Inspection on 05/09/06 for Winnie Care (Beverley House) Limited

This inspection was carried out on 5th September 2006.

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 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

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

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 Key Unannounced Inspection 5th September 2006 12:00 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.V311192.R02.S.doc Version 5.2 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.V311192.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Winnie Care (Beverley House) Limited Address Beverley House Beverley Road Saltersgill Middlesbrough TS4 3LQ 01642 828383 F/P 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.V311192.R02.S.doc Version 5.2 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. 28th November 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.V311192.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection covering all of the key standards. It commenced on 5th September 2006 and was concluded on 19th September 2006. During the inspection a tour of the building was conducted, records and care plans examined and the inspector spoke to service users, members of staff and the registered manager. The current scale of charges for the home is between £338 to £375 per week. What the service does well: What has improved since the last inspection? Since the last inspection there has been a big improvement in care planning and risk assessment. Care plans were well-organised and contained comprehensive and detailed information about residents and their assessed needs. Risk assessments and risk management strategies were in place. Various environmental improvements had taken place since the last inspection including: enclosing the reception style open office, the provision of new furniture in the lounge areas, the redecoration of various communal areas. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 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. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 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.V311192.R02.S.doc Version 5.2 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): 1,2,3,4,5,6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. Prospective residents and their relatives were able to visit and were given sufficient information to enable them to make an informed choice about the suitability of the home. The homes assessment procedure ensured that no one would be admitted unless his/her needs could be met. The home does not provide intermediate care. EVIDENCE: The home had a statement of purpose setting out the aims, objectives and philosophy of care. Each service user, on admission to the home, had been issued with a Service Users Guide and a copy of the terms and conditions of residence. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 9 Examination of four care plans and conversation with the manager and staff revealed that prior to admission a needs assessment was received from a care manager of the placing authority. Following receipt of a referral an invitation would be extended to the prospective resident and his/her family to visit and meet with staff and residents and to look round the home. 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 at Beverley House. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 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): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents health, personal and social care needs were met by the home and there was evidence of multi-disciplinary working. Systems were in place for the safe and efficient administration of medication. Personal care was conducted in a sensitive manner that upheld the dignity and privacy of residents. EVIDENCE: Four care plans were examined each showed assessments had been conducted, objectives set and action plans developed to meet identified need; areas covered included mental awareness, diet, continence, personal hygiene, ability to self-medicate etc. A monthly review ensured changing needs were identified and appropriate action taken. There was information about the general health of the individual and details of any specific ailment or medical condition. Constant monitoring of health was undertaken and healthcare needs addressed by community-based professionals e.g. G.P’s, district nurses etc. Risk assessments had been conducted in areas such as mobility, community access, risk of falls etc. and were regularly reviewed. Suitable management strategies had been developed to ensure that health related needs could be appropriately and safely met. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 11 None of the residents in the home was able to safely manage his/her own medicines. All medication was stored appropriately and securely and dispensed according to the homes policy and procedures for the receipt, recording, storage, handling and administration of medicines by staff who had received appropriate training. During the inspection it was observed that interaction between residents and members of staff was good and that residents were treated in a respectful and friendly manner. Members of staff were aware of the need to treat residents with respect and to ensure that dignity and privacy was protected, particularly when assisting with personal care. Care plans contained evidence that residents were encouraged and supported to be as independent as possible and were constantly reassured and informed about their care by staff who explained carefully what was happening and why. 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, unless medical needs dictated otherwise. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 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 Quality in this outcome area was good. This judgement was made from evidence gathered both during and before the visit to this service. Daily routines were flexible and allowed residents to exercise choice. Staff encouraged the maintenance of family and friendship links. A variety of activities were organised and residents were encouraged to participate. A healthy, varied and balanced diet was provided with alternatives always available. EVIDENCE: Observation during the inspection and conversation with staff and residents indicated there was a relaxed and friendly atmosphere in the home. Routines were flexible and allowed residents, subject to their individual plan and risk assessments, to exercise personal choice and to maintain control over their own lives. Residents were able to choose what time they went to bed and what time they rose in the morning. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 13 Meals were at set times and were generally taken in the dining room however there was flexibility to allow for personal wishes, and meals could be served in residents rooms if they wished. Menus showed a balanced and varied diet was provided with alternatives being available should a resident not wish to have the dish of the day. Residents expressed appreciation of the high standard of the meals. The staff team understood the importance of residents maintaining links with their family and friends and helped them to keep in touch by assisting with the making of telephone calls the sending of Christmas and birthday cards etc. Visitors could visit the home at any time, and residents were able to receive their guests in the privacy of their own room if they wished. Residents were encouraged to take part in a variety of in-house activities: Bingo, cards, dominoes, gentle exercises, games to aid hand/eye co-ordination etc., on the day of the inspection several residents were participating in a game of skittles. Other activities and events included: walks to local shops, visiting entertainers and a monthly motivation/reminiscent session organised by an outside provider. The home maintained a social link with a local school. The following comments were received from residents: “They look after me well, the food is good. I have no complaints.” “I can go to bed whenever I wish. I am very happy with the care and the food. The staff are good.” “The staff are always happy to help. I have never had to complain – I am quite happy. I like it here, everyone is friendly.” “I like the Bingo and singing.” Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The home had an appropriate system for dealing with complaints. Suitable policies and procedures were in place to protect residents from abuse. Staff had an awareness of what constituted abuse and what do to if they suspected abuse had occurred. EVIDENCE: On admission each resident was given a service users guide containing a copy of the Comments and Complaints Policy showing how complaints could be made, who would deal with them, the time scale for the process and what to do if not satisfied with the way in which the matter had been handled. Policies and procedures were in place to ensure the safety and protection of residents and to respond to any allegation of abuse. All members of staff had recently received training in the protection of vulnerable adults and in conversation were able to demonstrate an understanding of what constituted abuse and what action to take in the event of such an incident occurring. Examination of the complaints book showed no complaints had been received since the last inspection. The manager explained that residents and their families were encouraged to speak to staff about any problems or concerns they might have and that this generally resulted in matters being resolved at an early stage. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 15 Relatives’ satisfaction questionnaires that had been returned indicated a high level of satisfaction with the service. “I am well satisfied with everything.” “The staff are always helpful, they are easy to approach and always helpful.” “They are always alert to residents and helpful.” Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 16 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): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to the service. The environment was good, providing residents with an attractive, comfortable and well-maintained place in which to live. Sufficient specialist equipment was provided to meet the care needs of the residents. Health and safety policies and procedures were in place and suitable records maintained showing the building and equipment was regularly and safely maintained. EVIDENCE: The internal and external fabric of the building was maintained in good condition, décor throughout the house was pleasant and cheerful. The home was clean and hygienic and free from offensive odours. All necessary parts of the building were easily accessible to residents; furniture in communal areas was domestic in design and suitable for use by elderly people, some of who had mobility difficulties. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 17 Bedrooms were nicely decorated and comfortably and appropriately furnished; each had been individualised by the inclusion of personal effects such as pictures, photographs, ornaments, TV and small items of furniture brought from the occupants own home. None of the bedrooms had an en-suite facility, however all contained a wash hand basin. Sufficient and appropriate specialist equipment was available to meet the current needs of residents e.g. grab-rails in toilets and bathrooms, disabled bathing facilities. The home consulted with community based medical professionals to ensure that any additional equipment would be provided as required. There was a choice of bathing facilities (showers and baths) and seven toilets, all easily accessible from communal areas and bedrooms. An electronic call system was in place. Since the last inspection the provider had made various improvements to the home including: the enclosing of the reception style open office enabling records to be stored more securely and affording the privacy necessary for the conducting of confidential telephone conversations and meetings with relatives, doctors etc; the provision of new furniture in the lounge areas; and the redecoration of various communal areas. The provider informed the inspector that discussions, with the Cleveland Fire Brigade, were being held regarding their recommendation that self-closure devices were fitted to bedroom doors. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 18 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 Quality in this outcome area was good. This judgement has been made from evidence gathered both during and before the visit to the service. The home had a robust recruitment policy ensuring all checks necessary for the protection of residents were conducted. Staff were employed in sufficient numbers and received appropriate training to meet the assessed needs of residents. Personnel files for each member of staff were maintained in a satisfactory manner however it is important that records showing the content of induction training are maintained for each new member of staff. EVIDENCE: Observation during the inspection and examination of staffing rosters indicated that adequate numbers of staff were on duty at all times to meet resident’s needs. Examination of four personnel files showed the home had a robust recruitment procedure ensuring all necessary checks, including Criminal Records Bureau and Protection of Vulnerable Adults, were conducted and two suitable references received prior to commencement of employment. The manager said that all newly recruited members of staff received 2 weeks induction training; however records were not available to substantiate members of staff received induction training to Skills for Care specification within 12 weeks of appointment to their posts. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 19 Training records showed that in the last twelve months staff had received training in fire awareness, moving and handling and the protection of vulnerable adults. Future training was planned in the safe handling of medicines, dementia awareness and First Aid. Nine of the thirteen members of the care staff were qualified to a minimum of NVQ level2 in Care; another care worker had almost completed her portfolio leading to the award. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good. This judgement has been made from evidence gathered during and before the visit to the service. A well managed home with systems in place that protected residents and ensured their health, safety and welfare. There was evidence of staff supervision taking place, however not all members of care staff received a minimum of six formal supervision sessions per year. Appropriate arrangements were in place to ensure residents’ financial interests were safeguarded. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 21 EVIDENCE: Appropriate policies and procedures covering all aspects of the management of the home were in place and regularly reviewed. Records, including care plans, were maintained in good order and were held securely and appropriately. The manager and staff were aware of their responsibilities under Health and Safety legislation. Staff training was ongoing and covered such areas as Moving & Handling, Fire Safety etc. Policies and procedures were in place to cover the health, safety and welfare of residents and staff. Risk assessments were in place and updated where necessary. Regular checks of the building and equipment were carried out; maintenance and servicing was undertaken to ensure a safe and comfortable environment. The manager is the holder of the Registered Manager Award, NVQ level 3 in Care and an NVQ Assessors Award; she is shortly to register for the NVQ level 4 in Care. Members of staff spoken to during the inspection felt the manager was approachable and supportive, they said she would always listen to what they had to say and would consider any suggestions that were made to improve the running of the home and the welfare of residents. The home had appropriate quality assurance and monitoring systems, both formal and informal, to measure success in meeting its aims, objectives and statement of purpose and to obtain the views of residents and their families about the standard of care and the management of the home: staff meetings, regular reviews, a satisfaction survey, informal daily contact with residents and their families. There was a staff supervision policy and evidence that some supervision was taking place, however not all members of care staff received formal supervision on at least six occasions per year. A designated representative, generally a family member or the placing social services department, dealt with residents financial affairs. Bank accounts in the name of the individual resident had been opened and staff at the home handled only small amounts of cash; any item of value held for safekeeping on behalf of a resident was held securely and an appropriate record kept. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 22 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action 1 OP30 18 (c )(i) The manager must ensure that all newly appointed staff receive induction training to Skills for Care specification within the first 12 weeks of appointment. 01/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP19 OP36 Good Practice Recommendations The provider should consult with Cleveland Fire Brigade about the fitting of self-closures to bedroom doors. The manager should ensure that all members of care staff receive formal supervision at least six times per year. Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Winnie Care (Beverley House) Limited DS0000058599.V311192.R02.S.doc Version 5.2 Page 25 - 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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