Inspection on 24/08/05 for Athorpe Lodge

This inspection was carried out on 24th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Athorpe Lodge 12/03/09

Athorpe Lodge 12/06/07

Athorpe Lodge 23/11/05

Athorpe Lodge 24/03/05

Athorpe Lodge 11/10/04

Athorpe Lodge 26/02/04

Athorpe Lodge 27/05/03

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

CARE HOMES FOR OLDER PEOPLE ATHORPE LODGE Off Falcon Way Dinnington Sheffield S25 2NY Lead Inspector Rosemary Reid Unannounced 24 August 2005 10:00 th 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 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. ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Athorpe Lodge Address Off Falcon Way Dinnington Sheffield South Yorkshire S25 2NY 01909 568307 01909 563880 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Athorpe Care Limited Manager has been appointed Care Home with Nursing 89 Category(ies) of DE Dementia: 12 registration, with number OP Old Age: 77 of places PD Physical Disability: 77 ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. A separate unit is maintained for those users in the DE category 2. To allow a named service user under the age of 65 who requires personal care as a result of a physical disability to be admitted. Date of last inspection 24 March 2005 Brief Description of the Service: Athorpe Lodge is situated in the ground and at the rear of Dinnington Hall in the village of Dinnington. Athorpe Lodge is a purpose built home providing for 89 elderly people in need of care due to infirmity or dementia. The home provides personal care and nursing care in five units with a separte unit for people who have dementia. All bedrooms are for single occupancy with ensuite facilities. The home is contructed at ground and first fllor with a shaft lifts for ease of access fro residents. The home has its own garden are, which is separated from Dinnington Hall by wooden fencing and gates. There is a car park to the side of Dinnington Hall. Local facilites are within easy access from the home. ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 24th August from 10:00am to 16:35 and 25th August from 11:00 – 13:00. The home has had previous unannounced inspection in March 2005. Mrs Melanie Phillips had been appointed on the 13th June as manager and the Commission is processing this application. Five staff, four residents and three relatives were spoken with and the residents on Taylor, Cedar and James Payne units were observed for the majority of the inspection. A poster was placed in the entrance of the home to inform residents, staff and visitors to the home that an unannounced inspection was taking place. Comment cards and prepaid envelopes were left at the home so that service users or their representatives can contact the CSCI with their views about the home. At the time of writing no comment cards have been received from residents or relatives at the Commission’s office. All of the relatives spoken with had positive comments about the care their relative received. The comments from staff indicated that they felt supported by the new manager and said, “She is very fair”. There were no requirements from the previous inspection. The inspector focused on the four residents files from the units on the ground floor were case tracked along with medication, complaints, staffing rota, the environment and Adult Protection issues. Feedback was given at the conclusion of the inspection on the first with the manager and the Operations Director What the service does well: The staff at the home undertake in depth pre-admission assessments and at admission into the home for the benefit of each of the residents. Potential new residents are offered introductory and trial visits at the home to familiarise themselves with the environment, other residents and staff group before they make the decision to come to Athorpe Lodge. Each service user has a comprehensive plan of care and there is involvement with their representatives, which is recorded. There is an induction programme and ongoing training for the staff group to ensure that staff are trained to give an effective delivery of service to all their residents. All Health & Safety certificates were up to date to ensure a safe environment for residents and staff. ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 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. ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 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 standard(s) 1 & 4 The home has a Statement of Purpose and Service User Guide, which is given to prospective residents who are offered the opportunity to visit the home before they move in to enable them to make an informed decision on whether the home is suitable to meet their needs EVIDENCE: The home had a Statement of Purpose and Service User Guide. The manager had updated them and had photocopied the documents, which would be reissued to service users. There was evidence on file that residents and/or their relative had received they had received their copy of the Service User Guide along with a statement of terms and conditions/contracts. Trial visits are offered before making the decision to become a resident. Records show that all new service users have an assessment from a member of the assessment team and the home has updated assessment document which is used preadmission or on admission to the home. ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 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 standard(s) 7 & 9 The care plan system contained a range of information and outlined the staff action required to ensure identified needs were met. Staff are not working to the policies for the administration of medication, which promotes the wellbeing of residents. EVIDENCE: On this inspection only the files of residents who live on the ground floor units were checked Four care files were examined all of which had been updated to reflect residents changing needs. There was evidence that staff are reviewing care plans monthly to ensure that residents assessed and changing needs are in the care plan and the goals are met. There were four residents who had pressure sores two were admitted from hospital and two who developed them at the home. The four residents were seen by the Tissue Viability nurse and had pressure-relieving equipment and all care was given. Community nurses are involved when a referral is made for Tissue Viability and pressure care. Medication policies and procedures are in place, which promotes safe handling and administration of medication. However, there were members of staff who when administering medications did not follow the medication policies by failing to record the administrations of drugs. ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 Page 10 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 standard(s) These standards were not assessed at this inspection. EVIDENCE: ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 Page 11 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 standard(s) 16 & 18 The home has policies and procedures to protect service users from abuse. The home has a clear complaints system, which service users and relatives have used to register their grievances and/or concerns EVIDENCE: The company and staff at the home have reported any issues to the Adult Protection team. Adult Protection matters are part of the induction and included a unit on the NVQ course. Three complaints were recorded; both the manager and Director of Operations have taken action to investigate the complaints and issues. No complaints were given to the inspector during the inspection. Relatives and residents had only constructive comments to make about the staff group. ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 Page 12 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 standard(s) 19 - 26 Service users lived in a safe well-maintained environment, which was clean pleasant and hygienic. EVIDENCE: All bedrooms are single occupancy and there was evidence that many of the residents had personalised their bedrooms. Residents said, “I am satisfied with everything”; “I’ve no problems to tell you”. The Director of Operations told the inspector that refurbishment was to take place at Athorpe Lodge. All areas used by service users were clean without offensive odours. There is a programme of routine maintenance. ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 30 The number and skill mix of the staff met residents’ needs, staff are have had induction and trained to do their jobs. EVIDENCE: Staff had staff induction and further training ensuring that service users are in safe hands at all times. Seven staff have achieved NVQ level 2 in care with other 11 staff members who are enrolled or working toward the qualification. Five members of staff have completed NVQ level 3 with a further six staff enrolled on the course which evidences staff development and competence. Training has taken place, for example five sessions on Fire Prevention, 2 staff members have attended a course on Diabetes, there are places booked for a course on Palliative Care. ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 The health, safety and welfare of service users and staff are promoted and protected EVIDENCE: Mrs. Melanie Phillips is the appointed manager and has submitted an application to be the registered manager, which is being processed by the CSCI. She has enrolled in March 2005 on the Registered Manager Award course. Staff said they received support and guidance on a daily basis and there was evidence that staff supervision sessions are to take place every two months. There was evidence that there was a staff training profile and staff had attended Fire Prevention training which demonstrated that the environment for them to work in, therefore reducing the risk of harm to themselves and protect residents who live at Athorpe Lodge. Health & Safety certificates were checked at previous inspection 23/24th March 2005, which were satisfactory. ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 Page 15 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 3 ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 Page 16 No 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 OP9 Regulation Reg 13 (2) Sch 3 (i) Requirement Medication records must be completed accurately and at the time of administration as per medications policies and procedures and comply with The Medicine Act 1963, of the Royal Pharmacutical Society, requirements of the Misuse of Drugs Act 1974. Timescale for action Immediate 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 Good Practice Recommendations ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 Page 17 Commission for Social Care Inspection First Floor, Barclay Court Heavens Walk Doncaster DN4 5HZ 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 ATHORPE LODGE 20050808 Athorpe Lodge X00015 UI Stage 4 S3072 V202917 J55.doc Version 1.40 Page 18 - 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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