Inspection on 20/02/07 for Blackburn Lodge LSC

This inspection was carried out on 20th February 2007.

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

Blackburn Lodge LSC 02/02/09

Blackburn Lodge LSC 24/01/06

Blackburn Lodge LSC 13/09/05

Blackburn Lodge LSC 11/10/04

Blackburn Lodge LSC 22/04/04

Blackburn Lodge LSC 09/10/03

Blackburn Lodge LSC 22/04/03

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Blackburn Lodge LSC The Broadway Sheerness Kent ME12 1TS Lead Inspector Graham Cummings Key Unannounced Inspection 20th February 2007 10:00 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 Blackburn Lodge LSC DS0000037875.V317867.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. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blackburn Lodge LSC Address The Broadway Sheerness Kent ME12 1TS 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) 01795 667035 Kent County Council Mrs Vanessa Byrne Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Blackburn Lodge is a local authority Home which caters for older people needing residential care, the Home also provides recuperative care and there is a day centre on the premises. The service users are accommodated on the first floor of a Social Services building, with the managers office, the kitchen, the laundry, a day centre for 30 older people, some facilities used by occupational therapists and several care management offices occupying the ground floor. The premises are located on the seaward side of a busy main road in the centre of Sheerness, with transport and local amenities within walking distance. It provides 35 beds in 33 single and one double room. Seven beds are used by intermediate/recuperative service users. The weekly fees range from £322-00p to £350-00p. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was carried out by Graham Cummings on the 20th February 2007 and completed the home’s first Key Inspection. The inspection consisted of speaking to the Manager and staff, observing Service Users, looking at four Service User plans and three staff files and various documentation. The Inspector also viewed the premises. New Service User admissions have all had Pre Placement Assessments to ensure the home can meet their individual needs. The Occupational Therapy (O/T) team and staff working in the intermediate care team won an award as the best O/T team in Kent. Service User plans were informative and clearly written, some duplication in recording evaluation dates was noted by the Inspector. The home needs to make staff aware of individual procedures to follow for all Service Users that had Diabetes. Regular Service User meetings are held and the home has a lot of entertainment both participative and observational and encourages Service Users to participate as much as possible in the entertainment that is on offer. Since the last inspection the home has raised an Adult Protection issue that was dealt quickly and appropriately. Staff have received training in the Protection of Vulnerable Adults and Behaviour Management. The environment was well furnished, clean, tidy and free from any offensive odours. The staff training is very good and enables them to provide a good quality of care to the Service Users. The Inspector was pleased to see that home has been pro active in putting staff on Dementia training in order for them to meet the changing needs of some of the Service Users in residence. The Manager is hoping more staff will be attending Dementia training in the near future. The Inspector looked at three staff files and found they contained the details set out in Schedule 2 of the Care Home Regulations. There was a shortage of recorded supervisions, a list of supervision dates was on display in the office and when checked had been carried out but not recorded formally by a Team Leader responsible. Over 68 of staff employed have an NVQ Level 2 or higher. The home is well managed and run in the best interests of the Service Users. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Blackburn Lodge LSC DS0000037875.V317867.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 Blackburn Lodge LSC DS0000037875.V317867.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,6 Prospective Service Users have the information they require to make an informed choice about where to live. Service Users have a written contract and their needs were assessed prior to any placement taking place. All Service Users assessed for intermediate care are helped to maximise their independence. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide has been updated following the Recommendations of the last inspection. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 9 Service Users have a Statement of Terms and Conditions, these are in the process of being updated in preparation for April 2007 the new financial year. All of the Service User files seen had Pre Placement Assessments on them, these had been carried out by the Home Manager and/or the Deputy Manager. The Occupational Therapy team working with Service Users in the Intermediate care section have received an award as the best O/T team in Kent, staff working with Service Users in Intermediate care must also be complemented on their input and support to the O/T team. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 Service Users needs are set out in an individual plan and their healthcare needs are met. Service Users can be confident they will be are treated with respect and their wishes at their time of death are recorded. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Inspector looked at four Service User plans and found that they contained admission and personal details, dependency assessment, care plan with evaluations that were signed and dated, risk assessments and daily records of care. The individual life history on one file was not complete but the Manager had carried out spot checks on care plans had written a note to tell the keyworker that this was to be completed as soon as possible. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 11 The care plan document covered personal care, mobility, nutrition, continence, medication sleep, communication, social care and religion. One of the files seen indicated that the Service User had diabetes, there were no procedures or instructions for staff to follow or take into account when observing or monitoring his daily health needs. The Inspector noted that the home was using two differing forms to record the evaluation of care plans, the home are going to look at this and just use one method of recording. Service Users are all registered with a local Doctor, Optician and Dentist, a Chiropodist visits approximately every six week. The local authority responsible for the home have implemented a new form that is to be completed and sent to them when changes are made to any care plans. No Service User self medicates at present, the home has a policy in place should this ever arise. The Inspector noted that staff knocked on doors before entering Service User rooms and observed interactions and conversations between staff and Service Users that were respectful and dignified on both sides. The files seen recorded the wishes of Service Users regarding illness and death. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,15 Service Users have good contact with family and local community. Service Users are able to exercise choice in their lives and receive a nutritious and wholesome diet. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service Users have regular meetings, approximately every four to eight weeks, key-workers also meet with the Service User individually on a regular basis. The Manager informed the Inspector that it has been difficult to motivate and engage some Service Users to join in the activities on offer, they are trying to find new activities and ways to involve more of the Service Users to participate in activities. At Service User meetings the area of activities has been raised and suggestions asked for so that the home can purchase or arrange for specific activities asked for. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 13 Families and relatives visit regularly, one couple living in the home have just become engaged and spend a lot of time together. One of the Service Users has a double room that has been adapted into a ‘bed-sit’ but they do not, by choice, share the room at night. The menu is taken round to Service Users the night before and they make a choice from the three options available of what they would like, this can be changed at any time at the Service Users request. A Service User in the home is due to celebrate their 100th birthday in March and preparations are underway to ensure that it is an enjoyable occasion. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Service Users and their relatives are listened to and can be confident that Service Users are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There has been one Adult Protection issue in the home since the last inspection and this was dealt with in a competent and professional manner. Service Users were protected by the way the home reacted until the Service User, whose needs had changed, was moved onto a more appropriate placement. Staff have attended several training courses over the last year including Protection of Vulnerable Adults and Dementia. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,25,26 Service Users live in a comfortable, clean, safe well-maintained and pleasant environment. The home has specialist equipment to meet the needs of the Service Users Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has 5 lounge areas that allow Service Users to be able to have access to quiet areas if they choose to. These were seen when the Inspector toured the building and were well furnished, clean and welcoming. Work has just been completed on decking part of the garden and hope to add a water feature and table and chairs in the near future. Service Users are looking forward to the better weather so they can enjoy the new facility. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 16 The home has just purchased a mobile hoist due the decrease in some individuals ability to manoeuvre into and out of bed or the bath. The home has decorated several bedrooms and the main lounge and also purchased new curtains and chairs. A new dishwasher and steamer have been brought for the kitchen. The Deputy Manager is the designated Health and Safety officer and they carry out regular weekly checks around the home that are recorded, they also carry out fire alarm tests and water temperature checks. Kent County Council Health and Safety officer for the region to carry out unannounced visits to the home to ensure compliance with the regulations. The fire officer has recently visited and mad a number of minor recommendations that the home are implementing. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Service Users needs are met and they are in safe hands. Service Users are protected by the home’s staff recruitment policy and they have access to training. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff rota showed that the home had five staff on duty plus a Team Leader. The Manager and Deputy were also on site on Monday to Fridays. At weekends the Deputy or Manager were on call to advise and assist if required. Staff training since the last inspection include Protection of Vulnerable Adults, Challenging Behaviour, Food Hygiene, First Aid, Healthy Eating, Fire Awareness. Four Team Leaders have attended Team Building and Supervision course and two Team Leaders attending a Management course. The home has 68 of staff having achieved an NVQ Level 2 or higher. A number of the Service Users have been diagnosed with the onset of Dementia and the Inspector was pleased to see that the home had sent staff on Caring for Dementia training course. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 18 Following the recommendation of the last inspection report, the staff files now contained all of the items required under Schedule 2 of the Care Home Regulations 2001. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Service Users live in a home that is well run and managed and run in their best interest. Service Users’ finances are safeguarded and their health, safety and welfare promoted and protected. Whilst staff receive supervision there is a need for the manager to ensure that all supervision sessions are properly recorded. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 20 EVIDENCE: The home has continued to change and evaluate procedures and documentation since the last inspection and this has meant that there is a clear structure of responsibility and accountability if work is not carried out appropriately. The Manager has a new Line manager who is supportive and supervises the Manager on a monthly basis. The home has regular meetings with Service Users as a group or individually with the key-worker. This information is recorded and taken into account in the day to day running of the home wherever possible. The Inspector was informed that Residents finance procedure required 2 staff signatures for any transaction, this was usually the member of staff and an administrator. The Manager signs the finances off at monthly intervals. The Inspector looked at three staff files and found that some of the supervision notes had not been signed or dated and there were a number of supervisions that had been carried out had not been fully recorded, the Manager and Deputy will be addressing this issue with the individuals concerned and the forms completed, signed and dated. Service Users and staff health, safety and welfare are promoted and protected through regular Health and Safety checks and weekly fire drills. The Manager carries out spot checks at regular intervals on documentation and observation of care practice being carried out. Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 21 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 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 22 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 Home’s Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations That all Service Users diagnosed with Diabetes have a procedure in place to inform staff of any actions they need to follow should blood sugar levels be outside of the individuals normal level. That all supervisions carried out are recorded, signed and dated by all parties involved and that there are a minimum of 6 supervisions per year for each staff member. 2. OP36 Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Blackburn Lodge LSC DS0000037875.V317867.R01.S.doc Version 5.2 Page 24 - 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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