Archived: Beverley Lodge Nursing Home

Updated 24 February 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 24 January 2017 by one inspector and was unannounced.

Before the inspection we reviewed the information we held about the service, including statutory notifications submitted about key events that occurred at the service. We also reviewed the information included in the provider information return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

During the inspection we spoke briefly with six people and used the short observation framework for inspection (SOFI) during lunchtime in the communal lounge. SOFI is a way of observing care to help us understand the experience of people who could not talk with us. We also spoke to eight staff including the provider and the manager. We reviewed elements of six people’s care records. We reviewed the staff team’s training and supervision records and records relating to the management of the service. We also looked at medicines management processes.

Updated 24 February 2017

This inspection took place on 24 January 2017 and was unannounced. At our previous comprehensive inspection on 1 February 2016 the service was rated ‘requires improvement’ overall and in the three key questions, ‘is the service safe?’, ‘is the service responsive?’ and ‘is the service well-led?’ The service was rated good for the other two questions, ‘is the service effective?’ and ‘is the service caring?’ We identified breaches of three regulations relating to good governance, safe care and treatment and notifications of incidents. We undertook focused inspections on 16 June 2016 and 23 September 2016 to follow up on the action taken to address the breaches. By our inspection on 23 September 2016 the provider had taken sufficient action to meet the regulations that were previously breached, however the ratings given at the February 2016 comprehensive inspection remained to enable the changes to be embedded into service delivery.

Beverley Lodge Nursing Home provides accommodation and nursing care to up to 16 older people, most of whom are living with dementia. At the time of our inspection 16 people were using the service. This included two people who were receiving respite care.

The service had received a change in manager since our focused inspection in September 2016. The new manager was aware of their responsibility to register with the Care Quality Commission and had started the application process. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The provider had sustained the improvements made since our previous inspection to ensure safe medicines management. People received their medicines as prescribed and robust processes were in place to check stocks of medicines. Staff continued to safeguard people from abuse and the management team liaised with the local authority safeguarding team about any concerns raised. Risks to people’s safety were regularly reviewed and management plans were followed to minimise the risk from occurring. There were sufficient staff to meet people’s needs and staff responded promptly to people’s requests for assistance.

Staff continued to stay up to date with their mandatory training to ensure they had the knowledge and skills to undertake their roles. They were supported to undertake qualifications relevant to their role and received regular supervisions and appraisal. Staff adhered to the Mental Capacity Act 2005 code of practice and adhered to the conditions of people’s deprivation of liberty safeguards authorisations. People received the support they required with their health and nutritional needs. Staff liaised with relevant healthcare professionals if they had concerns a person’s health was deteriorating.

Care and support was provided in line with people’s wishes and preferences. Staff were aware of how people communicated and involved them in day to day decisions. People’s care records detailed people’s decisions in regards to end of life care and this was shared with other healthcare professionals involved in their care. Staff respected people’s privacy and maintained their dignity.

The provider had sustained improvements made since our previous inspection to ensure detailed, complete and accurate care records were maintained. People’s care records provided clear instruction to staff about how to support people and the level of support they required. Staff used the ‘red bag’ initiative from the London Borough of Sutton’s Vanguard project to enable consistent and coordinated transitions when people move between services. A complaints process remained in place to investigate and learn from concerns raised.

Robust processes had been maintained to monitor and improve the quality of service delivery, including a programme of audits and review of key performance data. Staff, people and their relatives were encouraged to feedback about the service through regular meetings and completion of satisfaction surveys. The provider liaised with the local authority and Clinical Commissioning group (CCG) to learn about new models of care and implement good practice initiatives. The provider adhered to the requirements of their Care Quality Commission (CQC) registration and submitted statutory notifications as required by law.