Care Home: Beaufort House

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What the care home does well The home has a friendly warm and inclusive atmosphere The manager and staff provide an environment in which each person living there is seen as an individual and there is an in depth understanding of individual needs. This is echoed in survey forms sent in by relatives, who were very complimentary about the level of care and support given. The home is extending and some refurbishment will follow, this is in order to meet the needs of service user more fully and enable those with less mobility to have access to better facilities. The home is responding to the increasing ages of service users and providing training in related subjects. Staff are well supported and trained and the staff turnover is low. Records are kept to a good standard and care plans are clear. Medication procedures are robust. What has improved since the last inspection? The home is undergoing substantial environmental improvement and although this is causing some disruption staff are keeping it to a minimum for service users and putting in place related risk assessments. The benefits can be fully assessed at the next key inspection, whilst two bedrooms had already been redecorated and one was near completion for a service user to move into, allowing them more space. Information about the service has been made more user friendly. Medication procedures have improved with the addition of thorough PRN guidelines. All staff have now attended POVA training and more care staff have gained an NVQ in care. Individual training plans are in place and there is tracking of training undertaken and updates needed. Safety has improved and the COSHH cupboard is kept locked and water temperatures kept safe. Risk assessments are in place for use of the garden especially in the current circumstances and carpets have been cleaned although some will need replacing. What the care home could do better: As service users are becoming older the home must make sure the care plans of those over 65 are reviewed every month. The home does it`s best to provide suitable activities for service users and the proposed plan of employing a dedicated part time activities coordinator needs to be followed through so that all service user have opportunities to participate in activities.The complaints procedure needs to be displayed in an area where it is accessible to visitors to the home. As building work is completed the garden must be tidied up and made a more attractive place for service users to access, the organisation needs to engage a dedicated gardener to make sure that the garden is well maintained as staff are engaged in other tasks. CARE HOME ADULTS 18-65 Beaufort House Beaufort House Chobham Road Knaphill Woking Surrey GU21 2TD Lead Inspector Debbie Sullivan Unannounced Inspection 15th July 2008 09:45 Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 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 Beaufort House DS0000013563.V366952.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 Adults 18-65. 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. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaufort House Address 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) Beaufort House Chobham Road Knaphill Woking Surrey GU21 2TD 01483 475536 Whitmore Vale Housing Association Post Vacant Care Home 7 Category(ies) of Learning disability (7), Physical disability (2) registration, with number of places Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The age/age range of the persons to be accommodated will be: 18 - 65 YEARS. Two of the 7 persons accommodated may be within the category PD in addition to being within the category LD. Up to six named persons may be within the category LD (E). Date of last inspection 4th September 2006 Brief Description of the Service: Beaufort House is part of the Whitmore Vale Housing Association that is a charitable Housing Society. It is situated in a residential area close to the centre of Knaphill Village on the outskirts of Woking. Beaufort House is registered to provide care and accommodation for 7 adults with complex daily needs and communication difficulties. The property has been converted from a private residence comprising seven bedrooms. One bedroom has en-suite shower and toilet facilities. There is a kitchen, large through dining/lounge room and a quiet/sensory room. Limited off street parking is available at the front of the property. The home is being extended and improved in 2008 to make it more suitable for the needs of service users. The service users have access to a secure fenced garden. The fees at the home range from £1,243.92per week to £1,282.20 per week. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection of Beaufort House took place over five hours. During the visit time was spent with the Deputy Chef Executive of the organisation, the Manager, the Deputy Manager, service users and staff on duty. A tour of the home took place and a range of documents and records were sampled, including care plans, staff files, risk assessments and policies and procedures in use at the home. The AQAA (Annual Quality Assurance Assessment) document completed by the manager provided good quality information that contributed to evidence and inspection and survey forms were received from relatives and one service user. The manager and other staff were very helpful in assisting the inspection and whilst communication with service users was limited due to the nature of the service, observation, records and discussion with staff provided evidence to judge the outcomes for service users. The quality rating for this service is 2 star. This means that people who use this service experience good quality outcomes. What the service does well: The home has a friendly warm and inclusive atmosphere The manager and staff provide an environment in which each person living there is seen as an individual and there is an in depth understanding of individual needs. This is echoed in survey forms sent in by relatives, who were very complimentary about the level of care and support given. The home is extending and some refurbishment will follow, this is in order to meet the needs of service user more fully and enable those with less mobility to have access to better facilities. The home is responding to the increasing ages of service users and providing training in related subjects. Staff are well supported and trained and the staff turnover is low. Records are kept to a good standard and care plans are clear. Medication procedures are robust. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: As service users are becoming older the home must make sure the care plans of those over 65 are reviewed every month. The home does it’s best to provide suitable activities for service users and the proposed plan of employing a dedicated part time activities coordinator needs to be followed through so that all service user have opportunities to participate in activities. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 7 The complaints procedure needs to be displayed in an area where it is accessible to visitors to the home. As building work is completed the garden must be tidied up and made a more attractive place for service users to access, the organisation needs to engage a dedicated gardener to make sure that the garden is well maintained as staff are engaged in other tasks. 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. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 4 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Information about the home is available to prospective service users and others and they are welcome to visit before making a decision to move in. Needs are fully assessed prior to admission. EVIDENCE: The service users living at the home are all well established and the last new admission was in 2003,there are no current plans for any changes to the service user group and the home is being altered so that it is more suitable for their current needs. The service users guide has been updated and each service user has a pictorial copy. Care plans contain pre admission assessments for current service users and any prospective service users would be assessed by the manager following an assessment and referral by their sponsoring agency. Prospective service users Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 10 are invited to visit the home and spend time there so that they familiar with the home, following admission there is a three month settling in period. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans reflect the individual needs of service users and are maintained to a high standard. Service uses are supported to be as independent as possible, risks are thoroughly assessed and risk assessments put into place. Service users have opportunities to be involved in the running of the home. EVIDENCE: Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 12 The care plans of three service users were read; they were all well maintained with clear information for staff about the needs, preferences and goals of service users. Information includes personal profiles, information on health and personal care needs, day activities, medication, goals, risk assessments and reviews. Risk assessments were thorough and up to date and all the written information was of very good quality. Additional risk assessments have been put in place where necessary in respect of current building works. One service user who is over 65 needed to have their needs reviewed on a monthly basis and recorded, although their care plan showed that needs were being very well documented and any changes managed well or referred onto to other agencies. The home plans to make care plans more accessible for service users. Each service user has a keyworker and co key worker. Only one of the service users has verbal communication skills so staff need to rely on the care plans and knowledge of each persons’ communication styles and abilities to be able to understand their needs fully. Discussion with the manager and another staff member and general observation showed that staff were confident in understanding needs and a relatives commented on a survey forms that “ Although my (relative) has little vocabulary the staff understand her needs and preferences” and the home “Treats each resident as an individual person with their own character and needs ----Staff always address her, not me all the time, to involve her as much as possible”. There have been some difficulties in securing the attendance of care managers at reviews as not all service users always have named care manager, however the manager said that this is improving. Service users are supported to make decisions and their views are respected. Regular residents meetings are held and the AQAA states that they are invited to attend staff meetings. During the visit service users were supported to choose activities and take part in them, to attend day centres and to access different areas of their choice in the home safely. The home has risk assessments in place for individual and group activities and due to work being done on the building that could cause new risks they are updated or written in response to any newly identified concerns. Written information about service users is kept confidentially and during the visit staff were discreet if discussing issues about service users. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users have opportunities to take part in a variety of activities at home and in the community. Service users are supported to keep in touch with relatives and their friends. Meals are varied and nutritious. EVIDENCE: Service users have individual weekly activity programmes that include in house and community activities. Each service user has differing interests and abilities and programmes are tailored to these. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 14 One service user is in paid employment two mornings a week as well as attending college and day services. The service user went to a cookery session during the visit and said they were going to make pies and liked the classes, they also attended a literacy class. Another service user returned from a daycentre after lunch. Day activities are regularly reviewed and a comprehensive report was read that had been written for a review due to be held that had been completed by a senior staff member, the report highlighted need for possible changes in activities. Other community activities include bowling, going shopping and going out for meals. Service users are supported to practice their religion and a comment from a relative was that “My (relative) is taken to a church service whenever possible”. Service users are experiencing changes in their needs due to ageing and staff do their best to provide suitable activities at home for those unable to go out as much as others. One service user was being supported to make a birthday card for another whose birthday was the next day; one was looking at holiday photos and another using the sensory room. There is a holiday allowance in the fee and a service user who does not cope well with staying away from the home is able to use it for days out. Others go on short holidays with staff; one service user was going on holiday the next day with their relatives. The manager had identified a need for work to be done on broadening the range of activities available, especially as suitable day or college service were becoming increasingly more difficult to find in the area. The manager was hoping to employ a part time activities coordinator to assist with this. Contact with friends and relatives is well supported, not all the service users have relatives but if possible they are helped to keep in touch with friends. Care plans contained references to family contact and a relative wrote on a survey “They always send Christmas and Easter cards and birthday cards to me and my husband as well as presents signed on my (relatives’) behalf. The rights of service uses are respected and they can have a key to their bedroom if they choose. Service users were using their bedrooms during the day and could choose where to eat meals and had access all communal areas of the home in line with current risk assessments. Service users are supported with their finances, spending money is available and records kept of transactions. The majority of service users have a representative of the organisation from head office as appointee, it is recommended that local authorities take on this responsibility. The menu is varied and healthy and service users contribute to meal planning, a service user’s survey form stated “lots of different meals and I am able to help write menus”. Service users can choose to eat in the kitchen or dining room, the main meal is in the evening and the manager said most service Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 15 users then eat in the dining room. Breakfast time is flexible depending on when service users are up and they can choose to take in their room. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of service users are well met and any health concerns are followed up. Preferences are respected when personal care is given. The policies and procedures in place for the administration of medication are thorough and protect service users. EVIDENCE: Personal and healthcare needs are well documented on care plans. There are thorough guidelines to direct staff as to how service users prefer their personal care to be given. Each service user has differing and complex needs, the majority of service users need support with most of their personal Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 17 care but are encouraged to be independent as far as possible. One service user mainly needs prompting. Personal care is delivered discreetly and during the visit staff were observed to respect privacy and knock on doors before entering. Equipment is available to assist with the safe delivery of personal care such as hoists, a Parker bath and adjustable bed. Any changes in health or emotional needs are documented and referred onto to other agencies if necessary. The manager said one service user who had very limited speech had recently verbalised more so is being referred to a speech and language therapist and another whose mobility decreased following knee surgery is now becoming more mobile so has been re referred for physiotherapy. Care plans show that service users are supported to attend health appointments such as those with the GP or chiropodist. Two service users have regular aromatherapy. Medication procedures are robust. Medication is stored safely and medication record sheets were correctly completed. PRN guidelines are kept with care plans and medication sheets, are completed to a very high standard and kept up to date. All staff who administer medication are trained to do so. The Boots MDS system is used; Boots had recently audited medication procedures at the managers’ request and had identified no concerns. Wishes in the event of death are recorded and as the current group of service users is ageing the home has started to provide staff with loss and bereavement training. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure that is available to service users and others. Safeguarding procedures are in place and staff awareness of what constitutes abuse has improved. Safeguarding concerns are swiftly acted upon. EVIDENCE: The home has a complaints procedure that is available to service users in a pictorial format. There had been no complaints recorded since that last inspection, a relative had put on their survey form in response to a question about awareness of how to complain, “I cannot imagine I would ever need to”. It is recommended however that the procedure be displayed more prominently in the home for visitors. The manager and another staff member said that service users make any concerns known via their methods of communicating. A recent concern raised by a service user that led to a safeguarding alert being raised by the home was Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 19 acted upon quickly and taken seriously. The Commission was promptly notified of the alert. Since the last inspection three safeguarding alerts had been raised by the home and they had acted properly if they were said to involve staff. Two are closed, with the recent alert remaining open at present. There is a safeguarding procedure in place and all staff are expected to become familiar with it. All staff have now been on POVA training and CRB and POVA checks are part of the recruitment process. Guidelines are in place for the management of challenging behaviour for the protection of service users and staff. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well maintained and clean and being extensively improved. Bedrooms reflect individual interests and for some service users are being made more suited to their needs. Equipment is in place to help to maintain and maximise independence. EVIDENCE: The home is undergoing substantial refurbishment; this will improve the overall environment for all the service users and make it more suitable for Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 21 service users with decreased mobility. The last inspection identified that carpets needed replacing and some redecoration was needed, plans are in place to replace carpeting and flooring and redecorate when the major building work is completed. In the meantime two bedrooms had been redecorated prior to the work being completed, the estimated timescale for completion at the time of the visit was three months. Improvements to the property will be a new upstairs bathroom that is designed to meet the increased needs of service users, a new bedroom for a service user who has increased mobility needs and a new laundry and office. An existing bedroom was being redecorated for a service user to move into within the next few days, the move was planned but was needed as soon as possible as due to building work just completed the service user was unable to open the windows in their current room. The home had acted quickly to install an air conditioning system and was considering an interim sleeping arrangement until the new room was ready. Bedrooms were all well decorated and clean, service users are consulted about the colour schemes for their rooms and they included lots of personal items such as model cars, TV’s, family photos and pictures. One service user was due to have new cupboards; a service user said they liked their room. The home was clean throughout and the living and dining room pleasantly decorated, some updating of this will be needed when building work is completed. Some areas that are carpeted are to be fitted with more suitable flooring that will be easier to clean. Equipment is available throughout the home for individual or shared use, the Parker bath needed servicing, as this was a little overdue, the manager said she would chase this up. There is a well-equipped sensory room. It was not possible to inspect the laundry as it was sealed off for the day for building work to take place, although the manager stated that there were normally no restrictions on it’s use and if there were alternative arrangements could be made. The garden is accessible to service users there is a ramp and a patio area. The garden is a good size but had become rather uncared for looking partly due to the work taking place and partly as there is no gardener, the manager was hoping to obtain a gardener for the home again. The fire route was clear and a staff member said that two service users like to access the garden independently; others use it with support in good weather. Staff were doing their best to minimise disruption to service users whilst the home was being improved and a relative stated on a survey, “ It is improving all the time, especially now, the home is having extensive extension work done with very little disruption to the service user’s routine”. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A competent and well-trained staff group meets the needs of service users. Staff are well supported and recruitment procedures are thorough. EVIDENCE: The home is adequately staffed for the needs of service users. Sufficient care staff as well as the deputy manager were on duty during the morning, the manager came on duty in the afternoon. There is one waking and one sleeping staff member on duty at night. Staff are responsible for all the cooking and domestic duties in the home. During the visit staff had time to spend with service users chatting with them or doing activities and accompanied those going out to and from day services. All the staff on duty were permanent, the manager said there are three bank staff sometimes used and if agency staff are employed they are known to the home. There is current recruitment taking place for permanent staff. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 23 Staff were observed to be confident and competent and as the staff group is well established they are very familiar with individual needs. They were attentive to the needs of service users and aware of mood changes. Comments from relatives on survey forms regarding staff included “She is very content and looked after so well by friendly, caring and efficient staff” and “Excellent care and individual attention to the needs of residents”. Staff are well supported and receive regular supervision. The deputy manager is now supervising some staff. Regular staff and managers meetings are held A requirement made at the last inspection that all night staff receive POVA training is now met. Training records show that core training is attended as well as training on some specialist topics such as the Mental Capacity Act, Equality and Diversity and Makaton. Three staff files were read, all included the necessary documents except one that was missing a birth certificate the manager arranged for this to be faxed through from head office during the inspection. Files also included records of interview responses, appraisal documentation and supervision recording. The organisation’s deputy chief executive was at the home for part of the day looking into a recruitment issue that was being dealt with appropriately by the organisation. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 and 43 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed in the best interests of service users and staff. The atmosphere is open, friendly and inclusive. The views of service users and others are sought and there are internal quality control procedures in place. EVIDENCE: Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 25 The home has a friendly, open and inclusive atmosphere and staff are respectful towards service users. The manager has been in post since mid 2007 and had experience of working at the home as deputy manager before promotion; she has nearly completed her NVQ4 and is undertaking her registered managers’ award. The manager said she was shortly to submit her application to the Commission to become registered manager. It was clear during the visit that staff are well supported and committed to providing a good service and that record keeping is considered very important for the smooth running of the home. The views of service users are sought at residents meetings and staff meetings that they are invited to attend. Relatives and other professionals are surveyed annually for their views on the home, some survey forms for August 2007 were read and they contained a large number of positive and complimentary comments. The manager operates an open door policy. The Annual Quality Assurance Assessment Document was well completed and gave a lot of good quality information that was helpful for this inspection. The home keeps the Commission informed of any incidents or occurrences that we need to know about and all information provided is clear and well presented. The Deputy Chief Executive visits the home monthly and reports of her findings were read. Health and safety checks are undertaken and the home is especially proactive in reviewing any risks with the current building work taking place. The home had met requirements from the last inspection that the cupboard containing cleaning materials must be kept locked and water temperatures safe. Fire records are up to date and thoroughly completed. A range of policies and procedures are in place that are available to staff and they are expected to read them during induction and then at least annually and sign that they have done so. A valid insurance certificate is on display. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 2 26 2 27 3 28 3 29 3 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 3 3 3 3 3 3 3 3 Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA12 YA22 YA24 Good Practice Recommendations It is recommended that the home consider engaging an activities coordinator and keep this under review. It is recommended the home display the complaints procedure to make it available to visitors. It is recommended that a gardener be employed so that the garden can be kept well maintained and made more attractive for service users. Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Beaufort House DS0000013563.V366952.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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