Inspection on 07/02/06 for Winnie Care (Beverley Lodge) Limited

This inspection was carried out on 7th February 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 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)... 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 Unannounced Inspection 7th February 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.V273395.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.V273395.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.V273395.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. 15th August 2005 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 DS0000058604.V273395.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was started on 7th February 2006 with additional visits being conducted on 10th and 13th February. What the service does well: What has improved since the last inspection? Since the last inspection care plans have been developed and are much improved. The dining room carpet has been replaced. Winnie Care (Beverley Lodge) Limited DS0000058604.V273395.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.V273395.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.V273395.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): These standards were assessed during the inspection conducted in August 2005. EVIDENCE: Winnie Care (Beverley Lodge) Limited DS0000058604.V273395.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 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: Since the last inspection work has continued to upgrade care plans. Risk assessments are much improved and are now more comprehensive and detailed. However the manager acknowledges that further development is required to ensure that all areas that challenge the service and pose a possible risk are assessed and suitable risk management strategies formulated. Winnie Care (Beverley Lodge) Limited DS0000058604.V273395.R01.S.doc Version 5.1 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 the following standard(s): 13,15 Staff at the home encouraged residents to maintain links with family and friends and the local community. A healthy, balanced and varied diet was provided. EVIDENCE: 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. There were no visitors to the home during the inspection, however 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. 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.V273395.R01.S.doc Version 5.1 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 the following standard(s): 16,18 The home had a satisfactory complaints system and policies and procedures to protect residents from abuse. 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.V273395.R01.S.doc Version 5.1 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 the following standard(s): 19 In general the building was well maintained, however there were some issues of concern that required addressing EVIDENCE: The inspection conducted on 15th August 2005, during which all of the environmental standards were assessed, revealed the décor and general fabric to be in good condition and the building clean, hygienic and free from offensive odours. Bedrooms were nicely appointed and contained furniture that was domestic in style and suitable for purpose. Communal areas were appropriately and comfortably furnished. A tour of the building on this occasion revealed that whilst generally the home was well maintained and provided comfortable and pleasant accommodation, some issues identified in previous reports had still not been addressed: Winnie Care (Beverley Lodge) Limited DS0000058604.V273395.R01.S.doc Version 5.1 Page 13 * The chairs in the main lounge and smoking lounge were stained and worn and were in need of being recovered or replaced. * Of particular concern, as highlighted in previous inspection reports, was the lack of any private and secure office accommodation/administrative 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. In addition to the above outstanding issues a recent report of an inspection conducted by Cleveland Fire Brigade stated: “It is recommended that self closing devices are provided to bedroom doors. A fire in a room with an open door can quickly spread fire and smoke along a corridor. If it is necessary to maintain bedroom doors open for the well being of residents then approved devices linked to the fire alarm may be utilised.” It is acknowledged that the above is a recommendation, however the provider should consult with the Cleveland Fire Brigade to ensure that the home is fully compliant with all Fire Precautions (Workplace) Regulations 1997 (as amended). The provider must furnish the Commission for Social Care Inspection with an action plan stating how and when the above issues will be addressed. Winnie Care (Beverley Lodge) Limited DS0000058604.V273395.R01.S.doc Version 5.1 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 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): 27,29,30 The home had a suitable recruitment procedure. Staff received appropriate training. The provider must ensure there are always sufficient staff on duty to meet residents needs. EVIDENCE: The home has 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 and each contained all of the information required to comply with Regulation 17 Schedules 2 & 4 of the Care Homes Regulations 2001. None however contained a photograph of the member of staff. Training records revealed all staff received relevant training that would aid their personal development and help them meet resident’s needs. Recently completed training included: POVA, Manual Handling, Infection Control, Fire Safety, First Aid, NVQ levels 2 & 3. “No Secrets” refresher training has been organised for all members of staff and is due to be delivered in the near future. Winnie Care (Beverley Lodge) Limited DS0000058604.V273395.R01.S.doc Version 5.1 Page 15 Since the last inspection the registered manager has completed the training course that took her away from the unit for one day each week. It is acknowledged that those hours have been designated supernumerary, however she remains included in the staffing roster for two days per week. As highlighted in the last inspection report on the days she is “rostered in” 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 work falling upon the other two members of the team. It is of concern that this could lead to a failure to meet residents needs. The provider must ensure there are always sufficient members of staff on duty to meet resident’s needs and it is recommended a staffing review be conducted to determine whether current staffing levels adequately reflect the changing needs of the current residents. Winnie Care (Beverley Lodge) Limited DS0000058604.V273395.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 The home had policies, procedures and records in place to safeguard the health, safety and welfare of residents. Arrangements were not yet in place for resident’s personal money to be paid into separate accounts. EVIDENCE: The manager is appropriately qualified and experienced and in conversation was able to demonstrate a good understanding of the management issues relating to the running of a care home and the needs of older people. Records were kept to safeguard resident’s rights and best interests and policies and procedures were in place to promote safe working practices and the health, safety and welfare of residents and staff. Members of staff received training in such areas as moving and handling, First Aid, Infection Control etc. Winnie Care (Beverley Lodge) Limited DS0000058604.V273395.R01.S.doc Version 5.1 Page 17 The views of residents and their families about the care they received and the general running of the home was sought on a daily informal basis. More formally a Residents/Family Satisfaction Questionnaire had been carried out as part of a quality monitoring and audit. Five comments cards were returned to the inspector, all expressed satisfaction with the general level of care and the overall running of the home – no adverse comments were received and some very positive comments made: “ All the staff are very caring and very friendly.” “My mother is happy in the home and never complains to myself about anything when I go to see her.” Personal money and items of value held in the home for safekeeping are held securely and an appropriate record kept. The provider is currently reorganising the company’s accounting system to ensure all monies held on behalf of residents are paid into an account in their own name. Winnie Care (Beverley Lodge) Limited DS0000058604.V273395.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x x STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 2 x x 3 Winnie Care (Beverley Lodge) Limited DS0000058604.V273395.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 3. Standard OP8 Regulation 14 Requirement 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. Timescale for action 15/08/05 4. OP19 23(1)(a) 31/10/05 5. OP27 18 15/08/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Winnie Care (Beverley Lodge) Limited DS0000058604.V273395.R01.S.doc Version 5.1 Page 20 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.V273395.R01.S.doc Version 5.1 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. 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