Inspection on 30/04/07 for Winnie Care (Beverley Lodge) Limited

This inspection was carried out on 30th April 2007.

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 Lodge)... 11/05/06

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 30th April 2007 14:00 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.V338046.R01.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 Lodge) Limited DS0000058604.V338046.R01.S.doc Version 5.2 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.V338046.R01.S.doc Version 5.2 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. 11th May 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. The current basic charge per week is £355. Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.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 30th April and was concluded on 13th May 2007. During the inspection a tour of the building was conducted, records were examined and the inspector spoke to residents, two visitors, members of staff and the registered manager. What the service does well: What has improved since the last inspection? What they could do better: The provider should follow the recommendations of the Cleveland Fire Brigade with regard to suitable self-closing and stay open devices being fitted to bedroom doors. Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.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 Lodge) Limited DS0000058604.V338046.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families are provided with information about the services and facilities available in the home. Pre-admission assessments are undertaken and there is opportunity to visit the home prior to admission. EVIDENCE: The home had a statement of purpose clearly setting out the aims and objectives. 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. Prior to admission an invitation was extended to the prospective resident and his/her family to visit and look around the home and meet with staff and residents. If more appropriate the manager would visit the prospective resident in his/her own home or hospital and conduct an assessment to determine if the persons needs could be met at Beverley Lodge. All admissions Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.S.doc Version 5.2 Page 9 were subject to a trial period followed by a review before a decision was made to make the stay permanent. Examination of the file belonging to the last person to be admitted showed the prospective resident had been visited by the Manager and Deputy Manager who had also met with family members and the social worker. Intermediate care is not provided at the home therefore Standard 6 does not apply. Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ healthcare needs were met and there was evidence of multidisciplinary 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: The manager and staff displayed a good knowledge of individual residents and their needs and were able to detail specific problems and conditions relating to the health of individuals. Constant monitoring and the support of community healthcare professionals such as G.P’s., District Nurses etc ensured the healthcare needs of residents were met. Examination of care plans and the accident records revealed that accidents were dealt with in an appropriate manner and, where necessary, referrals had been made to the Accident & Emergency unit for treatment. None of the current residents had been assessed as being able to control their own medication. All medicines were stored appropriately and securely and Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.S.doc Version 5.2 Page 11 were 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 appropriate training. Observation during the inspection indicated residents were treated with respect and their dignity and privacy was preserved. Sensitive situations were dealt with quickly and quietly with regard for the individual’s feelings. Residents were addressed courteously by their preferred name, as recorded in their care plan, and members of staff were seen to knock on bedroom doors and request permission before entering. In conversation staff spoke of the importance of upholding the dignity of residents, particularly when assisting with personal care. Three randomly selected resident files showed that since the last inspection the programme of improving care plans had continued. Each file was well organised and contained all required information: pre-admission and continuous assessments were in place; risk assessments had been carried out and risk management strategies developed; regular monitoring and updating ensured plans were kept up-to-date; background information was now much more comprehensive. Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. EVIDENCE: It was apparent from observation and conversation with staff, residents and a visitor that there was a relaxed and friendly atmosphere in the home. Routines were flexible and allowed residents to exercise personal choice and to maintain control over their lives, subject to their personal plan and risk assessments. Residents were able to choose what time to rise and retire to bed. Meals were generally served in the dining room at set times, although there was flexibility to accommodate personal wishes and circumstances; meals would be served in a resident’s bedroom if requested. Records of food served showed a healthy, balanced diet was provided and that there was always a choice of at least two main dishes. The home operated an “open door” policy and family and friends were welcome to visit at any reasonable time. Residents could receive their visitors in private Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.S.doc Version 5.2 Page 13 if they wished. A visitor told the inspector that he and his family visited the home several times each week and were always made to feel welcome and were provided with a drink of tea or coffee; he said that he considered the home to be well run and all the staff to be approachable and helpful. He said: “My wife has really settled here and there has been a big improvement in her condition since being admitted. It would break my heart if she had to leave.” Staff tried to motivate residents and include them in the day-to-day running of the home by encouraging the performance of simple household tasks such as looking after their own room, setting tables etc. Various activities were organised: dominoes, cards, sing-a-long, reminiscence therapy. Special events were organised for occasions such as Christmas, Easter, Halloween and birthdays. In addition a motivation team visited once a month and there were regular visits from a professional entertainer. Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 7 18.Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a satisfactory complaints system and policies and procedures to protect residents from abuse. EVIDENCE: The home had an appropriate policy and procedure 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 had been handled. Copies of the procedure had been placed in each bedroom. No complaints had been received since the last inspection, however there had been several complimentary letters received from relatives: “ With sincere thanks for your help and kindness. It meant a lot to our family to know that our father was treated with great care and consideration in his final days.” “We would like to take this opportunity to thank all staff for the professional care and attention shown to Mam during her stay at Beverley Lodge. During the four years we have been visiting we have nothing but praise for your efforts, devotion and kindness given to all residents and visitors alike.” “The warm and friendly approach from every member of staff was so obvious from our very first visit and continued throughout Mam’s stay there.” Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.S.doc Version 5.2 Page 15 Policies and procedures were in place for 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, who 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 Lodge) Limited DS0000058604.V338046.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,23,24,25,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environmental standard was good providing residents with a comfortable and homely place in which to live. There was sufficient specialist equipment to meet the current needs of residents. Bedrooms contained many personal effects and reflected the personality of the occupant. EVIDENCE: The building was maintained in good condition and was free from offensive odours. Décor throughout the home was pleasant. Sufficient 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 under floor 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.V338046.R01.S.doc Version 5.2 Page 17 Bedrooms had all been individualised by the inclusion of photographs, ornaments and small items of furniture etc and reflected the personality of the occupant. Each bedroom had en-suite facilities comprising toilet and washbasin. Since the last inspection the home had been re-decorated and new furniture provided in all bedrooms and communal areas. The reception style office had been enclosed and now provided a more secure and private administrative area. It was noted however that the provider had not yet complied with the recommendations made by Cleveland Fire Brigade 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. Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a suitable recruitment policy & procedures and employed staff in sufficient numbers to meet residents assessed needs. Members of staff received training to aid their professional development and enable them to meet residents’ needs. EVIDENCE: On the days of the inspection sufficient numbers of staff were employed to meet the assessed needs of residents. Examination of staffing rosters showed appropriate staffing levels were maintained at all times. The homes recruitment procedure ensured all necessary checks, including Criminal Records Bureau, were conducted and two suitable references received prior to commencement of employment. Four personnel files were examined, each contained evidence that all necessary procedures had been carried out. Staff records and conversation with the manager and three members of staff revealed an appropriate induction programme was in place for new employees and that all members of staff were encouraged to take part in on-going training. Recently completed training included: Protection of Vulnerable Adults, Advanced Care Practice, Fire Safety, Infection Control, Person Centred Care. In addition all members of the care staff were qualified to a minimum of NVQ level 2 in Care. Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed and had policies, procedures and records in place to ensure the health, safety and welfare of residents. EVIDENCE: The registered manager has appropriate experience in the managing of a residential home for elderly people. She is the holder of the Registered Managers Award and the NVQ Level 3 in Care and is shortly to register for the NVQ level4 in Care. To meet the National Minimum Standard she must hold a qualification at NVQ level 4 or equivalent in both Care and Management. Members of staff spoken to during the inspection considered the home to be well managed and expressed confidence in the registered manager, who they said, was approachable and supportive. There was a supervision programme that ensured all members of staff received at least six formal supervision sessions per year. Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.S.doc Version 5.2 Page 20 Appropriate policies and procedures covering all aspects of the management of the home were in place and regularly reviewed to reflect changing legislation and current good practice. 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 & 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 manner. Regular checks of the building and equipment were conducted and maintenance and servicing carried out as required. Personal money and items of value held in the home for safekeeping were held securely and an appropriate record maintained. Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.S.doc Version 5.2 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 X 18 3 3 3 X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO 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 OP19 Regulation 23(4) Requirement The provider must, after consultation with the Cleveland Fire Brigade make adequate arrangements for containing fires. Timescale for action 01/08/07 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 OP31 Good Practice Recommendations The registered manager should have a qualification at NVQ level 4 or equivalent in car and management. Winnie Care (Beverley Lodge) Limited DS0000058604.V338046.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V338046.R01.S.doc Version 5.2 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. 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