Care Home: Beulah Lodge

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What the care home does well Comments from residents were generally positive, with indication that staff is kind and helpful in meeting their care needs. Residents were observed to be treated with respect by staff and to have their privacy and dignity respected. Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them. The home encourages residents to make decisions about all aspects of their lives; this includes what to eat, where to go on holiday, for days out, and what clothes to buy. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. What has improved since the last inspection? Some of the care plans and risk assessments have been updated and they are now more comprehensive and reflect the needs of the residents. Formal supervision sessions are being held with all care staff at least six times a year for the delivery of good quality services. Fire alarm tests are now being carried out on a regular basis for the safety of staff and residents. What the care home could do better: Residents must be supported and protected by the home`s recruitment policy and practices. New staff must be confirmed in post only following completion of the required employment checks. All staff must receive relevant training that is focussed on delivering improved outcomes for people using the service. A recommendation is repeated for the registered manager to have access to a mentor or another professional for support in relation to her professional practice. CARE HOME ADULTS 18-65 Beulah Lodge 51 Beulah Road Thornton Heath Surrey CR7 8JH Lead Inspector Mohammad Peerbux Key Unannounced Inspection 29th April 2008 11:00 Beulah Lodge DS0000054125.V362391.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 Beulah Lodge DS0000054125.V362391.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. Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beulah Lodge Address 51 Beulah Road Thornton Heath Surrey CR7 8JH 020 8771 5691 020 8768 1445 charlesbasoah@hotmail.com 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) Graceland Care Home Limited Mrs Grace Basoah Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The second floor uppermost room, with wooden stairs leading to it, is not used as a service user`s bedroom. 19th June 2007 Date of last inspection Brief Description of the Service: Beulah Lodge is a care home for four younger adults with learning disabilities. The home is a 1900s semi-detached property situated in a residential part of Thornton Heath with access to local shops and amenities. There is a bus and railway station within walking distance. There is a secure garden at the rear of the property that can be used by residents. The ethos of the home is to provide a friendly, congenial and homely environment to assist younger adults with learning disabilities to live as full a life as possible within the wider community. The range of weekly fees is around £850 and this information was gathered on the day of the inspection (29/04/08). Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is two stars. This means the people who use this service experience good quality outcomes. This unannounced visit to the home was undertaken as a part of the inspection process for the year 2008/2009. In writing the report, consideration has also been given to information received throughout the year such as comments from people who use the service, reports of incidents and complaints. This is the first key unannounced inspection for the year 2008/2009.This inspection was facilitated by the Registered Manager. Some of the residents were spoken to and they commented positively on the care they are receiving. One resident stated, “They are good to me and I am happy here”. They are all thanked for their time and all of those who provided feedback for their support in the inspection process. A tour of the building was also carried out. All registered adult services are now required to fill in an annual quality assurance assessment (AQAA) .It is a self-assessment that the provider (owner) must complete every year. The completed assessment is used to show how well the service is delivering good outcomes for the people using it. Some information from this AQAA is included in the report. What the service does well: Comments from residents were generally positive, with indication that staff is kind and helpful in meeting their care needs. Residents were observed to be treated with respect by staff and to have their privacy and dignity respected. Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them. The home encourages residents to make decisions about all aspects of their lives; this includes what to eat, where to go on holiday, for days out, and what clothes to buy. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 7 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 Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 8 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): 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home undertakes an assessment of the healthcare needs of residents prior to their admission to ensure that their needs would be met. EVIDENCE: Two residents’ files were sampled at random and evidence suggests that prospective residents have a needs assessment carried out before they are admitted to the home. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. The assessments are generally undertaken satisfactorily. Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 9 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 and 9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Generally, residents’ care plans include detailed information about their needs and personal goals. This helps staff to know the residents’ needs and how to meet them. EVIDENCE: It was previously required that the home must ensure that care plans cover all aspects of personal and social support and healthcare needs of the residents. Two care plans were sampled at random and it was noted that one of them was reviewed and was more comprehensive. The care plan was person centred and was agreed with the individual. The plan also contained procedures for the resident who is likely to be aggressive and cause harm or self-harm, focusing on positive behaviour, ability and willingness. This is in line with a requirement made at the last inspection. Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 10 The second care plan was in the process of being updated as the manager was waiting for a formal review from the care management team. This standard is assessed partially met and will be reassessed at the next inspection. Maintaining independence and enabling residents to make their own decisions about how they wish to live is a key objective of the home. The home recognises the right of individuals to take control of their lives and to make their own decisions and choices. There is some evidence that individuals are involved in some decision making about the home, such as day to day living and social activities. All residents are also supported and encouraged to have an active role in the community. Each care plan includes a risk assessment, which is reviewed regularly. Management of risk is positive addressing safety issues whilst aiming for better quality of life. Where limitations are in place, the decisions have been made with the person and are recorded. The risk assessments have been reviewed and updated as previously required. They are now more comprehensive. It was previously recommended that a missing profile be developed for all the residents who are at risk of leaving the home without consulting the staff. The manager stated that these are now in place. Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 11 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): 12,13,15,16 and 17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are being provided with a range of opportunities for recreational and social activity that is in accord with their social, cultural and religious needs. They are assisted to maintain contact with family and friends, and links with the local community are encouraged. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. EVIDENCE: Central to the home’s aims and objectives is the promotion of the individual’s right to live an ordinary and meaningful life, both in the home and in the community appropriate to their peer group, and to enjoy all the rights and responsibilities of citizenship. The home understands the importance of enabling younger adults to achieve their goals, follow their interests and be integrated into community life and leisure activities in a way that is directed by the person using the service. Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 12 The home has a strong commitment to enabling people who use services to develop their skills, including social, emotional, communication, and independent living skills. People who use services are involved in meaningful daytime activities of their own choice and according to their individual interests and capability; they have been fully involved in the planning of their lifestyle and quality of life. The service is committed to the principles of inclusion and promotes, and fosters good relationships with neighbours and other members of the community. People who use the service have the opportunity to develop and maintain important personal and family relationships, and are able to access information and specialist guidance about issues such as intimate relationships. The practice of staff promotes individual rights and choice, but also considers protection of individuals, supporting people to make informed choices. The home actively supports people who use services to be independent and involved in all areas of daily living in the home. This includes where appropriate, taking responsibility for shopping, planning meals, and meal preparation. Good practice may include individuals being supported to be independent in the process following training and support. It was clear from the menus that a wide variety of different food options were available in the home with a lot of consideration given to the nutritional value of the meals provided. Staff are ready to offer assistance in eating where necessary, discreetly, sensitively and individually, while independent eating is encouraged for as long as possible. The meals are balanced and nutritious and cater for the varying cultural and dietary needs of individuals. Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 13 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 and 20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Overall the arrangement for health care needs of the residents is good and they receive personal support in the way they prefer. EVIDENCE: The delivery of personal care is individual, flexible and person centred. Staff respect the privacy and dignity of the residents and are sensitive to their changing needs. Where needed, guidance and support regarding personal hygiene is provided. Times for getting up/going to bed, baths, meals and other activities are flexible. Staff are aware that the way in which support is given is a key issue for younger adults. People who use services have access to health care services both within the home and in the local community. Generally health needs are monitored and appropriate action and intervention taken. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 14 administered and disposed of are recorded. It is however recommended that the allergies of residents be also recorded on their Medication Administration Records. Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 15 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 using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are generally managed well, which should ensure that residents’ and relatives’ concerns are listened to. EVIDENCE: The home has a complaints procedure that is conspicuously displayed in the home for all to view. The procedure explains how to make a complaint and that the complainant can expect a response about the outcome of any investigation to a complaint within 28 days. The current complaints procedure is good and gives a clear step-by-step guide of how to make a complaint. Residents who were spoken to stated that they are happy with the service provision and feel well supported. The home has an open culture where individuals feel safe and supported to share any concerns in relation to their protection and safety. Policies and procedures regarding Safeguarding Adults are available to staff and give them clear guidance about what action should be taken. People using the service and / or their representatives are made aware of what abuse is and the safeguards in place for their protection should they need them. Access to external agencies is actively promoted. The manager stated that staff had applied to have training in the area of protection of residents and how to deal with physical and verbal aggression however they were still waiting for dates to attend the training sessions from the local authority. Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 16 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 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is generally hygienic and clean, homely and comfortable; this environment therefore facilitates the residents’ health and emotional well being. EVIDENCE: The home is suitable for its stated purpose. It is accessible, meet residents’ individual and collective needs in a comfortable and homely way. Residents’ bedrooms are personalised to reflect their individual needs, and personalities. Overall the home is decorated to a good standard throughout and appears to be very comfortable, bright and warm. The home is kept very clean and hygienic and free from offensive odours throughout. Systems are in place to control infection in accordance with relevant legislation and published professional guidance. Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 17 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): 32,34,35 and 36 People using the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency and to ensure their safety. Care staff are receiving supervision on a regular basis, which contributes to the standards of care being provided to residents. However one concern was identified in regard to recruitment checks not being completed satisfactorily, which impinge on the safety and protection of residents being ensured. EVIDENCE: There are consistently enough staff available to meet the needs of the people using the service. The staffing structure is based around delivering outcomes for the people using the service. The registered manager informed that 50 of staff in the home are qualified in NVQ level 2 in care. As part of the inspection process one newly recruited staff records were sampled for references, criminal record check, application form and copy of identification. It was noted that the staff file did not have all relevant documentations. It was also identified that the staff did not have a CRB or Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 18 POVA check that have been carried out by the home. The manager stated that she thought that if the CRB’s were recently done, they could be portable. No staff should work unsupervised without having carried out a POVA check first on them and they have applied for a CRB check. A copy of the POVA check that was carried out by the home was forwarded to the Commission following the inspection. The home ensures that all staff within its organisation receives relevant training that is targeted and focussed on improving outcomes for residents. The manager is aware that there are some gaps in the training programme. These are being addressed and further training sessions have been arranged. The manager must also update the individual staff training records. From staff files sampled at random there were evidence that staff are being supervised on a regular basis. Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 19 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): 37,39 and 42 People using the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home appears to be well managed. There are clear lines of accountability within the home and the management style is open and transparent. Records held at the home provide evidence that maintenance is regularly carried out to ensure the well being of the residents. EVIDENCE: The registered manager has the necessary experience to run the home. She is aware of the need to keep up to date with practice and continuously develop management skills. She has a clear understanding of the key principles and focus of the service, based on organisational values and priorities. She works to continuously improve services and provide an increased quality of life for residents with a strong focus on equality and diversity issues. It was previously Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 20 recommended that the registered manager have access to a mentor or another professional for support in relation to her professional practice. This remains outstanding and would therefore be repeated. Effective quality assurance and quality monitoring systems, based on seeking the views of residents, are now in place to measure success in meeting the aims, objectives and statement of purpose of the home. The home has a health and safety policy that generally meets health and safety requirements and legislation. Records are of a good standard and are routinely completed. Certificates relating to health and safety were up to date servicing certificates. Beulah Lodge DS0000054125.V362391.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 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 X 2 3 3 X 4 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 22 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. 1. Standard YA6 Regulation 15(1) Requirement Residents’ care plans must cover all aspects of personal and social support and healthcare needs of the residents to ensure their needs are being met. (Previous timescale of 19/08/07 partially met). Residents must be supported and protected by the home’s recruitment policy and practices. New staff must be confirmed in post only following completion of the required employment checks. All staff receive relevant training that is focussed on delivering improved outcomes for people using the service. (Previous timescale of 19/08/07 partially met). Timescale for action 29/07/08 2. YA34 19 (4)(c) 29/05/08 3. YA35 18(1) 29/07/08 Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 23 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 YA37 Good Practice Recommendations It is recommended that the registered manager have access to a mentor or another professional for support in relation to her professional practice. It is recommended that the allergies of residents be also recorded on their Medication Administration Records. 2. YA20 Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Beulah Lodge DS0000054125.V362391.R01.S.doc Version 5.2 Page 25 - 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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