Inspection on 15/08/05 for Winnie Care (Beverley Lodge) Limited

This inspection was carried out on 15th August 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 Lodge)... 30/04/07

Winnie Care (Beverley Lodge)... 11/05/06

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

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 Unannounced 15 August 2005 08:30 am th 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. Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Winnie Care (Bevereley Lodge) Limited Address Saltersgill Avenue, Saltersgill, Middlesbrough. TS4 3LD 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) 01642 828977 01642 828977 Winnie Care (Beverley House/Lodge) Ltd Mrs Elizabeth Rose Whalen Care Home 17 Category(ies) of DE(E) Dementia - over 65 (17) registration, with number of places Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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 wash basin, 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 B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted on 15th August 2005 with additional visits being conducted on 17th August and 27th September. What the service does well: What has improved since the last inspection? 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 B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 6 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 Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 7 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) 1,2,3,4,5,5 The Statement of Purpose and Service Users Guide provided residents, prospective residents and their families with information about the services and facilities available in the home. Further development of care plans is required to include evidence of service user and family involvement. EVIDENCE: Each resident had been given a Statement of Purpose and a Service Users Guide setting out the aims, objectives and conditions of residency. The manager said that, prior to admission, a detailed assessment was completed to ascertain if the home could meet the prospective residents needs. Examination of individual service user files confirmed this however, as identified in the last inspection report, care plans must be further developed to include evidence of service user and family involvement. The manager said that all prospective residents were invited to visit the home to meet current residents and staff. A six weeks trial period was in place followed by a review to determine the suitability of the placement. Intermediate care is not provided at the home therefore standard 6 does not apply. Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 8 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, Further development is required to ensure that care plans contain detailed information and that comprehensive risk assessments and risk management strategies are carried out. EVIDENCE: Residents general health was monitored by staff at the home, with healthcare needs being addressed by community based professionals. Each of the three care plans examined during the inspection contained details of the general health needs and mobility etc of the individual. It is acknowledged that, since the last inspection, work had been undertaken to upgrade care plans however, further work was required to ensure that information in the individual files was more comprehensive. Specifically the plans should contain more detailed recording of 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. Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 9 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 procedures for the receipt, recording, storage, handling, administration and disposal of medicines. All staff responsible for the handling of medicines had received, or were currently undergoing, accredited training. It was observed during the inspection that staff treated residents with respect and addressed them courteously and appropriately. When interviewed members of staff were able to demonstrate an awareness of the importance of ensuring that resident’s privacy and dignity were respected at all times, particularly when assisting with personal care. Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 10 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) 12,14 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: Observation during the inspection indicated a relaxed and friendly atmosphere in the home with routines that were flexible and accommodating of individual wishes and needs. Residents were encouraged and supported to exercise personal choice and to retain as much control over their lives as possible, especially over everyday activities such as what clothes to wear, what time to rise and retire to bed. Various in-house activities were organised e.g. quizzes, reminiscence therapy, gentle exercise sessions. In addition to activities organised by staff the home received regular visits from a singer/guitarist and a group of gospel singers from a nearby church. Residents were encouraged to take part however staff, understood the importance of allowing residents the freedom to choose whether or not to participate and, respected their decision should they decide not to. Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 11 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) These standards were not assessed during this inspection. EVIDENCE: Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 12 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 In general the building was well maintained, however there were several issues of concern that require addressing. EVIDENCE: A tour of the building revealed décor and general fabric to be in good condition and the building clean, 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. Appropriate disability equipment e.g. hoist, grab-rails in corridors, toilets and bathrooms had been provided that met the current needs of residents. Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 13 Bedrooms were nicely appointed and contained furniture that was domestic in style 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 hand 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. Communal areas were clean and tidy and were appropriately and comfortably furnished. It was pleasing to note that since the last inspection the home had been made more homely by the provision of pictures on the walls. There were however some areas of concern: * The dining room carpet was extremely stained and in need of being replaced. The Provider said that it was his intention to replace it within the next four weeks. * The chairs in the main lounge and smoking lounge were stained and worn and were in need of being recovered or replaced. * The sideboard in the main lounge was very shabby. * A join in the carpet in the main lounge posed a potential tripping hazard and should be secured. * Of particular concern, as highlighted in previous inspection reports, was the lack of any private and secure office/administration space in the home. The open reception style office does not provide security for records; nor does it offer the degree of privacy necessary for confidential telephone conversations, the conducting of staff supervision sessions or meetings with relatives, social workers, doctors etc. It is appreciated that the physical limitations of the building impose severe restrictions on what can be done, however the absence of an appropriate office detracts from the efficient running of the home and compromises confidentiality. This issue was the subject of a Statutory Requirement in the report of the inspection conducted on 21st October 2004. The provider must, as a matter of urgency, address this issue and provide an action plan setting out how the matter can be resolved. * It was noted during the inspection that the door leading to the rear garden did not have a locking device that would prevent confused and vulnerable residents leaving the building unobserved. A more suitable lock must be fitted to the door. Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 14 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 The current staffing hours are not adequate to meet the needs of current service users whilst allowing the manager time to carry out her role as manager. EVIDENCE: It is of concern that despite being highlighted in previous inspection reports, the situation with regard to staffing levels has not changed. Examination of rosters showed the manager is only allocated two days (16 hours) to deal with all management/administrative issues, the remaining time being spent working in a hands-on capacity. It is appreciated that she is currently undergoing a training course that takes her away from the home for one day a week and that once completed this will free up an extra eight hours – it is important that this time, when it becomes available, is designated supernumerary and not used to cover shifts. It is also of some concern that when the manager is included in the staffing roster she is unable to devote all of her time to the running of the shift as, inevitably, there are other calls upon her time that result in a greater burden of the work falling upon the two other members of the team with the resultant possibility that they will not always be able to meet service user need. Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 15 The provider must, as a matter of urgency, formulate an action plan to ensure that the manager is allowed sufficient supernumerary hours to fulfil the requirements of the National Minimum Standards. Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 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) 36 Care staff at the home do not receive the required number of formal supervision sessions to meet the National Minimum Standard. EVIDENCE: As highlighted in the last inspection report the manager, because of time constraints, has been unable to ensure that staff at the home receive at least six formal supervision sessions per year. This matter must be addressed to ensure that all members of care staff receive the required number of supervision sessions to comply with the National Minimum Standards. Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 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 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 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 x x x x x x x x 2 x x Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 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 OP3 Regulation 14 Requirement All new admissions must be made only on the basis of a full assessment of need. Evidence must also confirm that this has been discussed with the service user, family/friends, as appropriate. Care plans and risk assessments must contain evidence that they have been discussed with the service user if appropriate and/or family. Care plans and risk assessments must be expanded to contain specific details of all care and health needs. The provider must produce an action plan setting out proposals and a time scale to address the issue of confidentiality and private space within the home. Additional hours must be provided in order to ensure that the manager has an adequate amount of time to manage the home effectively and efficiently. Formal supervision sessions must be carried out for all staff within the home. Timescale for action Immediate 2. OP7 14 Immediate. 3. OP8 14 Immediate 4. OP19 23(1)(a) 31/10/05 5. OP27 18 Immediate. 6. OP36 18 Immediate. Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 19 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 Good Practice Recommendations Winnie Care (Beverley Lodge) Limited B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Unti B - 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 B51-B01 SN58604 Beverley Lodge VN244454 150805 Stage 4.doc Version 1.40 Page 21 - 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!