Inspection on 17/10/05 for Autumn Lodge

This inspection was carried out on 17th October 2005.

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

Autumn Lodge 28/09/07

Autumn Lodge 23/05/06

Autumn Lodge 23/01/06

Autumn Lodge 21/02/05

Autumn Lodge 10/08/04

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

CARE HOMES FOR OLDER PEOPLE Autumn Lodge 35-37 Rutland Gardens Hove East Sussex BN3 5PD Lead Inspector Glynis McLeod Announced Inspection 17th October 2005 09:30 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 Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 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. Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Autumn Lodge Address 35-37 Rutland Gardens Hove East Sussex BN3 5PD 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) 01273 271786 Mrs Sheila Clare Bravery Vacant Care Home 35 Category(ies) of Dementia (35) registration, with number of places Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is thirtyfive (35). Service users must be older people aged sixty-five (65) years or over. Up to thirty-three (33) service users with a dementia type illness to be accommodated. One (1) service user with a dementia type illness and one (1) service user without a dementia type illness or two (2) service users without a dementia type illness may be accommodated in the designated respite flat. 21st February 2005 Date of last inspection Brief Description of the Service: Autumn Lodge is a private care home registered to provide care and accommodation for up to 33 older people with a dementia type illness; there is also a respite flat available for couples where a person with dementia can be cared for by their relative. Most of the care is long-term; however, the home does also offer respite and holiday care. The home does not provide nursing care. The home is located in a residential area close to the centre of Hove, with all local amenities and the seafront close by. The area is well served with bus and rail services, and parking is available on the private forecourt and in the street outside. The home also has its own mini-bus for outings. It has also received a Clean Food Award from Brighton and Hove City Council. The property comprises three converted houses that have been linked together, and service user accommodation, including 23 single and five shared bedrooms, plus the respite flat, is arranged on three floors that are accessed by a passenger lift or stairs. There is also a stair lift to the first floor in the ‘wing’. Communal areas include a large sitting and dining room, further lounges, two conservatories and an attractive courtyard area with a fishpond and an aviary. Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection, which was announced, took place over eight hours and was one of two inspections required over the year. A tour of the premises took place and records relating to care, medication, staffing and maintenance were inspected. Comment cards and letters from families were received and were very positive about the service. Two of the residents, three staff members, the acting manager and the owner were spoken to. The acting manager has only been in post for two months and is applying to become the registered manager of the home. The inspector would like to thank the residents, staff, acting manager and owner for their hospitality and assistance during the inspection. What the service does well: What has improved since the last inspection? Since the last inspection, the home has brought all staff files up to date and now ensures that all the necessary checks are made prior to staff starting work. This helps the management to recruit staff who are suitable to work in the home and who have the necessary skills and training to work with vulnerable people. Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 Page 6 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. Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 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 Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 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 4 Prospective residents are assessed appropriately by the acting manager or owner, and by other agencies where appropriate. The manager makes a decision based on each individual’s needs to ensure that the home can meet their particular care requirements. Staff have the experience and skills to meet the specialised needs of residents. EVIDENCE: The home always requests assessments from social workers or other health professionals before admission in order that the home has a clear understanding of the health and personal care needs for each individual. The home also completes its own assessment. On admission, an interim care plan is drawn up and a full care plan is produced after staff have had the opportunity to see how the resident is settling into the home and identified their long-term needs. The home has good links with the community mental health team and the Alzheimer’s Society, and receives specialised input from these and other agencies when required. A translation sheet for a resident whose first language is not English has been supplied to the home by the resident’s family and is a useful tool for both staff and the resident. Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 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 and 9 Comprehensive care plans are in place and useful templates are available for staff to identify and record individual care needs. A recommendation was made that staff receive training in how to record information fully and accurately to ensure that records are complete and that a resident’s particular needs are not lost or overlooked. Medication policies and procedures are clear and regular monitoring of medication issues means that residents receive their prescribed medication correctly. EVIDENCE: Each resident has an individual care plan, drawn up with the resident and their family, which a staff member spoken to described as ‘very useful’. All plans are reviewed monthly and any changes recorded. It was noted that some care plans had not been signed and dated properly and that not all the sections had been completed. The owner and acting manager had already picked up on the problem and are in the process of arranging training for staff. Medication policies and procedures were all in place and the home’s records of administration and drugs received into the home and returned to the pharmacy Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 Page 10 were up-to-date and accurate. Only the manager and three other senior staff, who have all been trained, are able to administer medication. The home has a good relationship with the pharmacy and feels able to contact them with any queries. Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 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 and 13 The home offers a comprehensive and varied programme of entertainment and events, and makes positive efforts to involve residents in both individual and group activities to stimulate their interest and keep their minds active. It is considered that the home exceeds this particular minimum standard. Visitors are welcomed to the home and residents are able to see their friend or relative in private. Staff assist residents to maintain relationships with their families. EVIDENCE: The home is rightly proud of its entertainment’s programme and supplied written and photographic evidence of some of the activities that had taken place. Special events are always marked and the home had recently arranged a successful Victory Barbecue, and an Edwardian Tea where staff and residents had dressed up in Edwardian clothing. One resident spoken to said she enjoyed the activities in the home and that staff were always ‘doing their best’. She also said she liked the trips out to the country in the minibus. As well as group events, staff also engage with residents on a one-to-one level, helping them with jigsaws, colouring and taking them for walks. Performers are invited into the home to put on shows and residents are also taken out to shows. Staff spoken to were very enthusiastic about the events put on and enjoyed taking part in them. Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 Page 12 Visitors are welcome to the home at any reasonable time; in fact, one relative wrote to say that she spent three full days a week with her father and felt very much at home there! Another said she was always made ‘to feel very welcome’. Staff make positive efforts to maintain relationships with residents’ friends and families by talking to them about their loved ones and helping them to make cards, for example, for special occasions. Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 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 Policies and procedures ensure that residents are protected from abuse and that complaints are properly listened to and investigated. A recommendation was made that the manager undertakes further adult protection training in order to equip her in her new role. EVIDENCE: The home has a clear complaints policy, which was updated on the day of the inspection to ensure that it fully met the standard. The last recorded complaint to the home was in September 2004, and records showed that it had been properly investigated and recorded. In March 2005 the Commission had received a further complaint, and this, too, had been properly dealt with by the home’s previous manager. The home has clear and comprehensive guidelines for identifying and reporting adult protection issues, and a rolling programme of adult protection training is carried out by the home. Although the acting manager had undertaken this training, a recommendation was made that she undertake further training in order to equip her to deal with any issues in her new role as manager of the home. Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 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): 26 The home is safe, well-maintained, clean and hygienic. EVIDENCE: The home has a dedicated housekeeping team, including two full-time domestic staff, two full-time laundry staff and a handyman. Despite the age and layout of the building, which does not lend itself to ease of cleaning, the home was clean, tidy and odour-free. Relatives, in their letters, commented positively on the cleanliness of the home. Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 Page 15 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): 29 In order to protect residents from unsuitable carers, the home carries out the necessary checks on staff before they begin working at the home. EVIDENCE: Recruitment procedures are thorough in the home and staff are required to provide documentary evidence of their experience and qualifications. Records showed that the individual files for each staff member contained all the information required by the standards and regulations. References, and the necessary police checks had been obtained, and staff had received their statement of terms and conditions and code of conduct. New staff are monitored and have to complete a probationary period before confirmation in their post. Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 Page 16 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 and 32 The acting manager is experienced and capable, and runs the home efficiently and effectively. Staff and residents benefit from her open management style. EVIDENCE: The acting manager has worked in the home for two years and for the company for three and a half years. She has over 20 years experience of working with the elderly and two years experience of working with people with dementia. She has recently started her registered manager’s award training and is in the process of applying to become registered manager at the home. The home has a very supportive management structure in place and this has ensured the smooth running of the home during this transitional phase. The acting manager describes herself as a hands-on manager who tries to be approachable and understanding. Staff spoken to confirmed that they felt valued and respected in their jobs and that they are encouraged to become involved in the life of the home. Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 Page 17 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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X 3 STAFFING Standard No Score 27 X 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 X X X Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 Page 18 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. 2. Refer to Standard 7 18 Good Practice Recommendations Staff should receive training in how to record information fully and accurately. The manager should undertake further adult protection training. Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Autumn Lodge DS0000014177.V262925.R01.S.doc Version 5.0 Page 20 - 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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