Inspection on 29/10/08 for Beverley Lodge

This inspection was carried out on 29th October 2008.

CSCI found this care home to be providing an Good service.

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

Beverley Lodge 14/01/08

Beverley Lodge 16/11/06

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 16/12/2008.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Beverley Lodge 122 Grove Road Sutton Surrey SM1 2DD     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Mohammad Peerbux     Date: 2 9 1 0 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 24 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Older People Page 3 of 24 Information about the care home Name of care home: Address: Beverley Lodge 122 Grove Road Sutton Surrey SM1 2DD 02086434128 02086430673 zeenatnanji@aol.com Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Name of registered manager (if applicable) Mrs Doreen Margaret Hynes Type of registration: Number of places registered: Mr Nanji,Zeenat Nanji care home 19 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 19 The registered person may provide the following category of service only: Care home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 19) Dementia - Code DE (of the following age range: 65 years and over) (maximum number of places: 8) Date of last inspection Brief description of the care home 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 a single large lounge, which is also used as a dining area. This area was extended previously. The home has the usual Care Homes for Older People Page 4 of 24 Over 65 8 19 0 0 Brief description of the care home facilities including toilets, bathrooms/ showers, laundry, sluice, kitchen and office. There is also a lift. 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. Care Homes for Older People Page 5 of 24 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This unannounced visit to the home was undertaken as a part of the inspection process for the year 2008/2009.In writing the report, consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. The registered manager facilitated the inspection. Some of the residents were spoken to and they commented positively on the care they were receiving.They are all thanked for their time and all of those who provided feedback for their support in the inspection process. A tour of the building was also carried out. All registered adult services are now required to fill in an annual quality assurance Care Homes for Older People Page 6 of 24 assessment (AQAA) .It is a self-assessment that the provider (owner) must complete every year. The completed assessment is used to show how well the service is delivering good outcomes for the people using it. Some information from this AQAA is included in the report. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 24 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 24 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home undertakes an assessment of the healthcare needs of residents prior to their admission to ensure that their needs would be met. Evidence: Admissions are not made to the home until a full needs assessment has been undertaken. For people who are self-funding and without a care management assessment, a skilled and experienced member of staff always undertakes an assessment. The assessment is conducted professionally and sensitively and involves the individual and their family or representative, where appropriate. Intermediate care for rehabilitation and return to the community is not provided by this home. Care Homes for Older People Page 10 of 24 Care Homes for Older People Page 11 of 24 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The plans of care for residents generally include detailed information about their needs and personal goals. This helps staff to know their needs and how to meet them.Overall the arrangement for health care needs of the residents is good and they receive personal support in the way they prefer. Evidence: Three care plans were sampled at random and it was noted they generally included information necessary to deliver care.Each resident has a plan that where possible has been agreed with them.This is written in plain language, is easy to understand and considers all areas of the individual life including health, personal and social care needs.The plan is reviewed by care staff in the home at least once a month, updated to reflect changing needs and current objectives for health and personal care, and actioned.The plan also includes a risk assessment where applicable. Areas have been identified where staff are willing to support residents to take some risks, which may have an impact on their rights. Care Homes for Older People Page 12 of 24 Evidence: The home actively promotes the right of residents in accessing health and remedial services that they need, both within the home and in the community. Records show that the home arranges for health professionals to visit residents in the home and provides facilities to carry out treatment. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. Staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms. Residents who were spoken to stated that they are happy with the way that the staff deliver their care and respect their dignity. Observation of the staff team interacting with the residents showed that the carers were mindful how they addressed residents, and they were seen to be polite and friendly. Care Homes for Older People Page 13 of 24 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are being provided with a range of opportunities for recreational and social activity that is in accord with their social and cultural needs. They are assisted to maintain contact with family and friends, and links with the local community are encouraged. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. Evidence: Staff are aware of the need to plan the routines and activities of the home in a way, which meets the choice, and wishes of residents. The home tries to be flexible and attempts to provide a service, which is as individual as possible by using its staff and resources effectively. As far as possible, the residents are consulted on how the home can work to provide them with a flexible lifestyle, and to achieve their wishes.The easy access to the garden has made it easier for residents who are wheelchair bound to use the outdoor facilities, this has also helped to organise outdoor activities so all residents can take part .Religious needs are met through a 2 monthly church service for all residents. Last year the home organised a firework display for the residents and relatives, this was a real success and they are intending to do another fire display this November.All other relevant festivities are observed by the home throughout the Care Homes for Older People Page 14 of 24 Evidence: year.An aromatherapist also come into the home for those who wish to use this service. The home has open visiting arrangements and residents know they can entertain their family and friends in their own room. If they prefer they can use communal areas of the home to talk to visitors. Maintaining independence and enabling residents to make their own decisions about how they wish to live is a key objective of the home. Residents have the choice to bring personal possessions with them on admission to the home and are encouraged to keep personal items, which are important to them in their own room. It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. Staff are ready to offer assistance in eating where necessary, discreetly, sensitively and individually, while independent eating is encouraged for as long as possible. The manager consults with residents and tries to meet the preferences and suggested dishes when preparing the menu. The home also offers residents cooked breakfast if they wish. Care Homes for Older People Page 15 of 24 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are generally managed well, which should ensure that the concerns of residents and relatives are listened to. Evidence: The home has a complaints procedure that is conspicuously displayed in the home for all to view. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. The current complaints procedure is good and gives a clear step by step guide of how to make a complaint. The home is clear when an incident needs to be referred to the Local Authority as part of the local Safeguarding procedures in place. The manager stated that most staff working within the home are fully trained in Safeguarding Adults and know how to respond in the event of an alert. Care Homes for Older People Page 16 of 24 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally hygienic and clean, homely and comfortable,this environment therefore facilitates the health and wellbeing of residents. Evidence: The home is suitable for its stated purpose. It is accessible, meet the residents individual and collective needs in a comfortable and homely way. The bedrooms are personalised to reflect the residents individual needs, and personalities. Overall the home was decorated to a good standard throughout and appeared to be very comfortable, bright and warm. The home has a rolling maintenance programme in place.The patio has been completed recently to enable residents to sit out if they wish. The home has displayed potted plants to make it more inviting for families when they visit to take their relatives to the patio. The home is kept clean, hygienic, and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. The Environmental Health inspector has visited the home and it has been awarded a four star certificate. Care Homes for Older People Page 17 of 24 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has the numbers and skill mix of staff sufficient to meet the needs of residents and to ensure their safety. There is a staff training and development programme in place. This ensures that staff fulfil the aims of the home and meet the changing needs of residents. Evidence: Copies of staff rotas show well thought out and creative ways of making sure that the home is staffed efficiently, with particular attention given to busy times of the day and changing needs of the residents. The registered manager informed that more than 50 of staff have an NVQ level qualification at level 2. Recruitment procedures seemed appropriate. Staff files were examined at random and found to contain all the information required by the Care Homes Regulations 2001 including a completed job application, terms and conditions of employment, an enhanced CRB check and proof of their identity. The home ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. Care Homes for Older People Page 18 of 24 Evidence: Care Homes for Older People Page 19 of 24 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home management generally provides guidance and direction to staff to ensure residents receive consistent quality care. There is a quality monitoring system and this ensures the home is run in a way that is in the best interests of the residents. Evidence: The registered manager has the required experience to run the home. She is aware of and work to the basic processes set out in the NMS.There is a strong ethos of being open and transparent in all areas of running of the home. She is also aware of current developments both nationally and by CSCI and plans the service accordingly. Effective quality assurance and quality monitoring systems, based on seeking the views of residents, are in place to measure success in meeting the aims, objectives and statement of purpose of the home.The home holds regular coffee mornings every 3 months with the residents,their friends and relatives. Various issues are discussed during these meetings and everyone is invited to speak at these forums.The home is Care Homes for Older People Page 20 of 24 Evidence: constantly looking at ways to improve the service and to provide a high standard of caring environment.They are planning to improve their documentation for pre assessment forms to include more details for example with the implementation of the Mental Capacity Act and Deprivation of the Liberty Safeguards Act. The registered manager informed that small amounts of money are kept in separate envelopes for each resident with a running balance sheet appropriately maintained for sundries, such as hairdressing costs. A sample of these was seen and was accurate and well maintained. Records with regards to health and safety are of a good standard and are routinely completed. Certificates relating to health and safety were up to date servicing certificates. Care Homes for Older People Page 21 of 24 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 22 of 24 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations Care Homes for Older People Page 23 of 24 Helpline: 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 We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2008) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 24 of 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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