Inspection on 28/11/05 for Winnie Care (Beverley House) Limited

This inspection was carried out on 28th November 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

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

Winnie Care (Beverley House)... 20/04/05

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 Winnie Care (Beverley House) Limited Beverley House Beverley Road Saltersgill Middlesbrough TS4 3LQ Lead Inspector Ray Burton Unannounced Inspection 28th November 2005 10:00 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 Winnie Care (Beverley House) Limited DS0000058599.V269812.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. Winnie Care (Beverley House) Limited DS0000058599.V269812.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Winnie Care (Beverley House) Limited Address Beverley House Beverley Road Saltersgill Middlesbrough TS4 3LQ 01642 828383 01642 828383 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) Winnie Care (Beverley House/Lodge) Ltd Mrs Lynne Atterton Care Home 18 Category(ies) of Dementia - over 65 years of age (18) registration, with number of places Winnie Care (Beverley House) Limited DS0000058599.V269812.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of service users shall not exceed 18 older people (over the age of 65 years) and suffering from a dementia. 20th April 2005 Date of last inspection 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 lounges 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. Winnie Care (Beverley House) Limited DS0000058599.V269812.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of two statutory inspections per year required under the Care Home Regulations 2001. It commenced on 28/11/05 and was completed on 16/12/05. Not all of the standards were assessed on this occasion. What the service does well: What has improved since the last inspection? What they could do better: Risk assessments and risk management strategies had improved but still required to be more comprehensive and detailed. Winnie Care (Beverley House) Limited DS0000058599.V269812.R01.S.doc Version 5.0 Page 6 Environmental issues outstanding from previous inspection reports had still not been addressed. 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. Winnie Care (Beverley House) Limited DS0000058599.V269812.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 Winnie Care (Beverley House) Limited DS0000058599.V269812.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): 3 The homes assessment procedure requires further development to ensure all areas of need are covered. EVIDENCE: These standards were assessed at the inspection conducted on 20th April 2005, on that occasion examination of care plans revealed assessments carried out by the home were very basic and did not cover all areas of need. Since the last inspection there had been improvement, however, further development was still required. Conversation with the manager and two members of staff indicated the staff team had an in-depth knowledge of each resident and his/her needs and how they could be met. The manager acknowledged the shortcomings of the care planning documentation and was aware of the importance of ensuring that comprehensive and detailed assessments were included in care plans, and was continuing to work towards improving the standard of recording. Winnie Care (Beverley House) Limited DS0000058599.V269812.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): 8,9 Residents were treated with respect and their healthcare needs addressed by staff at the home in conjunction with community based healthcare professionals. Care plans continue to be developed to ensure they cover all areas of need. EVIDENCE: All of these standards were assessed during the inspection conducted in April 2005.The report of that inspection acknowledged the work done by the manager to improve the standard of care planning but noted that further development was needed. Examination of care plans on this occasion revealed improvement had taken place. Plans now contained evidence that residents and/or their families had been involved in the care planning process. Risk assessments and risk management strategies had improved but still required to be more comprehensive and detailed. Since the last inspection the homes policies and procedures for the administration of medicines had been reviewed. Winnie Care (Beverley House) Limited DS0000058599.V269812.R01.S.doc Version 5.0 Page 10 Two visitors on the day of the inspection expressed complete satisfaction with the care that had been given to their relative during the seven years he had been resident in the home. “We couldn’t have chosen a better place. We have never had any problems. The care is fine and the girls always show great respect to the residents. We are always kept informed of progress, health etc. They are spot on with the doctor and always seek medical advice promptly.” Winnie Care (Beverley House) Limited DS0000058599.V269812.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): 15 Residents were provided a healthy, varied and balanced diet. EVIDENCE: Meals were at set times and were generally taken in the dining room, although residents could have them served in their own room if they wished. Menus showed a balanced and varied diet was provided with alternatives being available should a resident not wish to have the main dish of the day. One resident said: “The food is good, you can’t beat it. It is always very good – Five Star!!!” A relative told the inspector that food always appeared appetising and was nicely presented. Winnie Care (Beverley House) Limited DS0000058599.V269812.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): 18 Appropriate policies and procedures were in place to ensure the safety and protection of residents. EVIDENCE: Policies and procedures were in place to ensure the safety and protection of residents and to respond to any suspicion or allegation of abuse. Staff had completed “No Secrets “ training and were able to demonstrate a suitable understanding of what constituted abuse and what to do in the event of such an incident occurring. Winnie Care (Beverley House) Limited DS0000058599.V269812.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 The environmental standard was generally good providing residents with a comfortable and homely place in which to live, however there were some environmental issues outstanding from previous inspection reports. EVIDENCE: The inspection dated 20th April 2005, during which all of the environmental standards were assessed, revealed the décor and fabric of the building to be in good condition and the home to be clean, hygienic and free from offensive odours. Furniture in communal areas and bedrooms was comfortable and suitable for purpose. It was disappointing however to learn that various environmental issues, identified in previous inspection reports, had not been addressed by the provider. Winnie Care (Beverley House) Limited DS0000058599.V269812.R01.S.doc Version 5.0 Page 14 A tour of the building on this occasion revealed that whilst generally the home was well maintained and provided comfortable and pleasant accommodation, the issues identified in previous reports had still not been addressed: None of the bedroom doors had been fitted with self-closing devices this was contrary to the advice given to the home, by Cleveland Fire Brigade, in a letter dated 20th April 2005: “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.” It is acknowledged that the above is a “recommendation”, however, the provider should consult with the Cleveland Fire Brigade to ensure that the home is fully compliant with all Fire Precautions (Workplace) Regulations 1997 (as amended). The worn and split seat covers in the lounges had not been replaced. The issue of confidentiality had not been resolved. The reception style open office 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. The provider must furnish the Commission for Social Care Inspection with an action plan stating how and when these issues will be addressed. Winnie Care (Beverley House) Limited DS0000058599.V269812.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): 27,28,29,30 The home had a suitable recruitment policy and procedures and employed staff in sufficient numbers to meet residents current needs. There was an on-going training programme. EVIDENCE: Observation on the day of the inspection and examination of staffing rosters indicated that adequate numbers of staff were on duty at all times to meet residents needs. The homes recruitment procedure ensured all necessary checks, including Criminal Records Bureau, were conducted and two suitable references received prior to confirmation of employment. Four personnel files were examined, each contained evidence that all necessary procedures had been carried out. Training records and conversation with the manager revealed nine members of the care staff (64 ) were qualified to a minimum of NVQ level 2 in care and three were currently registered and working towards gaining the qualification. The two members of the kitchen staff were also the holders of an appropriate NVQ at level 2. Other recently completed training included: Safe Handling of Medicines, Food Hygiene, Dementia Awareness. The manager said that all members of staff had been registered on a POVA training course that was due to commence in January 2006. She was awaiting a date for all members of staff to undertake refresher training in manual handling. Winnie Care (Beverley House) Limited DS0000058599.V269812.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): 31,33,35,38 The home was well managed and had policies, procedures and systems to protect the health, safety and welfare of residents. Arrangements had not yet been put in place for residents personal money to be paid into separate accounts. EVIDENCE: Policies, procedures and records were in place to cover all aspects of the health, safety and welfare of residents and staff. Staff training was ongoing and covered areas such as moving and handling, First Aid etc. Winnie Care (Beverley House) Limited DS0000058599.V269812.R01.S.doc Version 5.0 Page 17 The manager was able to demonstrate an understanding of the management issues relating to the running of a care home. She is the holder of a level 3 NVQ in Care and an NVQ Assessors Award. She is currently working towards gaining the Registered Managers Award. Staff when interviewed considered the home to be well-run and expressed confidence in the manager and said she was very approachable. The views of residents and their families about the care they received and the general running of the home were generally sought informally on a daily basis, however the manager had recently implemented a resident/relative satisfaction survey as part of the homes quality assurance and monitoring system. Letters and cards had been received from relatives expressing appreciation for the care extended to their family members: “She was looked after as if she was family. She was cared for and cherished and her passing was eased because of this.” “The whole staff of this home went out of their way to be sympathetic and very supportive over the last few days of mum’s life.” As identified in previous inspection reports the provider must put in place arrangements for residents personal money to be paid into an account in their own name instead of a pooled account. It is acknowledged that this issue is currently being addressed, however, separate accounts in the name of individual residents have not yet been set up. Winnie Care (Beverley House) Limited DS0000058599.V269812.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 x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 3 2 x x x x x x x 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 2 x x 3 Winnie Care (Beverley House) Limited DS0000058599.V269812.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. Standard 1. OP8 Regulation 14 Requirement 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 registered person shall after consultation with the fire authority take adequate precautions against the risk of fire and make adequate arrangements for containing fires. Arrangements must be made for residents’ personal money to be paid into an account in their own name. The covers on chairs in the lounge areas must be replaced. Timescale for action 20/04/05 2. 3. OP19 OP19 23(1)(a) 23(4)(a) & (c)(i) 31/03/05 10/02/06 4. OP35 20 10/02/06 5. OP19 23(2) 10/02/06 Winnie Care (Beverley House) Limited DS0000058599.V269812.R01.S.doc Version 5.0 Page 20 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 Winnie Care (Beverley House) Limited DS0000058599.V269812.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Tees Valley Area Office Advance 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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