Christmas lights in London. As well as the regular entertainers used by the home, a carol singing group and a local dance school were booked to provide some additional festive entertainment An aroma therapist has recently started visiting the home and one of the service users said how much she enjoyed having aromatherapy. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 13 There is an open visitors policy and families are welcome to visit at any time, although the service users can choose who they wish to see. The visitor’s policy is included in the service user guide. A family member spoken to at the time of the inspection said that he visited often and always felt welcome at the home. Details of advocacy services for older people where on display in the home. Visitors can be seen in any part of the home including bedrooms. Personal items including furniture can be brought into the home if service users wish (if it is appropriate). This is recorded on the service users property file. Service users are on the electoral register and have postal votes. The service users are offered three meals a day as well as morning and afternoon tea’s. Having examined a random sample of menus, it was clear that a wide variety of well-balanced, nutritional food was available. The service users can also have seasonal choices such as salads. Medical needs are taken into account when planning menus. Any dietary needs are recorded in the service users care plan. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: Beverly Lodge has a complaints procedure, which outlines how a complaint is dealt with and timescales for action. The complaints procedure is included in the service uses guide. The home keeps a record of any comments or complaints made about the service. The home has in place procedures for responding to suspicion or evidence of abuse, including whistle blowing, and passing on concerns to the Commission for Social Care Inspection The London Borough of Sutton’s adult protection procedures were available in the office on request. The manager assured the inspector that any allegations or incidents of abuse would be reported to the appropriate authorities, including the Commission, and appropriate records maintained, including any action taken. The home provides staff training on issues of elder abuse. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The general décor of the home is good providing a comfortable, clean and safe environment for service users to live in. EVIDENCE: Beverly Lodge is located in a mainly residential area close to local amenities and transport links. The design and the layout appeared suitable to meet the needs of older people. On the morning of the unannounced inspection the home was comfortable, well ventilated and free from offensive odours. There were many “homely” touches such as plants and flower arrangements. The home has a lounge and dining room on the ground floor, which were suitable for the range of interests and activities preferred by service users. Communal areas appeared comfortable, bright and furnished appropriately to a satisfactory standard with adequate facilities for service users and their visitors to meet in private. There is also a garden to the rear of the building with seating to meet the service user needs. The home has a ramp to make access to the garden easier Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 16 for the residents. Service users bedrooms are pleasant and they have all been personalised by their occupants. Some bedrooms have ensuite facilities. The home has appropriate laundry facilities separate from the kitchen and the preparation of food. The laundry has suitable flooring. There is a locked cupboard for the Control of Substances Hazardous to Health products. The home has policies and procedures on the disposal of clinical waste. Various specialist equipment and adaptations were evident throughout the home. There are “Grab rails” a call bell system, mobile hoists, and other adaptations capable of meeting the assessed needs of the majority of the service users were in evidence through out the house. A passenger lift ensures that all parts of the home are accessible to service users The kitchen is clean and well equipped for preparing food hygienically. There are sufficient numbers of bathrooms and toilet facilities situated throughout the home. The facilities were noted to be clean, odour free and well maintained. The bathrooms and toilets are within close proximity to the communal areas and service users bedrooms. Paper towels and foot-operated pedal bins are provided in all the homes toilet and bathroom facilities for the disposal of paper towels, in accordance with good infection control guidance. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. 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. The staff team at the home have a range of skills and abilities, which enable them to meet the needs of the service users living at the home, ongoing training to build on staff skills is provided. EVIDENCE: The staff team receive an induction when they begin at the home relevant to the post that they are holding and a record is kept on the staff file. The homes duty roster demonstrated that staffing levels were maintained appropriately and included a sufficient skill mix of qualified nurses and care workers to meet the needs of elderly service users. The job descriptions for staff at the home staff clearly states what is expected of its employees in terms of their roles and responsibilities and the values that should underpin their conduct. Staff spoken to during the inspection demonstrated a sound knowledge of the care needs of older service users Staff files hold copies of the staff contracts, copies of passports/birth certificates, references and copies of Criminal Records Checks. The Staff team have attended training courses including Protection of Vulnerable Adults, manual handling and first aid. Evidence of training is kept on staff files. The home holds regular staff team meetings, which are recorded. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 18 The staff members spoken to during the inspection made positive comments on their experience of working at the home. The service users spoken to during the inspection said that the staff team treated them well. Observations of the contact between the staff team and service users confirmed this. There has been an improvement in the frequency of staff supervisions at the home although they are still not happening as frequently as they should. This will be reviewed at the next inspection. The home manager must also ensure that all staff members have an annual appraisal. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management style appears to be transparent with clear lines of accountability. In the main health and safety arrangements are adequate to ensure potential risks to service users health and safety are so far as reasonably possible identified and minimised. EVIDENCE: Doreen Hynes is registered with the Commission for Social Care Inspection as the manager of Beverly Lodge. Ms Hynes is a Registered General Nurse and has substantial experience in a care setting. Copies of the homes policies and procedures are kept in the staff room. The home has staff meetings, which are recorded. Environmental risk assessments are in place. The fire alarm system and emergency lighting is checked on a regular basis, however more fire drills should be carried out. Fridge and freezer temperatures are taken and recorded. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 20 Since the last inspection the home has completed a fire risk assessment. Records indicate that three fire drills have been undertaken in the previous year. The home manager must ensure that at least four drills take place per year, in line with national minimum standards and good fire safety guidance. The home has recently completed a quality monitoring exercise. Questionnaires were sent to service users, staff members and relatives. The home manager informed the inspector that the comments received were mainly positive with a few requests from the service users. One of the comments received from service users was regarding the television in the lounge area. As a result a new bigger television was purchased and put into the lounge. Water temperatures are checked and the findings are recorded. The standard of recording and administration in the home is good and all the information need to evidence that standards are being met were easily accessible A first aid box and a fire blanket are situated in the kitchen. There are fire extinguishers throughout the house. Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 x 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP36 Regulation 18(2) Requirement Staff must receive regular supervision at least six times a year and this must be recorded. Staff members should also have an annual appraisal. The home manager must ensure that at least four fire drills are carried out each year. Timescale for action 30/03/07 2. OP38 23. (4)(a) To (e) 30/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Beverley Lodge DS0000019077.V308230.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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