Inspection on 02/12/09 for St Pauls Lodge

This is the latest available inspection report for this service, carried out on 2nd December 2009.

CQC found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Similar services:

Snydale Care Home

Staveley Birk Leas Nursing Home

Fairmount Nursing Home

Currergate Nursing Home

Brookfield

Castlethorpe Care Home

Elmleigh Convent

Woodlands Respite Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 18/02/2010.

Key inspection report Care homes for older people Name: Address: St Pauls Lodge 2 St. Pauls Road W Yorkshire BD183EP     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Mary Bentley     Date: 0 2 1 2 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 27 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 27 Information about the care home Name of care home: Address: St Pauls Lodge 2 St. Pauls Road W Yorkshire BD183EP 01274593940 01274714141 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Just Global Ltd Name of registered manager (if applicable) Type of registration: Number of places registered: care home 21 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia physical disability Additional conditions: The maximum number of service users who can be accommodated is 21 The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Service users with Dementia - Code DE (maximum number of places: 20) Service users with a Physical Disability - Code PD (maximum number of places: 1) Date of last inspection Brief description of the care home St Pauls Lodge is an adapted property and it is registered to provide personal care for a maximum of 21 older people. The home is located in a residential area close to Shipley town centre. The home has 3 floors, accommodation is provided on the ground and first floors. The communal rooms are on the ground floor. There are 17 bedrooms some of which are Care Homes for Older People Page 4 of 27 Over 65 0 0 20 1 Brief description of the care home shared rooms. Seven bedrooms have en-suite toilet facilities, there are communal toilets and bathrooms which are easily accessilbe to people. The home does not have a passenger lift, there is a stair lift to the first floor and there are bedrooms on the ground floor if people are not able to use the stair lift. There is a well maintained garden with a patio which people can use when the weather permits. In December 2009 the weekly fees ranged from 397.95 to 425.18. Additional services such as private chiropody, hairdressing, newspapers, and escorts to appointments are provided at an additional cost. Please contact the home for more detailed information about the fees. Care Homes for Older People Page 5 of 27 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This is a new service and this was the first inspection. This is what we used to write this report: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. The results of any visits that we have made to the service in the last 12 months. We have not made any additional visits since the new owners took over. Surveys returned to us by people using the service. We received a total of 3 surveys from people using the service, some had been completed on their behalf by relatives. Care Homes for Older People Page 6 of 27 Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. Relevant information from other organisations. A site visit carried out by one inspector between the hours of 09:50 am and 4:30 pm. The visit was unannounced. During that time we spoke to people living in the home, visitors, staff and management. We looked at various records including care records, looked at some parts of the home and observed staff as they carried out their duties. This is a new service which means that the highest rating they can be awarded is 2 stars. More information on the way we award quality ratings is available on our website, www.cqc.org.uk We have reviewed our practice when making requirements to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated it is likely enforcement action will be taken. Care Homes for Older People Page 7 of 27 What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. Care Homes for Older People Page 8 of 27 The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 27 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 27 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples needs are assessed before they move in and people or those close to them are encouraged to visit the home before making a decision about moving in. This helps people to decide if the home is the right one for them or their relative. Evidence: The Statement of Purpose which provides information about the service is available in the home. Staff told us a copy of the Statement of Purpose and a brochure are given to people when they make enquiries about the service. We received three surveys from people living in the home, some had been completed by relatives on their behalf. Two people said they had been given enough information about the home before moving in, one said they had not. The home told us people are encouraged to visit before making a decision about moving in, in many cases it is a relative who visits. One relative told us they had been to look at the home when looking for a place for their mother. They said they are Care Homes for Older People Page 11 of 27 Evidence: pleased with the home and the way their mother is looked after. Peoples needs are assessed before they move in, we saw completed pre-admission assessments in the care records. Copies of assessments carried out by other professionals such as social workers were also available. This helps to make sure that the home will be able to meet peoples needs when they move in. Care Homes for Older People Page 12 of 27 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this 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 peoples personal and health care needs are met but this is not always reflected in the care records. Evidence: People looked well cared for and visitors said they are satisfied that their relatives are well cared for. They said people always look clean and nicely dressed and peoples clothing is looked after properly. Everyone living in the home has a care plan and during the visit we looked at two peoples care records. The care plans have information about peoples personal and health care needs. The care plans are written in a way that shows what people can do for themselves which is good because it helps people to maintain their abilities. However, when people are identified as needing help the care plans do not always provide enough detailed information for staff. For example one persons records said they needed the assistance of 1 staff but did not say what that member of staff should do. Another persons records said they sometimes get weepy and frustrated but it was not clear what staff should do when this happened. Care Homes for Older People Page 13 of 27 Evidence: Risk assessments are carried out for areas of potential risk such as falls, pressure sores and nutrition. However, in one persons records we saw that although they had been identified as being at risk of malnutrition when they moved in this was not reflected in the nutritional risk assessment. On further checking we found that the persons weight had not been recorded correctly. This was discussed. Staff were aware that this person needed help with nutrition. They gave an account of what the person eats in a typical day and said the person has gained weight since admission. The home has a new sit on scales which the staff are just getting used to which may account for the mistake with recording this persons weight. The weight records only show the month that the person has been weighed. This could make it more difficult to get an accurate picture of variations in peoples weight. For example, someone could be weighed on the last day of one month and the first day of the next month and this would not be clear from the records. This was discussed. The records relating to personal care, such as when people have a bath were not up to date. This was discussed. Staff make daily notes about the peoples care, the entries were signed with the names of all the staff on duty rather than the name of the person making the record. This was discussed, the care records are a legal document and should be dated and signed clearly by the person making the record. Relatives told us they are kept informed about peoples care needs. However, there was very little evidence in the care records to show that people, or those close to them, are involved in drawing up their care plans. The records showed that people have access to a range of NHS services such as district nurses and GPs. The owners told us they are in the process of arranging NHS podiatry services for people. Private chiropody is available in the home. The home has a hairdresser who visits weekly, she was in the home on the day we visited and people were enjoying having their hair done. One relative said the cost of hairdressing has risen alarmingly, from 5.00 pounds to 12.00 pounds in one year. There was no evidence that peoples capacity to make decisions is assessed and recorded. The owners are aware this is an area that needs to be addressed. There was very little information about peoples wishes in relation to end of life care, Care Homes for Older People Page 14 of 27 Evidence: this was discussed. There are suitable systems in place to make sure that medicines are managed safely and that people get their medicines as prescribed. Staff who help people with their medicines have received appropriate training and more training was scheduled to take place in the new year. Care Homes for Older People Page 15 of 27 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are a range of activities for people to take part in and people are given the support they need to make the most of their abilities and follow their personal interests. Evidence: The three people who completed surveys for us said there are usually activities for them to take part in if they want to. Other people said the activities during the week are very good but felt the weekends could be a bit boring for people because there are not usually any planned activities. One relative told us they had paid for an entertainer to come in one weekend so that there would be something for people to do. The home has an activities organiser who works from 9:00 am to 4:00 pm Monday to Friday and he keeps people busy with a variety of activities. When we visited people were making Christmas decorations. The activities organiser keeps records of the activities people have taken part in and he told us he sets time aside to spend with people who do not take part in group activities for whatever reason. Care Homes for Older People Page 16 of 27 Evidence: The care records have a life history section to record information about peoples past lives, interests and hobbies. However, they were not completed in the care records we looked at. Talking to staff it was evident they know about people and respect their individuality, however, this information should be recorded to reduce the risk of peoples needs being overlooked. Throughout the day there was a lively atmosphere in the home and plenty going on to engage peoples interest whether they were taking part in activities or watching what was going on. There are communion services in the home once a month for people who want to attend. The home told us children from a local school would be coming in for a carol service before Christmas. There is one person of the Muslim faith in the home. He has a prayer mat in his room so that he can say his prayers in private and the owners were talking to him about plans to visit the Mosque. Visitors told us they can visit at any time and are always made welcome. People told us the food is good and they are offered a choice. People can have a cooked breakfast and there is a choice of a hot or cold meal at tea time. The lunch is usually a set menu but alternatives are provided if people want something different. There is a display fridge in the dining room where snack food is available all the time so that people can have snacks between meals, for example sandwiches and yogurt. The meal service at lunch time was well organised, the tables were set and food was presented nicely. People were helped or encouraged discreetly so as not to make them feel embarrassed. Care Homes for Older People Page 17 of 27 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable systems in place to make sure complaints are taken seriously and acted on and to make sure that people are protected. Evidence: The three people who completed surveys for us said they know how to make a complaint if they need to. People we spoke to said the new owners and staff are approachable and they are able to talk to them if they have any concerns. The home has a complaints file. This showed that they have had 2 complaints since the new owners took over. The complaints were dealt with appropriately and action was taken to resolve them. Before this visit we received information from an anonymous source which identified some concerns about the service. These concerns were looked at during the inspection and discussed with the owners. There are procedures in place to make sure people are protected. Staff have attended training on safeguarding (adult protection) and more training is scheduled to take place in the new year. Staff are aware of how to report any concerns or suspicions of abuse. The owners are aware of the correct reporting procedures and have made one safeguarding referral since taking over. Care Homes for Older People Page 18 of 27 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this 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 usually clean and provides a comfortable and safe place for people to live. Evidence: The home was clean when we visited. One relative told us the home is always clean and never has any unpleasant odours but another said that the lounge sometimes gets a little smelly. Two of the three people who completed surveys for us said the home is sometimes clean and fresh. The new owners have started to redecorate some of the communal rooms to make the home look brighter and fresher, this was in progress when we visited. They told us they plan to make further improvements to the building over the coming year. This will include improving the signage to make it easier for people to find their way around. The home has an enclosed garden and a patio area where people can sit out when the weather is nice, this is directly off the main lounge and is easy accessible. When we looked around we saw that some of the towels and bedding were showing signs of wear and tear, the owner said she would replace them. Care Homes for Older People Page 19 of 27 Evidence: Most people spend their days in the communal rooms and bedroom doors are locked during the day. Staff told us this is to stop people wandering into other peoples rooms and disturbing or taking their belongings. They told us this is discussed and agreed with people and people can have access to their rooms at any time. Some people have keys to their bedrooms, others do not. This is decided by a risk assessment. We saw that people are encouraged to have personal belongings in their rooms. This helps to create a more homely environment. Some of the toilet doors are painted yellow to help orientate people. Staff said this helps people to find their way around. The home has a stair lift to help people get access to the first floor. The home has been given a 3 star (the highest is 5) rating by Environmental Health for its standards of food safety and hygiene. Care Homes for Older People Page 20 of 27 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are usually enough suitably trained and experienced staff to meet peoples needs. People are protected because all the required checks are carried out before new staff start work. Evidence: People told us that staff are usually available when they need them. One person said all the staff are very friendly and you can approach them about any concerns that you may have. Another person said sometimes the staff are all in the dining room with no one in the residents area. There are usually three care staff on duty during the day and two overnight. The home also employees housekeeping and catering staff. There are some vacancies for care staff and the owners told us they are recruiting to fill these vacancies. In the meantime staff from the companys other home in Barnsley work at St Pauls Lodge if needed to make sure there are enough staff on duty. Staff told us they are currently doing updates on mandatory training, such as moving and handling and that they are given the training they need to care for people properly. This was confirmed by the training records. Staff said they enjoy working in the home, they said things were a bit unsettled for a Care Homes for Older People Page 21 of 27 Evidence: while when the new owners took over but said this has now settled down. Information provided by the home showed that 55 of care staff have achieved an NVQ (National Vocational Qualification) at level two or above. New new staff are enrolled on NVQ training when they complete their induction. We looked at the files of two new staff employed since the change of ownership. They showed that all the required checks are done before new staff start work, this includes PoVA (Protection of Vulnerable Adults) and CRB (Criminal Records Bureau) checks and two written references. Care Homes for Older People Page 22 of 27 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are suitable systems in place to make sure the home is properly managed. People are given the opportunity to share their views and contribute to the ongoing development of the service. Evidence: The home does not have a registered manager at present. The owners told us they are in the process of recruiting a manager, in the meantime they are providing management cover. The home completed an annual quality assurance assessment (AQAA) for us before the visit, it was sent back to us in good time and gave us the information we asked for. Staff told us they have attended training on the Mental Capacity Act and Deprivation of Liberty legislation and information is available in the home. This helps staff to make sure peoples rights are promoted and protected. Care Homes for Older People Page 23 of 27 Evidence: Since taking over the new owners have issued questionnaires to people to give them the opportunity to share their views of the service. We saw 5 completed surveys and they showed that generally people are satisfied with the service. They have also had a meeting with people using the service where the topics discussed included food and activities. People told us the staff and management are approachable and listen to what they say. The home holds some small amounts of personal money for people. All transactions are recorded and receipts are kept for any items purchased on peoples behalf. Information provided by the home showed that there are suitable systems in place to make sure health and safety are maintained. Equipment and installations are serviced at the required intervals. The annual gas safety check had been carried out but the certificate had not been issued when we visited. The owners agreed to provide us with a copy as soon as it is available. The owners told us that the fire officer has visited the premises and is satisfied with the fire safety arrangements. Care Homes for Older People Page 24 of 27 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 27 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 2 7 7 The care plans should provide clear information for staff on how to support people. Records relating to how peoples care needs are met, for example personal care records, should be kept up to date. Entries should be dated and signed by the person who has provided the care. Information about peoples social, cultural and leisure needs and interests should be recorded so that peoples individual needs are not overlooked. The home should be kept clean and free of unpleasant odours at all times. The owners should keep us informed about the management arrangements and when a new manager is appointed they should apply for registration with the Commission. 3 12 4 5 26 31 Care Homes for Older People Page 26 of 27 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 27 of 27 - 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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