Inspection on 19/12/05 for Beverley Lodge

This inspection was carried out on 19th December 2005.

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 16/11/06

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 Unannounced Inspection 19th December 2005 10:30 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.V272462.R01.S.doc Version 5.0 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.V272462.R01.S.doc Version 5.0 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.V272462.R01.S.doc Version 5.0 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 28th September 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.V272462.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/6. The inspection was unannounced and took place on the morning of 19th December 2005. The home was inspected under the National Minimum Standards Care Homes for Older People. A previous inspection took place on 28th September 2005 when most of the standards that the Commission for Social Care Inspection considers as key standards were inspected. Methods of inspection included talking with the service users, a partial tour of the premises, and observations of contact between staff and service users, meeting with the manager and other members of staff. 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? There has been a considerable improvement in the recording on the homes Medicine Administration Record Sheets over the last two inspections and all records were complete at the time of the inspection. The home has recently undergone a period of refurbishment to reorganise the room arrangements and replace the homes three bedded rooms with five single rooms with ensuite facilities. The service users spoken to during the inspection were very happy with the recent changes and liked their bedrooms and the way they were decorated. The home now has only two double rooms. Since the last inspection the home management team have also replaced the carpet on the stairs, and hallways. The home manager has a good awareness of has a health and safety issues and the homes health and safety policy has been updated recently. Beverley Lodge DS0000019077.V272462.R01.S.doc Version 5.0 Page 6 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.V272462.R01.S.doc Version 5.0 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.V272462.R01.S.doc Version 5.0 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): 1,3 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 the service users care needs can be met at the home. EVIDENCE: Beverly Lodge has a statement of purpose and a Service users guide in place. Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or other relevant person has been received. The home also has an admission procedure, which is completed in conjunction with the care manager’s assessment. A care manager’s assessment was seen on the service users files sampled during the inspection. Families are encouraged to visit and “test drive” the home before making a decision to move there permanently. A trial period is also offered to ensure that the home can meet service users needs. This home does not offer intermediate care therefore standard six does not apply. Beverley Lodge DS0000019077.V272462.R01.S.doc Version 5.0 Page 9 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): 7,9,11 Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ medication is well managed to ensure good health. Service users have been consulted on their personal and cultural preferences in relation to illness, death and dying, thus ensuring their individual wishes are respected. EVIDENCE: The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. All medicines administered are recorded on Medicine Administration Record Sheets. There has been a considerable improvement in the recording on the homes Medicine Administration Record Sheets and all records were complete at the time of the inspection. The service users are registered with a local General Practitioner 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 health care professionals routinely visit the home. Beverley Lodge DS0000019077.V272462.R01.S.doc Version 5.0 Page 10 The home has care plans in place that carries on from the original care plan and assessment. Residents’ individual needs were identified and the actions to be taken to meet the requirements. The care plans are reviewed regularly and the staff team at the home monitor the plans and make regular entries to record daily activities and any areas of concern. Service users spoken to during the inspection said that the staff team at the home were nice to them and they were looking forward to the Christmas holiday. Service users are asked about issues around death and dying before admission to the home, this includes any cultural or religious wishes. A record of any particular cultural, ethnic or religious wishes are kept on file. Beverley Lodge DS0000019077.V272462.R01.S.doc Version 5.0 Page 11 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 The daily routines and house rules promote residents’ rights and encourage independence. The home has an open visitors policy to ensure family links are maintained. EVIDENCE: On the day of the inspection the homes forth coming Christmas activities and the lunchtime meal choices were all displayed on the homes notice boards. The home had already organised a Christmas party, which was well attended by friends and family members. As well as the regular entertainers used by the home, a carol singing group and a local dance school were also booked to provide some additional festive entertainment 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. Visitors can be seen in any part of the home including bedrooms. Visitors to the home also include members of local churches. One family visitor spoken to during the inspection said they could visit at any time and the staff team made them feel welcome. 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. Beverley Lodge DS0000019077.V272462.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18, There is a complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives and ensures that their concerns and complaints will be dealt with promptly and efficiently in a timely manner. The home has the appropriate policies and procedures in place to protect service users from abuse. 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.V272462.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 The general décor of the home is good providing a comfortable, clean and safe environment for service users to live in. EVIDENCE: The home is situated in a residential area of south Sutton and is within reasonable walking distance of shops and public transport. The design and the layout appeared suitable to meet the needs of older people. The home has a ramp to make access to the garden easier for the residents. A passenger lift ensures that all parts of the home are accessible to service users On the morning of the unannounced inspection the home was warm, comfortable, bright, well ventilated and free from offensive odours. The homes communal areas had been decorated for the Christmas period. There is ample communal space through out the home. The communal areas appeared comfortable, bright and furnished appropriately with areas for service users and their visitors to meet in private. The home has recently undergone a period of refurbishment to reorganise the room arrangements and replace the homes three bedded rooms with five single rooms with ensuite facilities. The service users spoken to during the Beverley Lodge DS0000019077.V272462.R01.S.doc Version 5.0 Page 14 inspection were very happy with the recent changes and liked their bedrooms and the way they were decorated. The home now has only two double rooms. Since the last inspection the home management team have also replaced the carpet on the stairs, and hallways. Beverley Lodge DS0000019077.V272462.R01.S.doc Version 5.0 Page 15 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, 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 home manager confirmed that there is always a minimum of three staff on duty during the day at the home. This is a mix of qualified nurses and care staff. The home also employs a handyman, cook and two cleaners. 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. The home arranges for additional staff to be on duty if the need arises, such as escorting a service user to a hospital appointment. The home holds regular staff team meetings, which are recorded. The staff members spoken to during the inspection made positive comments on their experience of working at the home Beverley Lodge DS0000019077.V272462.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 31,36,38 The management style is open and the home appears to be well run. 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. This will be further enhanced with the production of a fire risk assessment 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. Members of the staff team spoken to during the inspection felt supported by the home manager and said that they would be happy to speak to the manager if they had a concern. 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 Beverley Lodge DS0000019077.V272462.R01.S.doc Version 5.0 Page 17 The home manager demonstrated a good awareness of health and safety issues. The home has a health and safety policy in place, which has been recently updated. The staff team receive training on issues such as basic food hygiene, fire and manual handling. The home has fire drills in keeping with the standards and the home manager is in the process of completing a fire risk assessment. The fire alarm system and emergency lighting is checked on a regular basis. Beverley Lodge DS0000019077.V272462.R01.S.doc Version 5.0 Page 18 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 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 X 2 Beverley Lodge DS0000019077.V272462.R01.S.doc Version 5.0 Page 19 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 Requirement Staff must receive regular supervision at least six times a year and this must be recorded. A fire risk assessment for the home should be completed Timescale for action 30/03/06 2. OP38 23. (4)(a) To (e) 30/12/06 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.V272462.R01.S.doc Version 5.0 Page 20 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.V272462.R01.S.doc Version 5.0 Page 21 - 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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