Inspection on 09/02/06 for Autumn Lodge

This inspection was carried out on 9th February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Autumn Lodge 30/11/06

Autumn Lodge 11/08/05

Autumn Lodge 07/03/05

Autumn Lodge 23/08/04

Autumn Lodge 23/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Autumn Lodge 41 Moss Lane Orrell Park Liverpool Merseyside L9 8AB Lead Inspector Les Smith Unannounced Inspection 9th February 2006 09:00 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 Autumn Lodge DS0000025326.V282926.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. Autumn Lodge DS0000025326.V282926.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Autumn Lodge Address 41 Moss Lane Orrell Park Liverpool Merseyside L9 8AB 0151 525 0555 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) Mr Delpinto Mrs Delpinto Mrs Kathryn Delpinto Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Autumn Lodge DS0000025326.V282926.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To provide care for thirty-three older persons (aged over 65 years) and one named person with dementia, excluding learning difficulty or mental disorder over 65 years of age 11th August 2005 Date of last inspection Brief Description of the Service: The home is situated in the Orrell Park district of Liverpool and is easily accessible by public transport. Gardens are at the rear of the home and there is car parking to the front aspect. Registered with the Commission for Social care inspection to provide personal care for 33 older people. All accommodation is provided in single rooms. A passenger lift and wide corridors facilitate access to all areas of the home. The home has aids in place to promote the independence of residents such as assisted baths, grab rails and staff call system. The home is managed by an experienced manager and has a stable well-qualified workforce. Autumn Lodge DS0000025326.V282926.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of seven hours in the presence of the registered person and the registered manager. The inspector examined both care and home records and spoke to residents, staff and visitors during the course of the inspection. The inspector found a happy, welcoming home, well decorated and furnished that provided a high standard of care. One resident spoken to asked the inspector ‘what do you think of our wonderful home’ What the service does well: 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. Autumn Lodge DS0000025326.V282926.R01.S.doc Version 5.1 Page 6 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 DS0000025326.V282926.R01.S.doc Version 5.1 Page 7 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): 1,2,3,4,5 There is good information available to allow prospective residents to make a fully informed choice about where they want to live and be confident that their individual needs will be assessed and met. EVIDENCE: The statement of purpose and service user guide meets the required standard and is available to prospective residents. Service user guides are also available in each room as a source of reference for individual residents. Residents files examined all had a Statement of Terms and Conditions or contract in place depending upon whether they were funded or private residents. It is recommended that the room number be included on these documents. The registered manager carries out pre-admission assessments using the care management plan as a guide to needs. Assessments are carried out with the involvement of the prospective resident, family, social services if relevant and any other individuals currently involved in providing care. Pre-admission assessments are sufficiently detailed to enable the home to construct an initial Autumn Lodge DS0000025326.V282926.R01.S.doc Version 5.1 Page 8 care plan and obtain any necessary services or aids and have them in place for the day of admission. Prospective residents are positively encouraged to visit the home to assess its’ suitability for them. Whilst visits are made at any time the manager encourages a full day visit when the individual has the opportunity to take meals, take part in activities and have social interactions with existing residents. Five members of staff have NVQ2 and six have NVQ 3 with a further three working towards NVQ2 and overall 66 of staff members have a qualification in care. The home does not provide intermediate care. Autumn Lodge DS0000025326.V282926.R01.S.doc Version 5.1 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): 7,8,9,10,11 There is a comprehensive and consistent care planning process in place that supports the residents by providing staff with the information they need to satisfactorily meet the residents identified and changing needs. Medication management is not fully compliant with current good practice requirements and guidelines and potentially could put residents at risk. EVIDENCE: A random selection of care plans and related documentation was examined as part of the case tracking process. Care plans included biographical, physical and cognitive ability and relevant risk assessments. Care plans detailed specific interventions for personal care needs. Designated key workers reviewed care plans on a regular monthly basis and the case tracking process demonstrated that changing needs were reported and acted upon in a timely way. The inspector noted that short-term care plans including appropriate risk assessments were present to take account of minor ailments and that care needs were met. Changing care needs were discussed with the manager prior to any major changes being made. A separate record within the care plan recorded all visits by health care professionals and records were seen detailing visits by GPs, district nurses, continence specialists etc. Autumn Lodge DS0000025326.V282926.R01.S.doc Version 5.1 Page 10 It is strongly recommended that the manager review the documentation of discussions with family and significant others in relation to care and changing needs. There were no residents self-medicating at the time of inspection. Residents wishing to do so would be supported to do so following a full risk assessment. The current system for receipt, storage, administration and disposal of medications does not easily facilitate accurate records and risk of error is present. MAR sheets are not printed and photocopied to save hand writing them each month. The current system cannot accommodate all needs with the result that there are three different storage elements for each resident; a cassette type container, a blister for tablets that cannot go into the cassette and a further container for other medications e.g. in a box or bottle. The MAR sheets were fully completed and signed with no gaps but it was not possible to check that the administration was correct. Controlled drugs were checked and found to be correct. A large stock of night sedation was found and this is a result of the inflexibility of the system in use. Containers of creams were seen with the labels removed and partly used. It will be a requirement of this report that the system of medications be reviewed and brought up to the required standard. Residents spoken to were all highly complimentary about the home and staff. Direct observation throughout the day evidenced a clear demonstrable focus on respect for the individual and maintenance of privacy at all times. The home has policies and procedures in place for death and dying and the inspector saw letters and cards from relatives praising the staff for the caring and sensitive way in which they had been treated at a difficult time for them. Autumn Lodge DS0000025326.V282926.R01.S.doc Version 5.1 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): 12,13,14,15 As far as possible residents have choice and flexibility in how they spend their day in the home, and pursue leisure activities according to their choice and preferences thereby promoting independence and individuality for each resident. Meals at Autumn Lodge are good, offering choice and variety whilst catering for residents dietary needs or cultural preferences EVIDENCE: The inspector was able to observe residents’ autonomy and choice being exercised whilst in the home. Residents’ spoken to all said that they were able to get up and go to bed when they wanted, chose their own clothes and spend the day as they wished. Staff members were seen supporting residents to maintain their independence e.g. assisting and advising a lady to put makeup on. The home has recently appointed an activities co-ordinator for 20 hours per week and has arranged for her to attend an appropriate course in order to extend the range of activities on offer, which currently include bingo, knitting circle, karaoke and weekly religious services. The home also organises outings to the theatre, shopping centres and welcomes any suggestions from the residents. Autumn Lodge DS0000025326.V282926.R01.S.doc Version 5.1 Page 12 Visiting at the home is unrestricted and residents are able to receive their visitors in their own room or any of the communal rooms. Residents are encouraged to maintain their links with friends, family and the local community. One resident has a friend who comes and has a meal with her each week. Residents may take their meals in their own room or in a very bright and attractive dining room. A varied menu is based upon a four weekly cycle, which is regularly reviewed to reflect seasonal vegetables and fruit. An alterative choice is always available and is displayed on the daily menu. Residents spoken to were all complimentary about the food both in terms of quantity and quality. The inspector observed the mid-day meal being served, which was well presented, and assistance were required was provided by staff in a sensitive and unobtrusive way. The minimal waste at the end of the meal indicated how much the meal had been enjoyed and residents confirmed that the portions were sufficient. Special diets for medical or cultural preferences are catered for. Autumn Lodge DS0000025326.V282926.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): 16,17,18 Residents and their families can be confident that any complaints or concerns will be listened to and appropriate action taken. The home has a complaint and adult protection policy and procedure in place that helps promote the safety and welfare of residents. EVIDENCE: The home has a complaints procedure which management encourage residents’ and their families to use based on the philosophy that if management do not know of a problem they are unable to resolve it. Visitors spoken to by the inspector were very positive in relation to any concerns as if they mention a concern to any of the staff it is always addressed promptly without recourse to the complaints procedure. All residents are registered on the electoral roll and vote in any elections. If required the home provides transport to take residents to polling stations. The home has policies and procedures in place for the protection of vulnerable adults and this includes whistle blowing. Staff spoken to demonstrated a good knowledge of recognition of abuse and what to do if they suspected an occurrence. Autumn Lodge DS0000025326.V282926.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): 19,20,21,22,23,24,25,26 Autumn Lodge presents as a well maintained home providing a homely, safe and comfortable environment for residents to live in. EVIDENCE: The home is well maintained both internally and externally benefiting from an ongoing planned programme of maintenance and refurbishment. Communal and individual rooms are pleasantly decorated and residents are involved in choosing colours and wallpapers. Furnishings are of a high standard and reflect the needs of the residents. The registered person is continually looking at ways of improving the home and current plans include the conversion of two bathrooms into walk-in showers. The providers’ commitment to providing a comfortable environment is demonstrated by an example whereby several residents were having difficulty in depressing handles on cisterns so they were changed to push button flush mechanisms. Autumn Lodge DS0000025326.V282926.R01.S.doc Version 5.1 Page 15 Residents have access to all parts of the home via the passenger lift and clear wide corridors. Assisted baths, grab rails and a staff call system all help promote independence and safety. Residents are encouraged to bring their own possessions into the home and this was evidenced by the high degree of personalisation seen by the inspector. Emergency lighting is provided throughout the home, which is tested regularly as demonstrated by the records held. Individual and communal rooms are well lit and ventilated. On the day of inspection the home was clean and pleasant. Autumn Lodge DS0000025326.V282926.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): 27,28,29,30 Residents benefit from a stable work force and are supported by a recruitment policy that helps promote good quality and continuity of care. EVIDENCE: Staff members are deployed in sufficient numbers and skill mix to meet the assessed needs of the residents. The home has exceeded the target for NVQ qualified staff with 66 of staff holding the qualification and a further three working towards NVQ2. A random selection of staff files including recent starters were examined and found to contain most of the required documents including two references and CRB checks. Two of the files lacked a copy of contracts of employment and documentary evidence of identity. The inspector was informed that this would be addressed without delay. It was evident from records and confirmed by staff spoken to that new members to the staff team have an induction. It is strongly recommended that types of abuse, recognition of abuse and procedures to follow when abuse is suspected is included in the induction programme. The training programme at Autumn Lodge has slipped since the last inspection particularly in relation to the mandatory training requirements and this needs to be addressed as a priority. The inspector was informed that the new activities co-ordinator is employed for 40 hours per week and will be undergoing a trainers course so that they are able to do a great deal of the mandatory training in-house. Autumn Lodge DS0000025326.V282926.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): 31,32,33,35,36,37,38 Residents benefit from a qualified, experienced manager who is competent to promote and protect the health, safety and welfare of residents. EVIDENCE: The manager has the appropriate qualifications and experience and manages the home in an open and transparent manner. Discussion with residents and staff showed that the manager operates an open door policy and was approachable at all times. The staff had a strong sense of motivation and team belonging generated by the leadership and guidance given by the management team. The inspector observed a good rapport between the management and staff, staff and residents and management and residents. The management at the home send out questionnaires to the residents and their families to obtain feedback on the quality of the service provided. The inspector noted that observations made via the last questionnaire had been acted upon for the benefit of the residents. Autumn Lodge DS0000025326.V282926.R01.S.doc Version 5.1 Page 18 Monies held on residents’ behalf were checked and found to be correct in accordance with the records kept. Receipts for any expenditure are held with the account records. There are no monies held in bank account for residents. The manager supervises staff on a daily basis encouraging; advising and helping whenever appropriate to do so. However formal staff supervision does not happen although yearly staff appraisal records were seen. The manager must introduce formal staff supervision for all care staff and keep relevant records to show that the supervision has taken place at least six times per year. Policies and procedures are reviewed on a regular basis or following notification of changes in the legislation. Records for the home and residents are held securely in accordance with the Data protection Act 1998 and residents can have access to their records at any time they wish to see them. The inspector saw the fire log book showing regular fire alarm and emergency lighting tests. Contracts and service certificates were seen for the fire alarm system, emergency lighting, fire extinguishers and lift. The inspector was unable to see valid and satisfactory gas or electrical safety certificates. The periodic electrical inspection had been carried out but not all the remedial work required had been carried out. It will be a requirement of this report that both these certificates are forwarded to the CSCI within the stated timeframe. The registered person carries out the required PAT tests himself, however there is no record of the items tested or calibration certificate of the instruments used. A further requirement will be that the PAT tests are recorded and appliances labelled with date test done and evidence provided that the testing was carried out correctly. As previously mentioned under standard 30 there has been a lack of the mandatory training and this must be addressed as a priority in the areas of moving and handling, fire awareness and prevention, first aid and food hygiene and handling. Autumn Lodge DS0000025326.V282926.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 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 3 18 3 4 3 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 2 3 2 Autumn Lodge DS0000025326.V282926.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES 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 13(2) Requirement The registered person must make arrangements for the receipt, recording, handling, safekeeping, safe administration and disposal of medications received into the care home in accordance with the Medicines Act 1968 and the Royal Pharmaceutical Society guidelines The registered person must ensure that the documents as detailed in schedule 2 of the Care Homes Regulations are obtained The registered person must ensure that formal supervision for all care staff is carried out at least six times per year and that relevant records are kept The registered person must ensure that gas and periodic electrical certificates are obtained and forwarded to the CSCI within the stated timeframe DS0000025326.V282926.R01.S.doc Timescale for action 31/03/06 2 OP29 19(1)(b) 31/03/06 3 OP36 18(2) 30/04/06 4 OP38 13(4) 31/03/06 Autumn Lodge Version 5.1 Page 21 5 OP38 13(4) The registered person must ensure that PAT tests are carried out and demonstate that the tests have been carried out correctly The registered person must ensure that staff receive training in moving and handling, first aid, food hygiene and handling and fire awareness and prevention 30/04/06 6 OP38 23(4)(d) 13(4-6) 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 4 Refer to Standard OP2 OP7 OP30 Good Practice Recommendations It is recommended that the homes Statement of Terms and Conditions be updated to include the room number. It is recommended that discussions with family or significant others in relation to changing needs are documented within the care plan. It is strongly recommended that training in recognising abuse, the various types of abuse and procedures to follow be included in the induction training. Autumn Lodge DS0000025326.V282926.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 DS0000025326.V282926.R01.S.doc Version 5.1 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!