Inspection on 20/04/05 for Winnie Care (Beverley House) Limited

This inspection was carried out on 20th April 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

Winnie Care (Beverley House)... 05/09/06

Winnie Care (Beverley House)... 28/11/05

Winnie Care (Beverley House)... 15/10/04

Winnie Care (Beverley House)... 22/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Beverley House Beverley Road Saltersgill Middlesbrough TS4 3LQ Lead Inspector Ray Burton Unannounced 20 April 2005 08:30 am 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 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 House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Beverley House Address Beverley Road Saltersgill Middlesbrough TS4 3LQ 01642 828383 01642 828383 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Winnie Care (Beverley House/Lodge) Ltd Mrs Lynne Atterton Care Home 18 Category(ies) of DE(E) Dementia over 65 - 18 registration, with number of places Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th October 2005 Brief Description of the Service: Beverley House is a purpose built single storey home for the care of 18 older people suffering from a dementia. The home is divided into three, six bed units, sharing two loun ges and a dining room. There is a small enclosed garden for the use of residents. Accommodation is provided in single rooms and residents are encouraged to bring with them furniture and other items from their own homes. Beverley House is close to a local shopping area and has transport links to all areas of Middlesbrough. Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Although there had been some improvement in care planning since the last inspection further development was necessary, especially in the area of risk assessment. The manager must review the procedures relating to the administration of medication. The manager must ensure that all necessary checks are received prior to staff commencing employment. Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 Page 6 It was disappointing that environmental issues, the subject of previous inspection reports, had still not been addressed by the provider. 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 House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4,5,6 A pre-assessment process was conducted, however the homes assessment document required development to ensure that all areas of need were covered. EVIDENCE: The home had a Statement of Purpose setting out the aims, objectives and philosophy of care. Each resident had been issued with a Service Users Guide and a copy of the terms and conditions of residence on admission to the home. All of the care plans examined on the day of the inspection contained a needs assessment from a care manager of the placing authority or a transfer summary if the resident was being admitted from hospital. Following receipt of a referral an invitation to visit the home would be extended to the prospective resident and his/her family. If service users were not able to visit, the manager would visit them in hospital or their own home to conduct an assessment to determine if the person’s needs could be met by the home. Care plans contained copies of the homes assessment, however these were very basic and did not cover all areas of need. Intermediate care is not provided therefore this standard does not apply. Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10,11 Residents were treated with respect and their healthcare needs addressed by staff at the home in conjunction with community based healthcare professionals. Care plans required further development, especially in the area of risk management. The homes procedure for the administration of medication must be reviewed. EVIDENCE: Residents general health was monitored by staff at the home with healthcare needs being addressed by community based professionals e.g. residents own general practitioner, District Nurses, dietician, chiropodist, dentist etc. Examination of care plans showed that since the last inspection there had been an improvement in care planning, however further development must be undertaken especially in the area of risk assessment that should be more comprehensive and risk management strategies that should be more detailed. It is also important that the home provides evidence that care plans have been discussed and agreed with residents and their relatives. The manager acknowledged the shortcomings in some of the care plans but said that she had embarked on a programme of improvement that was still ongoing. Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 Page 10 The residents were unable to control their own medication therefore all medication was stored centrally and dispensed by care staff. The medicines were appropriately and securely stored, however there were some concerns in relation to the administration of medication: * The homes procedure for the administration of medication stated that two members of staff should administer medication. On the day of the inspection it was noted that only one member of staff had given out medication at breakfast time. * The homes procedure stated “senior care assistant signs MAR sheet, then takes medication to the resident.” When questioned staff stated that they signed the MAR sheet, “popped” the tablets into a plastic pot then took them to the appropriate resident. All medicines should be administered to residents directly from the containers in which they are dispensed. Secondary dispensing, which is the removal of medicines by care staff from the original container into a secondary container is an unsafe system. The opportunity for error to occur is high. The home must cease the practice of secondary dispensing with immediate effect. The manager should, as a matter of urgency, review the homes policy and procedures for the administration of medicines. She must ensure that all members of staff responsible for the giving out of medication are fully conversant with the revised procedure and comply with it. It was observed during the inspection that staff/resident interaction was good and residents were treated with respect and addressed courteously. Members of staff were seen to knock on bedroom and toilet doors before entering and to deal discreetly and quietly with any problems that occurred. When interviewed, staff talked sensitivity about the feelings of residents and about the way in which care, especially personal care should be delivered. They displayed an awareness of the importance of promoting the dignity and privacy of the individual. A suitable policy was in place to deal with dying and death and residents were able to remain at Beverley House during their last days with additional support from medical professionals and, if needed, the MacMillan Nurses. Family members were encouraged to remain with their loved one and were supported and comforted by the staff at the home. Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 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 standard(s) 12,13,14 Daily routines were flexible and allowed residents to exercise choice. Staff encouraged the maintenance of family and friendship links. EVIDENCE: Observation during the inspection indicated that there was flexibility in the daily routines to allow residents to exercise personal choice over their own lives, subject to their individual plan. Residents were able to choose what time they went to bed and what time they rose in the morning. Meals were at set times and were generally taken in the dining room however residents could, if they wished, have their meals served in their rooms. The importance of residents maintaining contact with their families and friends was recognised by the manager and staff, and the home operated an “open door” policy with visitors being welcome at any reasonable time. Contact with local churches was encouraged and the home received regular visits from representatives of the nearby Gospel Hall and the priest from the Roman Catholic Church who gave Holy Communion to those who wished to receive it. Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 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 standard(s) 16,17 The home had a satisfactory complaints system and a suitable policy dealing with the legal and civic rights of residents. EVIDENCE: The home had an appropriate complaints procedure and residents, relatives and staff had all been made aware of it. Examination of the complaints record showed that the home had not received a complaint since the last inspection. The home had a policy dealing with the legal and civic rights of residents. The manager said that at the last election only one resident exercised his right to vote. Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 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 standard(s) 19,20,21,22,23,24,25,26 The environmental standard was generally good providing residents with a comfortable and homely place in which to live, however the worn furniture covers in the lounge areas detracted from the overall comfort in the home. There was sufficient specialist equipment to meet the current needs of residents. Bedrooms contained many personal effects and reflected the personality of the occupant. Several environmental issues remained outstanding from previous inspection reports. EVIDENCE: A tour of the building revealed décor and fabric to be in good condition and the building clean and hygienic and free from offensive odours. All areas of the home were centrally heated and radiators had been covered with suitable guards to ensure a low surface temperature. Hot water outlets accessible to residents had been fitted with pre-set valves to provide safe water temperatures. Lighting was domestic in nature and emergency lighting had been provided throughout the home. There were seven toilets accessible to Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 Page 14 residents and each unit had suitable bathing and shower facilities. None of the bedrooms had an en-suite facility but all contained a wash hand basin. Sufficient and appropriate disability equipment was available to meet the current needs of residents e.g. grab-rails in toilets and bathrooms, hoists. A call system was in place in all rooms. The home consulted with community based medical professionals to ensure that any additional requirements e.g. specialist mattresses would be provided as required. All bedrooms were nicely decorated and contained furniture that was domestic in style and suitable for purpose. Each room had been individualised by the inclusion of furniture and other items such as photographs, TV., ornaments etc brought from the occupants own home. It was noted, however, that none of the bedroom doors had been fitted with self-closing devices, this was contrary to the advice given to the home in the letter dated 20th April from Cleveland Fire Brigade. “It is recommended that self closing devices are provided to bedroom doors. A fire in a room with an open door can quickly spread fire and smoke along a corridor. If it is necessary to maintain bedroom doors open for the well being of residents then approved devices linked to the fire alarm may be utilised.” Communal areas were clean and tidy and were appropriately and comfortably furnished. There were however some areas of concern: The seat covers in the lounges that had been identified in the last inspection report, as in need of attention had still not been replaced. It is noted that the inspector had been told on that occasion that the matter was in hand. The provider must forward an action plan stating a timescale for the refurbishment or replacement of lounge furniture. One of the two doors leading into the large lounge had been wedged open. This door should be fitted with an approved device linked to the fire alarm system. Of particular concern was the reception style open office. This area does not provide security for records etc nor does it provide the degree of privacy necessary for the conducting of confidential telephone conversations or meetings with relatives, social workers etc. This issue has been identified in several previous inspection reports. Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 Not all personnel files contained evidence that satisfactory CRB and POVA checks had been received prior to commencement of employment. EVIDENCE: Since the last inspection, when concerns were raised that the staffing hours were not adequate to meet the needs of current service users whilst allowing the manager time to run the home, there has been some improvement in the staffing levels. Staffing levels are now 441 care hours plus 40hrs manager (although the manager attends a training course one day each week for which there are no replacement hours given) plus 64 hours domestic and 59.5 hours kitchen. Monitoring of the staffing complement must continue, to ensure that the home always has staff employed in sufficient numbers to meet the assessed needs of residents and to allow the manager time to manage the home in an efficient and effective way. Examination of personnel files revealed that all necessary checks, including Criminal Records Bureau, were carried out and that two suitable references were received prior to confirmation of employment, however one file did not contain evidence of CRB or POVA checks being received. Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 The home did not have a register of all staff working in the home. EVIDENCE: The manager was not able to produce a register of staff who worked at the home. Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 2 3 3 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 2 x x x x x x x x x Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 Page 18 yes Are there any outstanding requirements from the last inspection? 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 7 Regulation 15 Requirement Care Plans & Risk assessments must be discussed with either service users, if appropriate, or family and signed and dated. Care plans and risk assessments must be expanded to contain specific details of all care needs, including health needs. The issue of confidentiality, previously flagged up as an issue, must be addressed and resolved. The manager must ensure that Criminal Record Bureau disclosures and Protection of Vulnerable Adults checks have been received in respect of all current staff, and copies of these are available for inspection. A register of all staff working in the home must be put in place. The covers on chairs in the lounge areas must be replaced. Timescale for action Immediate. 2. 8 14 Immediate. 3. 19 23(1)(a) 31/3/05 4. 29 19(1)(a) Immediate 5. 6. 37 19 17 23(2) Immediate. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 Page 19 No. 1. Refer to Standard Good Practice Recommendations Beverley House B51 B01 S58599 Beverley House V222437 200405 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Unit B, Advance House St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. 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