Inspection on 28/09/05 for Beverley Lodge

This inspection was carried out on 28th September 2005.

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

The inspector 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 19/12/05

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 28th September 2005 2:00 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 DS0000019077.V253530.R02.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. DS0000019077.V253530.R02.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 DS0000019077.V253530.R02.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 20/01/05 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. DS0000019077.V253530.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was inspected under the National Minimum Standards Care Homes for Older People. The inspection took place on the afternoon of 28th September. The inspector would like to thank Doreen Hynes the home manager and Sue Self, the service users and staff, for their time and willingness to facilitate the inspection process. Methods of inspection included observation of contact between staff and service users, talking to staff and service users and a discussion with the registered manager and admin manager. Records examined included the service users plans, complaints, staffing records, training records, Medicine Administration Record Sheets and Criminal Records Bureau Checks. What the service does well: What has improved since the last inspection? The home has recently undergone a planned programme of improvement. Previously the home had two “three bedded” rooms. These have now been replaced with five single rooms with ensuite facilities. The service users using these rooms said that they were very happy in their new rooms. The home now has fourteen single rooms and two double bedrooms. Other areas have also been redecorated. Doreen Hynes has now been registered with the Commission for Social Care Inspection to manage Beverley Lodge and therefore has undertaken all the procedures to determine her fitness for this task. DS0000019077.V253530.R02.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. DS0000019077.V253530.R02.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 DS0000019077.V253530.R02.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): 1,2,3,4,5 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. Each of the service users is issued with an individual contract setting out the terms and conditions of the placement, which safeguards the interests of both parties. EVIDENCE: A statement of purpose and service users guide is available to interested parties, which outline the service and facilities available to prospective residents. 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. The service user and their family (if it is appropriate) are involved and consulted in each stage of the admission. Service users and their families are DS0000019077.V253530.R02.S.doc Version 5.0 Page 9 encouraged to visit the home before a decision to move is made. It is usually a family member that visits the home. A trial period is offered and a review meeting takes place between the care managers, the service user, their family and the management team at the home. The home has a contract in place, which includes rooms to be occupied, who is liable for breech of contract, fees, complaints and the trial period. The home does not provide intermediate Care so therefore standard six is not applicable. DS0000019077.V253530.R02.S.doc Version 5.0 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 The service users have individual care plans, which are regularly updated to ensure the service users changing needs are met. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. EVIDENCE: The home manager stated that issues of respect and how to treat service users with dignity is incorporated into the induction training of new staff. 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 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. The service users have an “Activities of Daily Living” chart on their file. The staff team at the home updates the care plans on a daily basis as well as a monthly basis. The home has a policy on the receipt, recording, storage, handling, administration and disposal of medication. Records examined showed that all medicines administered are recorded on Medicine Administration Record DS0000019077.V253530.R02.S.doc Version 5.0 Page 11 Sheets. Although there has been some improvement in the recording on Medicine Administration Record Sheets, there were still some gaps in the medication records. The home must ensure all medication records are filled in correctly. DS0000019077.V253530.R02.S.doc Version 5.0 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 There is an activities programme in the home, which appears to suit the needs of the service users, and relatives and friends are always welcome to visit. 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, nicely presented, and clearly based on the service users food and drink preferences, providing them with daily variation and healthy eating options. EVIDENCE: There is an activities programme in the home and notices around the home detail those on offer, which include Bingo, Exercise to music and out side entertainers. The service users birthdays are celebrated with a cake. One of the service users is due to celebrate her 100th birthday and the staff team at the home are arranging a party for her and a visit from the local paper. A hairdresser visits every fortnight and a chiropodist also visits regularly. DS0000019077.V253530.R02.S.doc Version 5.0 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. There are no restrictions with regard visiting times, providing there arrive at ‘reasonable’ times of the day (e.g. not late at night etc…). Representatives from local churches call at the home. Visitors can be seen in any part of the home including bedrooms. The home invites relatives and families to any social events. The service users at Beverly Lodge are offered three meals a day as well as morning and afternoon tea’s. The manager stated that the menus are changed on a regular basis and the preferences of the service users are taken into account. Seasonal options are also offered. Any dietary needs are recorded in the service users care plan. Personal items including furniture can be brought into the home if service users wish. This is recorded on the service users file. Service users are on the electoral register and have postal votes. DS0000019077.V253530.R02.S.doc Version 5.0 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 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 home keeps a record of any comments or complaints made about the service. There has been one anonymous complaint since the last inspection, which was sent directly to the Commission for Social Care Inspection. The complaint was investigated by the Commission for Social Care Inspection and not upheld. The home has an Abuse policy and any concerns would be referred in line with the Vulnerable Adults Procedure. The home also has a copy of the local authority Adult Protection Policy on site. The staff team at the home receive training on abuse issues. DS0000019077.V253530.R02.S.doc Version 5.0 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): 19,23,25,26 The general décor of the home is good providing a comfortable, clean and safe environment for service users to live in. Service user’s bedrooms provide privacy and reflect individual interests and preferences. EVIDENCE: The home 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. The home was clean and generally odour free on the day of the inspection. 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. The home has recently undergone a planned programme of improvement. Previously the home had two “three bedded” rooms. These have now been replaced with five single rooms with ensuite facilities. The service users using these rooms said that they were happy in their new rooms. The home now has fourteen single rooms and two double bedrooms. DS0000019077.V253530.R02.S.doc Version 5.0 Page 16 The dining room and parts of the hall way have been redecorated and a new carpet has been laid in the hall and up the stairs. Service users have been encouraged to personalise their rooms. There were many “homely” touches such photographs, plants and flower arrangements. The home has appropriate laundry facilities separate from the kitchen and the preparation of food. The washing machine is capable of washing clothes at high temperatures, which helps with the control of infections. 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. DS0000019077.V253530.R02.S.doc Version 5.0 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 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. The staff team have all had Criminal Records Check, as a safeguard to offer protection to the homes service users EVIDENCE: The home manager stated 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 Staff files hold copies of the staff contracts, copies of passports/birth certificates, references, working time regulations forms, copies of Criminal Records Checks as well as induction and training records. The home manager stated that all the care staff at the home are registered to do a National Vocational Qualification. Staff have access to a range of other training courses including manual handling, food hygiene and first aid. Evidence of training was seen on the sample of personnel files viewed DS0000019077.V253530.R02.S.doc Version 5.0 Page 18 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): 31,33,35,36,38 The management style is open and the home appears to be well run. There are clear lines of accountability, which is aimed at ensuring the interests of the service users, are safeguarded and their safety and welfare are protected. EVIDENCE: Doreen Hynes is the manager of Beverly Lodge and has recently completed the registration process with the Commission for Social Care Inspection. Ms Hynes is a Registered General Nurse and has substantial experience in a care setting. She is in the process of completing the National Vocational Qualification level four. 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. DS0000019077.V253530.R02.S.doc Version 5.0 Page 19 Regular staff meetings are held and minutes were seen. The staff team at the home are required to sign as confirmation that they have read the minutes. The staff team also have daily hand over meetings. Service users relatives or the local authority handle the majority of residents’ finances if they are unable to do this themselves. No one at the home acts as appointee for any service user. The home holds small amounts of “pocket money” for the hairdresser etc. Monies checked during the inspection were correct. Environmental risk assessments have been completed for most areas although a risk assessment should be completed for room eight which has a low window. Width restrictors are fitted to windows above the ground floor. The homes policies and procedures are kept in the office area. The staff team are given individual copies and they are also discussed at the team meetings. The admin officer at the home is currently updating the health and safety file. Magnetic release catches are fitted on all doors. Records indicate that fire drills at the home are not happening as often as they should. Fire drills should be undertaken quarterly, in line with good fire safety guidance. A fire risk assessment for the home should also be completed. DS0000019077.V253530.R02.S.doc Version 5.0 Page 20 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 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 X X X 3 X 3 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 DS0000019077.V253530.R02.S.doc Version 5.0 Page 21 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 2 Standard OP36 OP9 Regulation 18 Requirement Staff must receive regular supervision at least six times a year and this must be recorded. The home manager must ensure all medication records are correctly filled in at all times The home manager must ensure regular fire drills take place A fire risk assessment for the home should be completed A risk assessment should be completed for room eight which has a low window. Timescale for action 01/02/06 10/10/05 17 (1)(a) Sch 3 3(i) 23. (4)(e) 23. -(4) (a) To (e) 13. -(4) (a) 3 4 5 OP38 OP38 OP38 10/10/05 31/12/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000019077.V253530.R02.S.doc Version 5.0 Page 22 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 DS0000019077.V253530.R02.S.doc Version 5.0 Page 23 - 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!