Inspection on 11/05/06 for Winnie Care (Beverley Lodge) Limited

This inspection was carried out on 11th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 Lodge)... 30/04/07

Winnie Care (Beverley Lodge)... 07/02/06

Winnie Care (Beverley Lodge)... 15/08/05

Winnie Care (Beverley Lodge)... 21/10/04

Winnie Care (Beverley Lodge)... 29/04/04

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

CARE HOMES FOR OLDER PEOPLE Winnie Care (Beverley Lodge) Limited Beverley Lodge Saltersgill Avenue Saltersgill Middlesbrough TS4 3LD Lead Inspector Ray Burton Key Unannounced Inspection 11th May 2006 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 Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 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 Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Winnie Care (Beverley Lodge) Limited Address Beverley Lodge Saltersgill Avenue Saltersgill Middlesbrough TS4 3LD 01642 828977 01642 828977 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 Elizabeth Rose Whalen Care Home 17 Category(ies) of Dementia - over 65 years of age (17) registration, with number of places Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the number of service users shall not exceed 17 over the age of 65 years and suffering from a dementia. That the Registration of Beverley Lodge be varied to permit one named resident under the age of 65 years to reside in the home. 7th February 2006 Date of last inspection Brief Description of the Service: Beverley Lodge is a purpose-built home for the care of 17 older persons suffering from a dementia. The home is single-storey, comprising two units of bedrooms, a shared lounge and a dining room. All bedrooms have en-suite toilet and washbasin, and rooms can be furnished according to the personal choice of service users. The home is situated approximately two miles from the centre of Middlesbrough and is within easy walking distance of a small parade of local shops. Bus services are accessible from the home. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 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 11th May 2006 and was concluded on 24th May 2006. During the inspection a tour of the building was conducted, records were examined and the inspector spoke to service users, visitors, staff and the registered manager. An important part of the inspection process was the “case tracking” of three residents to see whether they had been given sufficient information before making a decision to enter the home and whether the care they were receiving after admission met their individual needs and wishes. The process involved examining care plans, talking to members of staff and, where possible service users and their relatives. What the service does well: What has improved since the last inspection? Considerable work has been undertaken, and is continuing, to improve the standard of care plans. The dining room carpet has been replaced. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 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 Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 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 Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 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): 1,2,3,5, Quality in this outcome area was good. Prospective residents and their families were provided with information about the services and facilities available in the home. Pre-admission assessments were undertaken and there was opportunity to visit the home prior to admission. EVIDENCE: The home had a Statement of Purpose clearly setting out the aims and objectives of the home. A brochure giving information about the aims, objectives and accommodation provided was available to prospective residents and their relatives. Residents had been issued with a Service Users Guide setting out the aims, objectives and conditions of residency. Each care plan contained a copy of the resident’s contract with the home; this had been signed by the resident or by a relative. The manager said that prior to admission an invitation was extended to the prospective service user and his/her family to visit and meet with staff and residents and to look around the home. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 9 If the service user were unable to visit, the manager would visit the prospective resident in his/her own home or hospital and conduct an assessment to determine if the person’s needs could be met at Beverley Lodge. All admissions were subject to a trial period followed by a review before a decision was made to make the stay permanent. Intermediate care is not provided at the home therefore Standard 6 does not apply. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 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 Quality in this outcome area was adequate. Progress had been made in the upgrading of care plans, however further development was needed to ensure that all care plans contained detailed information and that comprehensive risk assessments and risk management strategies were carried out. EVIDENCE: Residents general health was monitored by staff at the home, with healthcare needs being addressed by community based medical professionals e.g. general practitioners, district nurses, chiropodists etc. None of the current residents had been assessed as being able to control their own medication. All medicines were stored appropriately in a secure facility and dispensed according to the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines by staff who had received appropriate training. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 11 The report of the inspection conducted on 7th February 2006 acknowledged an improvement in care planning but highlighted areas requiring further improvement. “Specifically the plans should contain more detailed recording in all areas of healthcare needs e.g. moving and handling, mental state etc. Areas that challenge the service, such as aggression, should be risk assessed and careful risk management strategies developed and recorded that would clearly indicate to staff members any possible triggers, how these could be avoided and the action to be taken should they occur.” Examination of three care plans on this occasion revealed a continued improvement in care planning. Each was well organised and contained information about the general health of the service user and details of any specific condition or ailment. Risk assessments and risk management strategies were being developed in key areas such as mobility, risk of falls, mental awareness etc. It is important that the very real progress made since the last inspection continues and that care plans are further developed so that each presents a comprehensive and detailed picture of the service users needs and how they can be met. There was a good rapport between residents and members of staff and it was observed that residents were treated with respect and were addressed courteously and appropriately. In conversation members of staff demonstrated an awareness of the importance of ensuring that privacy and dignity was maintained at all times, particularly when assisting residents with personal care. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 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 I this outcome area was good. Residents, within the context of their individual plan, were able to exercise control over their lives. Routines within the home were flexible and able to accommodate individual preferences and expectations. A variety of activities and social events were organised and residents were encouraged to participate. EVIDENCE: The general atmosphere in Beverley Lodge was relaxed and informal. Routines were flexible and able to accommodate individual wishes and needs. Residents were encouraged to take part in various activities organised by staff e.g. music, chair exercises and reminiscence therapy. Special events and activities were organised for occasions such as Christmas, Easter, Halloween and birthdays. In addition to activities organised by staff, a motivation team visited once a month and a singer/guitarist visited to lead a “sing song” when residents could join in with the songs of their younger days. Residents were encouraged, in so far as was possible, to continue with activities and interests they had pursued before coming to live at the home: One resident was an avid reader, another continued to attend church each week and a third enjoyed visiting a social club with her family. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 13 The manager and staff recognised the importance of residents maintaining contact with their family and friends and helped them to keep in touch by the sending of Christmas and birthday cards etc. There were no restrictions on visiting, and residents were able to receive visitors in private. Relatives and friends of residents were always welcome to visit, particularly for special events such as birthdays and Christmas. The manager said that sometimes they would stay to have a meal with their relative. A relative visiting the home during the inspection made some very positive comments about the manager and staff and told the inspector: “Staff are always courteous and helpful. My mother is very happy here. I can’t complain about anything.” Relatives/visitors comment cards that were returned to the inspector indicated a high level of satisfaction with the overall care. All said they were made welcome whenever they visited and felt they were consulted about their relatives care and kept informed of important matters affecting them. One relative wrote: “I find staff are always on hand. It is a small compact home - not too large, therefore there’s always staff available.” Another said: “I find the staff are very friendly, helpful and caring.” Meals were generally taken in the dining room at set times, however there was a great deal of flexibility to accommodate individual wishes and needs, and residents were able to have their meals served in their own room if they wished. The record of meals served showed a healthy, balanced and varied diet was provided. Alternatives were available should anyone not wish to have the dish of the day. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 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): 16,17,18 Quality in this outcome area was good. The home had an appropriate complaints system and policies and procedures to protect residents from abuse and to protect their legal rights. EVIDENCE: The home had an appropriate policy and procedures for the handling of complaints that stated how complaints could be made, who would deal with them and what to do if not satisfied with the way in which the matter was handled. Copies of the procedure had been placed in each bedroom. There had been no complaints received within the last twelve months. Policies and procedures were in place to ensure the safety and protection of residents and to respond to any suspicion or allegation of abuse. A copy of the “No Secrets” adult protection procedure was available to members of staff. The manager stated that “No Secrets” training was ongoing and the majority of staff had completed it. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26 Quality in this outcome area was adequate. The building was well maintained and was clean and hygienic, however there were environmental issues outstanding from previous inspection reports. EVIDENCE: The internal and external fabric and decor of the building was maintained in good condition. Sufficient and appropriate specialist disability equipment such as hoist, grab-rails in corridors, toilets and bathrooms had been provided and records showed that regular checks and servicing was undertaken. All areas of the home were heated by underfloor heating. 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. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 16 Bedrooms were nicely appointed and contained furniture that was domestic in design and suitable for purpose, all had been individualised by the inclusion of furniture and other effects such as photographs, ornaments etc brought from the occupants own home. Each bedroom had en-suite facilities comprising toilet and wash basin. An emergency call system was provided in each room. In addition to the en-suite facilities there were three toilets as well as shower rooms and bathrooms, all accessible from bedrooms and communal areas. The home presented as being clean, hygienic and free from offensive odours. Since the last inspection the dining room carpet had been replaced, however there were still some environmental issues outstanding from previous inspection reports: * The chairs in the main lounge and smoking lounge had not been replaced, although the inspector was told they had been ordered and delivery was expected within two to three weeks. * The lack of any private and secure office/administration space in the home had still not been addressed, however the inspector was told that plans had been drawn up for the enclosing of the reception style office. The work was scheduled for completion by the end of August this year. * Following an inspection by Cleveland Fire Brigade it had been recommended that self-closing devices should be fitted to bedroom doors and that if residents expressed a wish for their door to remain open throughout the night then approved stay-open devices linked to the fire alarm should be utilised. The inspector was told that following further discussion with the Fire Brigade it had been decided that such devices would be fitted to bedroom doors. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area was good. The home employed staff in sufficient numbers to meet the assessed needs of service users. Staff were encouraged and supported to undertake training to aid their personal development and help them meet service users needs. EVIDENCE: The home had a recruitment policy and procedures to ensure all necessary checks, including Criminal Records Bureau were conducted and two suitable references received prior to commencement of employment. Three personnel files were examined, each contained all of the information required to comply with Regulation 17 Schedules 2 & 4 of the Care Homes Regulations 2001. Training records and conversation with the manager and four members of staff revealed all staff received relevant training that would aid their personal development and help them meet residents needs. Recently completed training courses included: Manual Handling, Infection Control, Fire Safety, First Aid, Safe Handling of Medicines, Advanced Care Practice. Nearly all members of staff had completed POVA training. 50 were qualified at NVQ level2 in care and two had NVQ level 3. Further NVQ training at levels 2 and 3 was ongoing. On the day of the inspection, sufficient numbers of staff were employed to meet the assessed needs of residents. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 18 Examination of the staffing rosters showed appropriate staffing levels were maintained at all times. It was pleasing to learn that following a staffing review the manager’s hours were no longer included in the care hours; this had allowed the manager more time to carry out the managers role and also to provide back-up cover for emergency situations that might arise in the home. Staff when interviewed said they felt much happier and more settled in their work, they said they received good support from the registered manager and received regular formal supervision. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 19 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 Quality in this outcome area was good. A well managed home with systems in place to protect residents and ensure their health, safety and welfare. EVIDENCE: The registered manager has appropriate experience in the managing of a residential home for elderly people, has recently completed the Registered Managers Award, is the holder of an NVQ level 3 in Care and is shortly to register for the NVQ level 4 in Care. To meet the National Minimum Standard she must hold a qualification at NVQ level4 or equivalent in both Care and Management. When interviewed, members of staff said they found her to be approachable and supportive. They said they were encouraged to undertake training and received regular formal supervision (examination of supervision records and conversation with the manager confirmed all members of staff would receive six supervision sessions per year). Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 20 Management and staff were aware of their responsibilities under health and safety legislation and all necessary records and policies and procedures to cover the health, safety and welfare of residents were in place and maintained in a satisfactory fashion. Members of staff received training in such areas as moving & handling, 1st aid, infection control etc. The home had various systems, both formal and informal, to measure success in meeting the aims, objectives and statement of purpose. The views of residents and their families about the care they received and the general running of the home were sought on a daily informal basis. More formally a Residents/Family Satisfaction Questionnaire had been conducted as part of a quality audit. Personal money and items of value held in the home for safekeeping were held securely and an appropriate record kept. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 21 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 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 3 3 3 Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 22 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 OP7 Regulation 14 Requirement Care plans and risk assessments must be expanded to contain specific details of all care and health needs. The provider must address the issue of confidentiality and private space within the home. Timescale for action 01/09/06 2. OP19 23(1)(a) 31/08/06 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 Refer to Standard OP20 Good Practice Recommendations The stained and worn chairs in the communal areas should be replaced. Winnie Care (Beverley Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 23 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 Lodge) Limited DS0000058604.V292702.R01.S.doc Version 5.1 Page 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!