Inspection on 12/01/06 for Arbour Lodge

This inspection was carried out on 12th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Arbour Lodge 23/05/08

Arbour Lodge 31/05/07

Arbour Lodge 06/08/06

Arbour Lodge 14/06/05

Arbour Lodge 01/11/04

Arbour Lodge 29/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Arbour Lodge Arbour Lodge 92 Richmond Road Compton Wolverhampton West Midlands WV3 9JJ Lead Inspector Mr Ian Harris Unannounced Inspection 12th January 2006 08:00 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 Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 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. Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Arbour Lodge Address Arbour Lodge 92 Richmond Road Compton Wolverhampton West Midlands WV3 9JJ 01902 771136 01902 565522 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) Arbour Lodge Limited Mrs Tania Mason Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (22). Dementia - over 65 years of age (7) of places Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1 2 All DE category service users must be accommodated on the ground floor. The agreed staffing levels are: 8am - 12 noon Senior Carer 4 care staff 12 noon - 6pm Senior Carer 3 care staff 6pm-9pm Senior Carer 4 care staff Night staffing 2 waking care staff Care Manager hours are supernumerary Separate catering/domestic/laundry staff/activity organiser must be provided in addition to care hours. These are minimum staffing levels - and must be increased in the event of any increase in dependency of service users accommodated. CSCI will continue to monitor the staffing levels and may require levels to be increased should CSCI feel that care needs are not being met. All care staff must complete agreed training programme before March 2006. Until such time as all staff have completed the required training, staff rotas must ensure that at least one member of staff that has completed the training is on shift at all times day and night. 3 Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 5 Date of last inspection 14th June 2005 Brief Description of the Service: Arbour Lodge is a large, semi - detached Victorian building which has been adapted to accommodate 29 older people in 27 single bedrooms and 1 double room. All the bedrooms have en-suites and will meet the National Minimum Standards. The home has a large garden at the front and side of the building and ample road parking. The home is situated in a residential area of Compton, approximately a quarter of a mile from the Compton shops. Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 4 hours. The fullest co-operation was given to the inspection officer by the Care Manager staff and residents. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 5 of the 19 care staff were on duty, and 8 of the 24 residents were spoken to. On the day of inspection the atmosphere within the home was found to be warm, friendly, comfortable and safe with contented residents. This was confirmed by the comments made by the residents spoken to that they were happy content and well looked after. What the service does well: What has improved since the last inspection? Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 7 The home has implemented all the outstanding recommendations contained in the inspection report dated 14th June 2005 and in addition have redecorated 5 residents bedrooms and provided new dining room furniture. 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. Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 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 Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 The home provides clear and accurate information to prospective residents on the services provided, enabling them to make a properly informed choice about the home. All residents are given a written contract on admission to the home. EVIDENCE: Each resident is provided with a detailed service users guide and statement of terms and conditions when they move into the home. Residents are encouraged to visit the home prior to admission. An introductory visit is always offered to prospective residents, on some occasions the visits are declined and relatives visit on behalf of the prospective resident prior to admission. A trial period is included in the statement of terms and conditions of residence and the homes contracts. It was confirmed by a resident recently admitted to the home that they had been invited to the home for lunch before moving in. A trial period is included in the statement of terms and conditions of residence and the homes contracts. Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 11 Each resident has a comprehensive, individual care plan that is reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. The systems for the administration of medication are good with clear and comprehensive recording arrangements are in place to ensure resident’s medication needs are met EVIDENCE: The home provides a comprehensive Care Plan for each individual resident based on the initial assessment. The Care Plans are drawn up by the Care Staff in consultation with the resident and their family. There was evidence on the files to show the care Plans are being carried out and reviewed on a monthly basis. Medication is administered by means of a monitored dosage system. The system appears to be working very well. The home receives good support from the local pharmacist who does a three monthly audit of the homes medication. All care Senior Staff have been trained to use the system before they are allowed to administer medication. The home has very good policies and Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 11 procedures, which are used as an integral part of the staff induction programme. All residents have single rooms with en-suite. No personal care interventions take place in communal areas. Observed practice on the day of inspection was appropriate and showed respect for the residents. Consultation with health care and social care professionals is carried out within the resident’s bedrooms. Visitors are able to meet residents in their bedrooms or the small quite lounge offers privacy when not being used. All staff have received induction and N.V.Q. training that covers these issues. Residents’ wishes with regard to terminal care and arrangements after death are obtained at the assessment stage, if possible. Family members are involved in these discussions if appropriate. Unless there are medical reasons for not doing so, service users are able to spend their final days in their own rooms. Where the needs of service users change, re-assessments are requested. The home has clear policies with regard to dying and death. The Care Manager and Care Staff are conscious of the need to provide extra support to the residents in their final days at the home. All the Staff are very aware of the need to be particularly sensitive, caring and attentive to the residents needs prior to their death. The care manager is also aware of the support the staff should provide to relatives and colleagues. Resident’s relatives are encouraged to be fully involved in the residents care at this particular time. All senior staff have received training on dealing with bereavement. Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 and 15 Staff work in close liaison with residents and their relatives to understand their individual lifestyles and preferences in order that these can be continued when they move the home. Individuals are enabled to exercise choice and control over their lives wherever possible balancing the rights and risks with each individual The meals in the home are good homely type offering both choice and variety and also catering for special dietary needs. EVIDENCE: The staff at the home encourage regular contact between residents and their relatives by inviting them to parties, fetes, outings and celebrations. It was noted, that approximately 6 residents are regularly taken out by their relatives. The residents and staff stated that the residents are consulted regarding the day-to-day running of the home through residents meetings, reviews and by feedback from their key-workers. The key-workers also identify interests that the residents wish to pursue. A number of residents stated that they had enjoyed the Christmas festivities particularly the food. Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 17 The home has a satisfactory complaints system and there is evidence that residents’ and their families feel that their views are listened to and acted upon All residents are assisted to exercise their legal rights, either by family, staff or where appropriate by an advocate. EVIDENCE: The home has a comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence and the service users guide. Also copies are placed on the notice board in the hall. The home has a complaints book in which all complaints are recorded. It was noted that the home has not received any formal complaints since the last inspection all minor complaints are dealt with appropriately and quickly. Residents are assisted to exercise their legal rights, either by family, staff or where appropriate an advocate. All residents have been placed on the electoral role. They may vote if they wish either by post, or they are assisted to go to the polling station if this is requested Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The standard of the environment is high providing service users with a safe well-maintained environment to live in. The standard of cleanliness reflects the on-going cleaning schedule, which maintains a high standard throughout the home. EVIDENCE: The home offers a comfortable and well-maintained environment to all residents. The home has ample communal space - three lounges and dining room. The home is safe and is suitable for its stated purpose. The home has an ongoing rolling programme of redecoration to maintain good standard. The garden/patio and grounds are also being well maintained for the use of service users. All the bedrooms have en-site facilities. There are adequate communal toilets, bathrooms and washing facilities. The home has undertaken an assessment of the premises and facilities by an occupational therapist. The home has also provided suitable aids and adaptations in the home to meet the general and specific needs of all residents. There is good standard of furniture Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 15 and fittings provided in the service users’ bedrooms. It was also noted that the bedrooms have been personalised by the service users. During the inspection the home was found to be clean and tidy and free from any unpleasant odour. The home has good policies and procedures, regarding infection control, and all staff has received in-house induction training in infection control and they are made aware of the dangers of cross-infection. Several members of staff have also attended the formal infection control training. Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29 The home is well staffed with adequate numbers and skill mix. The home has good policies and procedures regarding the recruitment of staff, which are being followed. There is a good training programme in place that ensures that the staff are competent to do their job. EVIDENCE: The inspection of staff rotas and discussions with staff indicated that the home is well staffed. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. The sickness level of staff is low and so is the staff turnover. The home operates an efficient procedure and has registered with the West Midlands Care Homes Association in order to complete the appropriate checks on staff. There was evidence within the home that all the checks are being carried out. All staff at the home are committed to developing their knowledge and skills through training and have regular opportunities to do so through external and internal training activities. The home has a programme of N.V.Q. training has now exceeded the minimum standard and all but one care staff have now completed N.V.Q. level 2 or 3 training. Also the care staff have attended courses on Safe handling of medication, Risk assessment, Dementia care, and Moving and lifting, First Aid, Infection Control and Fire Prevention. Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 36 and 37 The home is a well managed one, where service users interests and welfare are well processed and promoted. EVIDENCE: The Care Manager is a highly qualified in both practice and management and has considerable experience in caring for older people in a residential home setting. There are clear lines of accountability within the home and the manager is well supported by the proprietor. Observations made and discussions with residents and staff indcated that the Care Manager is very approachable and operates an open door policy and is proactive in meeting all the residents on a daily basis. The staff and residents who could express themselves stated that they are happy to approach the Care Manager with any problems they might have and are confident that they will be resolved. The home has introduced a quality assurance system into the home to monitor performance and has also achieved the Investors In People Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 18 Award. The home has a formal supervision system in place and there is evidence on file that supervision meetings are taking place. All the Financial records and administrative procedures within the home that were, inspected were found to be well ordered and maintained Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 19 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 3 3 X 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 3 X Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP30 Good Practice Recommendations The Registered Provider should consider providing training courses for staff in Dementia, disability awareness and adult protection from all forms of abuse. Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: 0845 015 0120 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 Arbour Lodge DS0000020879.V261533.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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