Inspection on 11/07/08 for Totham Lodge

This is the latest available inspection report for this service, carried out on 11th July 2008.

CSCI 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.

Other inspections for this house

Totham Lodge 27/07/06

Totham Lodge 08/12/05

Totham Lodge 21/07/05

Totham Lodge 03/03/05

Totham Lodge 22/10/04

Totham Lodge 30/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 30/01/2009.

CARE HOMES FOR OLDER PEOPLE Totham Lodge Broad Street Green Road Great Totham Maldon Essex CM9 8NU Lead Inspector Sharon Thomas Unannounced Inspection 11th July 2008 12:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Totham Lodge DS0000017982.V369497.R02.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Totham Lodge Address Broad Street Green Road Great Totham Maldon Essex CM9 8NU 01621 891209 01621 893582 page@tothamlodge.wanadoo.co.uk 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) Mrs Maureen Page Mrs Joanne Wells Care Home 28 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (14), Old age, not falling within any other of places category (28) Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 28 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 14 persons) The total number of service users accommodated must not exceed 28 persons One named service user, under the age of 65 years, who requires care by reason of dementia whose name was provided to the Commission in February 2007 21st June 2007 Date of last inspection Brief Description of the Service: Totham Lodge is a large fully detached grade 2 listed property. The home was built in 1830 and was originally used as a hunting lodge. It is situated in a rural location accessed by a long private gated driveway. Accommodation is provided on two floors, in nineteen single and four shared rooms. All but two bedrooms have private en-suite wcs. Communal areas comprise of the large inner hallway sitting area, an inner conservatory, a large lounge/dining room and a small dining/sitting room, all on the ground floor. Access between floors is provided by a passenger shaft lift. Totham Lodge is set in approximately thirty-five acres of grounds, all enclosed. Many rooms in the home benefit from views of the grounds and surrounding countryside. Ample visitor car parking is available to the front of the property. Totham Lodge DS0000017982.V369497.R02.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 2 star. This means the people who use this service experience good quality outcomes. A range of evidence was looked at when compiling this report. Documentary evidence was examined, such as menus, staff rotas, care plans and staff files. The manager completed an Annual Quality Assurance Assessment with information about the home. This document will be referred to as the AQAA throughout the report. An unannounced visit to the home took place on 11th July 2008. The manager of the home is on maternity leave and does some of her work from home. The bulk of the management responsibility of the service is undertaken by the home’s care co-ordinator, and the owner of the home. On the day of the inspector’s visit the atmosphere in the home was relaxed and welcoming and we, the Commission for Social Care Inspection (CSCI), were given every assistance from the acting manager, the proprietor and the staff team. The visit included a tour of the premises, discussions with people living in the home, the acting manager, members of staff, two visiting relatives and a visiting GP. Observations of how members of staff interact and communicate with people living there have also been taken into account. During the visit people living in Totham Lodge and members of staff were spoken with and their comments are used throughout the report. If you would like to know how people are cared for and supported in Totham Lodge you can read the inspectors report. You can ask the person in charge of the home for a copy, or contact the inspector. What the service does well: Totham Lodge is a large country property that is conducive to a family type home. The home is clean and hygienic and the atmosphere is friendly and relaxed. Staff are friendly and helpful and generally know the people who live there, most having worked at the home for a number of years. Feedback from relatives indicated they appreciated the culture of the home “the home is run as one big family and does not feel like an institution, which I find very comforting”. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 6 The proprietor and acting manager are accessible to individuals and relatives. One relative stated, “The [acting manager] listens and deals with issues that we have raised, in a positive manner”. The standard of personal care and health care are generally good and there are good links with GPs and district nurses who provide health care at the home. People are treated with respect and have some choice and dignity through their daily lives. What has improved since the last inspection? What they could do better: This inspection identified a number of minor regulatory shortfalls that must be addressed for the well being of people living in the home. These shortfalls are identified from viewing a random selection of records, from discussion, from completed surveys and from direct observation. Details of the above have been detailed within the body of the report and are summarised in this section. The home has to develop the pre-admission procedure to ensure that the management gathers all relevant information to enable them to admit people who they can be sure that they can provide a service to. Record keeping relating to care plans and risk assessments is not well organised and does not reflect or support the good standard of care that is actually provided by the home. Activities should be developed to meet the abilities and preferences of each person, and staffs’ skills in meeting these should be developed and supported. The overall eating experience in the home is not altogether positive. The meal times must be a pleasant experience where people are not rushed. People in the home must have input into menu planning, and people must be given more menu choices. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 7 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. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 & 6: Quality in this outcome area is good. People choosing to live at Totham Lodge receive sufficient information about the home and in general may be confident their needs will be assessed before admission. Totham Lodge does not provide intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s pre-admission needs assessment document is unchanged. This included assessment headings of: mobility, toilet needs, continence, dressing, eating/feeding, washing, bathing, speech, sight, hearing, memory, orientation, awareness, behaviour, social needs, breathing, travel needs, sleep, oral health, diet, weight, dying, personal safety, hobbies. The proprietor says that the manager or acting manager would be responsible for the pre-admission procedure. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 10 The care files and pre-admission of the three newest people choosing to live in Totham Lodge were looked at. One of these had all of the information relating to a good admission process. However, the other two care plans did not contain a sufficient degree of information. One care file did not contain a Social Service assessment and the information gathered by the home in their own pre-admission document was limited and lacked the detail that would be needed to make sure that the home could meet the persons needs. The other did not have a full range of pre-admission information resulting in a care plan that was also limited in its content. Neither of these care files had a photograph of the person in place that could be used to identify the person if required. Written information is provided to people thinking of coming to live in the home detailing the services and facilities available to them. Staff spoken with stated that they were generally happy with the information they receive when someone is admitted to the home, but said that sometimes there is not enough information and that they have to “muddle through until they get to know the person”. The manager’s AQAA states, “A full assessment of needs for each prospective service user is undertaken by the proprietor and the manager or care coordinator. This is done at the service user’s home or in hospital in the presence of the service user’s representatives and any relevant professionals. This assessment covers all aspects of care for the prospective service user including social interests, hobbies, religious and cultural needs and a care plan is generated out of this assessment. We carry out our own assessment regardless of whether the individual has a care assessment from a council or health body and we do not usually take in emergency admissions”. Generally the AQAA reflects what we found relating to this outcome group on the day of inspection. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10: Quality in this outcome area is good. Generally people can be confident that their personal and healthcare needs will be met in Totham Lodge and they may be confident that they will be treated with respect. However, People cannot always be assured that their care plan documentation will identify all of their care needs and that those needs will be met. Neither can they be assured that their risk assessment documentation is thorough. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three care plans were sampled at random as part of this inspection. Care records showed that further development of the management team’s care planning and risk assessment processes is needed. Staff, need to make sure that individual’s needs are fully recorded and detail the interventions required so as to ensure that the correct care is provided. Overall the care plans covered peoples needs and wishes but if a little more information were to be added, staff would be able to provide an even better quality of care than they currently do. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 12 Some areas of the care plans were noted to be general and given this there is a potential that the care provided by staff may not be in line with people’s specific care needs. Identified shortfalls in care planning was discussed with the care co-ordinator and the owner. This included the care plan for those people who are demonstrating some signs of dementia. The management team must consider how dementia and other conditions associated with older people impact on the individual person and their daily living skills. However, we found that one care plan for a person with some mental health issues, contained information relating to their condition and a risk assessment was in place, but, there was less information regarding this persons other needs and although the individual was subject to other risks the care plan did not contain risk assessments for these. The records for one person with a specific health issue indicated that there was no care plan devised identifying how their physical condition impacted on their daily life, the symptoms it presented, or the care that staff are required to provide. We had a discussion with the proprietor of the home who assured us that the care plans would be reviewed as a matter of urgency and changes would be made where necessary. Two people living in the home stated that they were “very happy” with the care that they receive and that “although staff are stretched they get around to us in the end”. One relative spoken with said “we cannot fault the care here sometimes staff are slow to do things but they get done in the end” while another said “carers are generally kind and helpful but on occasion I am not so confident that they know what [relative] really needs, they seem to do a bit of guessing”. It must be noted from discussion with the staff on duty it was clear that they knew the needs of the people living in the home and are able described the care that they needed in detail, this wealth of information should be documented for use by other people working in the home. The manager’s AQAA says, “Every resident has a very comprehensive care plan which is generated from the pre-admission assessment. The care plans include general risk assessments as well as risk assessments for manual handling, pressure sores, and falls. The plans are reviewed at least monthly and are updated every time a resident sees the GP or the visiting optician or dentist. They include hospital visits and all aspects of care for the resident including specific daily needs and oral and foot care”. The above information contained in the AQAA is not reflected in the documentation that we saw in examination of care plans on the day. Generally the care plans contained information relating to people’s healthcare needs but some of the entries were vague and follow up actions were not Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 13 recorded leaving staff not knowing what had happened with a particular situation, however the proprietor confirmed that staff are aware of the changes through the hand over process and recorded in the home’s handover book. Within the care plan documentation there is a place to record visits health care professionals. There had been some recent entries. The acting manager said that the home has a good working relationship with local health care professionals. Relatives spoken with are confident that their relative’s healthcare needs would be dealt with in a professional and timely manner by the staff team. The managers AQAA says “We have a very good relationship with our local GP. Our local pharmacy delivers new medications on the day they are ordered as well as collecting unused supplies. We also have a good relationship with our district nurses who offer invaluable advice and provide pressure relieving aids and equipment. We are regularly visited by the continence advisor who provides close support and advice and annual re-assessments are compiled for all residents with continence support needs. Service user’s psychological health is monitored regularly and Community Psychiatric Nursing and Consultant Psychiatric support is on-going to residents in need of this service”. The home’s medication records and medicines round, was observed throughout the day. It was positive to note that medication was administered professionally to people. The home’s policy on the storage, administering and returning unused medication was seen. This includes written guidelines regarding receipt of new supplies, administration and returns of unused stocks. The home does not have suitable storage in place for controlled medication that needs to be stored and recorded separately. The home must follow the correct guidelines and have controlled drug cabinet installed and a controlled drug register for use. It must be noted that at the point of publishing this report it was confirmed that the home has installed a controlled dug cabinet and register for use. Medication administration records were inspected, and there was one gap in recording of administration. Only senior staff deal with medication and they must sign each shift to accept responsibility for the safe keeping of keys to medication supplies. One senior staff spoken with demonstrated an awareness of good practices around the storage and administration of medication. We observed medication being administered by this member of staff, who explained to the person what they were being given and encouraged them to take a drink with the medication. The acting manager takes overall responsibility for ordering and checking-in delivered medication and staff receive in-house training. At the time of the inspection no one living in the home administered his or her own medication. The manager’s AQAA says that “We have the appropriate policies and Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 14 procedures for dealing with medicines and staff administering them have received certificated training on safe handling of medicines”. The manager states in the AQAA that people are treated with respect at all times and are addressed by staff by their chosen name. Observations on the day of the inspection confirm that staff are courteous and treat people with respect. Staff spoken with demonstrate a positive attitude and affection for the people they are caring for. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. Generally people living in Totham Lodge have opportunities to maintain a lifestyle that meets their needs and wishes. Generally people have a varied diet that most enjoy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The sample of care plans we looked at showed us that generally there is some information regarding peoples’ personal and social histories, personal choices, and daily social routines. Because of this it is difficult to assess how well the daily routine caters for the individuals’ needs and choices. No in-depth assessment of social need is evident in care plans although people’s participation in activities is recorded. The proprietor says that there is a formal daily programme of activity some of it specifically tailored for people with dementia. People in the home are aware that activities take place but two people said that they get confused as to what is on offer. While one relative said that “there is always something going on”. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 16 Totham Lodge offers people weekday activities including exercise, bingo, and board games afternoon. One person spoken with said that “I don’t take part in the activities on offer but that is my decision and I could if I wanted” and another said, ”the staff try their best to keep us entertained, the birthdays are well celebrated”. Relative comments and staff spoken with indicated that the service encouraged relatives to maintain an active role in the peoples’ lives following admission. One relative said the home always provides a warm welcome, and they are able to visit family members or friends in private. Several visitors were observed to visit the care home on the day of inspection. Staff, were observed to have a good rapport with visitors. One visitor spoken with advised that they were always made to feel welcome by staff and confirmed that they could visit their member of family at any time. Generally, people were observed to be able to move around the home and involve themselves in activities and routines they felt happy doing. Relatives surveys confirmed this and stated, “staff always speak, smile and make one welcome” and “staff are always very helpful and always seem to make you welcome when you visit”. People spoken with were generally positive about the food that they have in the home. The chef on duty has the skills and knowledge around providing nutritional appetising meals. Food stores were examined and there was evidence of a variety of fresh food available. However, a variety of food stocks were low and were ‘value’ brands. The chef stated that the home was never without food stocks. The menu was examined and does not in itself show that a choice of food is available. On the day of the inspection the home served ‘takeaway’ fish and chips that was enjoyed by the majority of the people eating it. Some people did have the alternative, which comprised of mashed potatoes, tinned tomatoes and fish. This meal did not look appetising and when questioning staff it was agreed that the meal did not look or taste appetising. The staff said that this is what people chose; however there was no evidence that people did choose this meal or evidence of how or by whom this decision was made. One member of staff when discussing the lunchtime meal arrangement described people who need support with eating the ‘feeders’ this term is wholly inappropriate and has the potential of negatively labelling people who have less capacity to support themselves. The dining room has an open plan layout, which ensures that meals are served up fresh and hot. We saw that mealtimes for people at Totham Lodge is a sociable occasion with some people enjoying their meal and chatting. The staff assisting people with their meal sat quietly beside the person, offering them discreet support. However, one member of staff stood over a particular individual and ‘spoon fed’ them, not telling what they were doing or why, in due course the person became agitated and left the dining area in a state of distress throwing the food into a nearby bin. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 17 Two people spoken with said that the meals in the home varied some were “good and some not so” and “it depends on the day, we get enough to eat but sometimes it is cheap and tastes bland”. A visiting relative said, “the food is marvellous with a good choice and loads of it”. The manager’s AQAA says “We provide good, home-cooked food and our main cook is very experienced having been with us for 20 years. Staff are always available at mealtimes to offer assistance and support. Our satisfaction surveys show that meals are generally rated as good or excellent. Nutrition records are kept including portion sizes eaten”. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. The home has People who use the service have access to an effective and understandable complaints procedure that ensures that they are listened to. There are procedures in place to protect the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure that is included in the statement of purpose and service user guide. Feedback received from relatives indicated they knew there was a complaints procedure and who to refer to if they had a complaint. People living in the home who spoke to us were clear that they felt able to tell someone if they had any concerns. Since the previous inspection one complaint had been received by the home and this was dealt with in a professional manner in a timely fashion. Training records suggest that the majority of staff working within the home have received training in protecting/safeguarding vulnerable people. Some of the training was noted to have been undertaken 2-3 years ago and for some people this was planned for September/October 08. One member of staff questioned was able to demonstrate an understanding of safeguarding procedures and issues. The home has a sound set of policies and procedures relating to this issue and these are available to staff. The acting manager Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 19 discussed the action that she would take if an allegation were made and she confirmed through this discussion that she is more than capable of dealing with a situation should one arise. The manager’s AQAA says that “I feel that we do everything we can to achieve this outcome. More staff have received P.O.V.A training and have had refresher training. The proprietor and care co-ordinator have attended a conference on abuse. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager’s AQAA says” Totham Lodge is a Grade 2 listed building set in spacious and peaceful grounds. There is an enclosed area of garden suitable for residents with dementia who are prone to wandering. “We keep our home clean and tidy and well decorated”. “50 members of staff have recently been on an infection control course”. There is a handy man to carry out minor repairs and a maintanence book is in place. A partial inspection of the premises was made that included communal areas, bathrooms, a number of peoples’ rooms, the kitchen, sluices, and the laundry. There have been improvements made since the previous key inspection including covering all of the radiators in the home and 5 en-suites have been Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 21 refitted and decorated. While three bathrooms have been replaced, new carpets have been fitted to the stairs, landing and main lounge. Of those peoples bedrooms inspected, all were seen to be personalised and individualised with many personal items displayed. In general terms the home was observed to be clean and tidy and there were no unpleasant odours except within one bedroom. People living in the home were positive about their environment and described it as “homely” and “comfortable”. Relatives of people living in the home said,” my [relative] room is always clean and the home is always tidy” and “it feels like home here, I love it” and “ not all of it is great to look at but this is like a family home and it is relaxing and comfortable”. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. People living in Totham Lodge benefit from an established staff team. Training for staff is satisfactory and the recruitment procedure in the home provides the safeguards that makes sure that appropriate staff are employed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three members of staff spoken with were positive about working at Totham Lodge. One person said, “working here is rewarding, it is a relaxed home. There are good relationships between staff” and “the acting manager is good and she is never too busy for anyone”. The staffing rota indicated that the staffing levels were appropriate for the number and needs of the people living in the home. The rota did not fully record who was on duty at any time with particular regard to the registered manager. The home must keep an accurate record of who is working in the home and when. It was noted that the home does not use agency or bank staff this was reflected in the number of hours that some staff work. The home employs eighteen care staff ten of who have NVQ level 2 training or above. The percentage of staff with NVQ level 2 training was in excess of the 50 recommended. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 23 The recruitment process used in the home is thorough and robust. The personnel files of three of the most recently employed staff were inspected. All contained evidence that the required checks had been obtained (two satisfactory references, CRB/POVA checks) and copies of birth certificates, passports, and photographs obtained before the individuals commenced employment at the home. The staff training records we looked at did not accurately reflect the training that staff had been provided with. According to the records the home does not offer a full range of appropriate training that would give staff the relevant skills, but from discussion with staff appropriate training is provided on a regular basis. The home provides staff with moving and handling training, continence promotion, safeguarding adults, dementia, and first aid as well as induction training when initially employed. The manager’s AQAA says “Totham Lodge is staffed by well-trained, competent and caring people and many staff have been with us for a long time and are very experienced. 8 staff members have been with us for between 4 and 7 years. 75 of our staff have either gained an NVQ in care or are working towards one and we have an induction training package which covers the Common Induction Standards as well as training specific to Totham Lodge. Our Household Supervisor has gained an NVQ level 2 in cleaning and we employ extra staff for cleaning, cooking, kitchen, laundry and maintenance as well as a care co-ordinator and an administrative manager, in addition to the registered manager and the registered provider. As is evident from the number of staff with NVQs our staff are eager to improve their skills and participate in training and they receive a minimum of 3 days paid training a year. The registered manager is an NVQ assessor and a moving and handling and POVA trainer. The registered provider is also a POVA trainer”. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Totham Lodge is competently managed and run in the best interests of the people who live there. The health and safety of individuals living and working there is promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager remains on part time maternity leave. As previously stated the care co-ordinator has been in an acting management role. The staff and relatives visiting the home have a great deal of respect for the acting manager and made positive comments throughout the visit about her skills and knowledge. The proprietor agreed to write to us at the CSCI to clarify the management system being used in the home at this point in time. Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 25 On the day of the inspection the Quality Assurance system was discussed with the acting manager. Records confirm that there is a process in place for gaining the views of people using the service. Surveys are sent to relatives and a few were completed and returned. The registered manager and proprietor examine these and act upon any information that they receive that may improve the service. Records examined also confirm that staff meetings and residents’ meetings takes place. The acting manager confirmed that the service does not manage anyone’s finances. Records examined show that appropriate maintenance checks are carried out. These include a Portable Appliance Testing certificate, emergency lights, electrical installation, gas certificate, lifting equipment, bath seat lifter and a current Local Authority environmental services premises inspection. The manager’s AQAA says that “I am the registered manager and I have been working at Totham Lodge for 11 years. I therefore have experience of each role in the structure of the workforce and know how to set achievable and realistic goals. I have gained the City and Guilds Advanced Management in Care Award and NVQ Level 4 in Health and Social Care as well as the D32, D33 NVQ Assessors Award. I am also a Moving and Handling and POVA trainer. We seek the views of service users and relatives when monitoring systems that are in place to measure our success in meeting the aims, objectives and statement of purpose of the home and we summarise the results of quality assurance surveys and implement action plans for improvement. We adhere the standards regarding financial procedures and service users money and record keeping and staff are appropriately supervised. Staff are trained in moving and handling, first aid, fire safety, food hygiene, health and safety and infection control and all equipment in the home is tested at appropriate intervals. Totham Lodge DS0000017982.V369497.R02.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Totham Lodge DS0000017982.V369497.R02.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. 1. Standard OP3 Regulation 12,13,15. Timescale for action Every person choosing to live in 31/10/08 the home must have a detailed pre-admission document in place. This document must include all aspects of health and welfare, social, emotional and mental health issues, and medication administration. Care planning used in the home 31/10/08 must identify, and be effective in meeting all peoples’ assessed needs and ensure that these are regularly updated to reflect the most up to date information. The overall eating experience in 31/10/08 the home must be improved. The meal times must be a pleasant experience where people are not rushed when eating. People in the home must have input into menu planning, and people must be given more menu choices. Requirement 2. OP7 15(1)(2) 3. OP15 12 (1) (a) & (b) Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 28 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 OP12 Good Practice Recommendations Activities provided in the home must be suitable for all of the people living there. Particular regard must be given to people with dementia and activities must provide social stimulation at their level of understanding. As a matter of good practice risk assessments must be completed for all areas of assessed risk so that the risk to people can be minimised and staff can offer safe and effective care to people living in the home. 2. OP7 Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Totham Lodge DS0000017982.V369497.R02.S.doc Version 5.2 Page 30 - 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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