Inspection on 06/08/06 for Arbour Lodge

This inspection was carried out on 6th August 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 12/01/06

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 Key Unannounced Inspection 6th August 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.V297468.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V297468.R01.S.doc Version 5.2 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 Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (22) of places Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 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 - 12noon Senior Carer 4 care staff 12noon - 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. Date of last inspection 12th January 2006 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. It was noted that the fees per week range from £336 to £395 Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 5. hours in the presence of the Deputy Manager. 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 and the last reports of the Fire Prevention Officer and Environmental Health Officer were concidered. 3 members of staff 6 residents were spoken to. What the service does well: On the day of inspection the atmosphere within the home was found to be warm, friendly and comfortable with contented residents. All the residents spoken who could express themselves in a meaning full way expressed their satisfaction with the care they received and there were comments as follows “ the food is good here” “I have been in three homes but this is the best” “ The staff are very good they I only came for a short stay but I will be staying here for good” and 2 residents said “this is a very nice home.” Arbour Lodge continues to provide a high standard of care. The home communicates well with families/friends and representatives. The visitors’ book indicated a lot of activities. The residents spoken with said that they are content, happy and enjoy living in a homely and caring home. Residents were in three lounges/sitting areas engaging in their daily activities and they further commented that they were comfortable and satisfied with the care provided. The Care Manager and staff are to be commended on their efforts to encourage the residents to maintain their independence through social activities both within and outside the home. Observations during the inspection saw very attentive staff providing for the individual needs of the residents. A number of residents confirmed that the care staff are very supportive and caring. The home has a very good staff- training programme, which all staff are involved in, this ensures that they are improving their knowledge and skills to meet the changing needs of the residents. Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 7 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.V297468.R01.S.doc Version 5.2 Page 8 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): 3 and 6 The home has a satisfactory admissions procedure ensuring the individual needs of the residents are fully met. The home does not provide intermediate care they only provide short stay and introductory stays when the home has a vacancy. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: All the residents who are funded by the Local Authority undergo a full multidisciplinary assessment prior to admission. The residents’ who are self funding are assessed by the Care Manager, using the homes assessment forms. Copies of the assessment, Care Plan and Reviews are on the residents’ files. The Six residents files and care plans inspected contained pre admission assessments of the persons needs, both from assessments by the home’s staff and other relevant professionals. Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 9 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, 8, 9, and 10 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 being in place to ensure resident’s medication needs are met. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. 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. Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 10 The home is well supported by local G. P. s. and all of the paramedical services. Wherever possible, the residents are encouraged to retain their own G. P s, Opticians, and Dentists. It was noted that if the resident has moved out of their area the Care Manager ensures that, these services are provided by local practitioners. The records indicate that resident’s medical needs are being met this was confirmed by a number of residents and through observation on the day of inspection. A number of residents stated that the staff arrange hospital visits and G.P. visit and that they feel that their health is much better since coming into the home. Medication is administered by means of a Boots monitored dosage system. The system appears to be working very well. The home receives good support from the Boots pharmacist who visits the home every three months to check the system and offer advice and training. All Senior Staff have been trained to use the system before they are allowed to administer medication and are currently under going a Safe Handling of Medication training course. The home has very good policies and procedures, regarding the administration, storage and recording of medication. 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 quiet lounge on the ground floor offers that privacy when not being used. It was observed that residents’ were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. Those residents and spoken to were complimentary regarding the quality of their lives at the home. Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 11 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): 12, 13, 14, and 15 The home provides a good programme of social activities within the home, which are designed to meet the resident’s capabilities, which, the staff encourage residents to pursue. The Care Manager and staff encourage family and friends to maintain good contact with their relatives at the home. The meals in the home are good offering both choice and variety and also catering for special dietary needs. The quality outcome in this area is adequate. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The routines and activities within the home are flexible and are built around the needs of the residents. There was also evidence to show staff do consult with the residents regarding the choice of meals and activities within the home through residents meetings and via. The key-workers. The home has a staff member designated to organised social and leisure activities and who identified interests that the residents wish to pursue. It was also noted that the home Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 12 organise entertainment delivered by external entertainers. Comments from residents regarding these activates were very good and it is obvious that the residents benefit from them The records of activities enjoyed by the service users are being appropriately maintained. The residents keep contacts with the local community facilities – for example, some are escorted to, local shops and the park. The staff encourage regular contact between residents and their relatives by inviting them to parties, fetes, outings and celebrations. It was noted that approximately 16 resident’s are regularly taken out by their relatives. All residents were very complimentary about the standard and choice of food provided. It was apparent that the menu is changed to incorporate seasonal changes. Several service users told the Inspector that the food was nice, tasty and well prepared. The kitchen is well equipped, kept clean and tidy. The catering staff are trained in food safety and hygiene matters. Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 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 18 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 The home has good policies and procedures regarding protection from abuse, which includes a whistle blowing policy. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home has a very good comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence, the service users guide, which a is issued on admission to the home. A copy is also placed in the reception 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. The home has good policies and procedures regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which, includes a WhistleBlowing policy. These issues are also covered in internal and N.V.Q. training, which all care Staff is undergoing. Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 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 within the home is good providing the residents with a comfortable, homely and safe place to live. The home was found to be clean tidy and free of unpleasant odour. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home is long established and has undergone alterations over the years in order to provide appropriate accommodation for 29 older people. All the bedrooms are of good size with en-suite facilities. The home is maintained to a good standard. It was noted that 2 bedrooms, 2 lounges have been redecorated. New dining room furniture has been purchased and a new bin store created. It was also noted that the dining room floor covering needs replacing with more suitable floor covering and the dining room and ground floor corridors should be redecorated. Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 15 The home was found to be clean and tidy and free from odour. The home has good policies and procedures regarding infection control and the staff have received training in food hygiene and Infection Control. From observations and discussions with staff they appeared to be conscious of the dangers of cross infection. Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 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, 28, 29, and 30 The home is well staffed with adequate numbers and skill mix of staff. The staff have a very good understanding of the residents support needs. The home has good policies and procedures regarding the recruitment of staff. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. 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. It was noted that there have been minimal staff changes since the last inspection The home operates an acceptable recruitment procedure. On inspecting 6 staff files, there was evidence within them that all C.R.B. checks are being carried out. The Care Manager and staff are committed to developing their knowledge and skill through training. The home has a very good training and induction programme programme. The home now exceeds the 50 N.V.Q. trained care staff. In addition to the N.V.Q. 2, 3 and 4 training programme all of the care staff have attended training courses on the following subjects. Safe handling of medication, Risk assessment, Dementia care, Manual Handling, First- Aid, Health and safety, Disability awareness, Infection control and Fire Prevention. Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 17 Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 18 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, 33, 35, and 38 The home is well managed, where service users interests and welfare is promoted. The home is operating a good system to assist residents with the safe handling and keeping of their personal finances and good records are being kept of all transactions made. The records inspected, were found to be well ordered and maintained. The home has good policies and procedures regarding Health and safety The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home is well managed by the Care Manager who is qualified in both practice and management and has considerable experience in caring for older people in residential homes There are clear lines of accountability within the home and the manager is very supportive of both staff and residents. Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 19 Observations made and discussions with residents’ and staff indicated that the Care Manager is very approachable and operates an open door policy. The staff and residents who could express themselves stated that they are happy to approach the Care Manager and staff with any problems they might have and were confident that they would be responded to. There is a good staff supervision system in place and there is evidence that the staff have regular supervision meetings. It was also noted that the home has a Quality Assurance system in place, which includes a monthly internal audit and questionnaires to residents, visitors and relatives to obtain feedback on the quality of service. The feedback from the last issue of questionnaires was very positive with all feedback stating they are satisfied with the care they are receiving. The home has also been awarded The Investors In People award this year. The routines and activities within the home are flexible and built around the needs of the residents. There was also evidence to show that staff consult with the residents regarding the choice of meals and activities. All the Financial records and administrative procedures within the home that were, inspected were found to be well ordered and maintained. The home has a good heath and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training on these issues. All recommendations and requirements made at the last inspections of the Fire Prevention Officer and Environmental Health Officer have been actioned. All safety equipment is regularly checked and well maintained. Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 20 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 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? 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 OP19 Regulation 23 Requirement The registered person must ensure that the Dining room and ground floor corridors are redecorated. The registered person must ensure that the floor covering in the dining room is replaced Timescale for action 01/12/06 2 OP19 23 01/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Arbour Lodge DS0000020879.V297468.R01.S.doc Version 5.2 Page 22 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.V297468.R01.S.doc Version 5.2 Page 23 - 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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