CARE HOMES FOR OLDER PEOPLE
Blackburn Lodge LSC The Broadway Sheerness Kent ME12 1TS Lead Inspector
Graham Cummings Unannounced Inspection 24th January 2006 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 Blackburn Lodge LSC DS0000037875.V279132.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. Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 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 Vacant Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 13th September 2005 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. Eight beds are used by intermediate/recuperative service users. Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Graham Cummings carried out the inspection on the 24th January 2006. The inspection consisted of meeting with the Manager Vanessa Byrne and Deputy Manager Judy Thompson and touring the home. The Manager had only been in post since November 2005 and the Inspector spent most of the inspection with them discussing their thoughts on the home and any plans for changes. The requirement from the previous inspection has been implemented with all staff now receiving regular supervision, two of the team leaders will be attending a Supervision training course as a refresher. The Manager said that she had found the staff team to be excellent, they are sensitive, dedicated, work well together and respect the Service Users and each other at all times. The Manager made the Inspector aware that they have changed the Senior Management rota so that they all have 2 days a month to carry out paperwork and supervision. A key-worker system is to be implemented and care plans and staff files are going to be reorganised. The providers Kent County Council are in the process of changing their policies and protocols on medication and a draft document has been distributed for discussion and comment. The Manager discussed the future options the home may consider in order to meet the care demand. The Manager discussed an incident that had occurred on the Sunday evening and gave the completed Regulation 37 paperwork to the Inspector, on the information available the home acted appropriately and will keep the Inspector informed of the process and outcome. The Inspector left with no concerns. What the service does well: What has improved since the last inspection?
The home has implemented a Staff supervision program and arranged for senior staff to attend supervision training. The Manager has created a new rota for the Management team that gives them 2 days a month off the care shift for office work and staff supervision, they are also looking to implement a keyworker system. Training completed since the last inspection includes, Manual Handling, Bereavement and loss, Stroke care, Ageing process, Infection
Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 Page 6 control, Medication and N.V.Q’s. The home has redecorated 2 bedrooms and a hallway, they have a new freezer, beds and mattresses. 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. Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 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.V279132.R01.S.doc Version 5.1 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): 1,5 Prospective Residents have the information needed to make an informed choice about where to live. Prospective Residents and relatives have an opportunity to visit and assess the quality of the home. EVIDENCE: The Manager informed the Inspector that they were in the process of updating the Statement of Purpose and Service User Guide to reflect the change in Manager and how the provision of care is provided, both documents will be sent to the Inspector when completed. Blackburn Lodge LSC DS0000037875.V279132.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 The Residents health, personal and social care needs are set out in a plan. EVIDENCE: All of the Residents have full access to a Doctor, Dentist and Opticians. The existing care plans are to be reviewed, the Manager is considering changing the format and was aware that at the Announced Inspection the Inspector had noted that they were lacking in detail. Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 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 the following standard(s): 13,14,15 Residents maintain contact with family and friends. Residents are encouraged to have choice and control over their lives. Residents have a healthy and nutritious diet. EVIDENCE: The Inspector was told that Residents friends and families visit whenever they wish and on the walk around the home the Inspector noted that visitors were present. Residents are encouraged to retain as much independence as possible in their care and social activities. The menu was on display in the dining room and showed the main course as Beef Stroganoff. The Manager confirmed that the high standard of food remained as written in the last inspection report. Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 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 the following standard(s): 16,18, Residents are confident that their complaints are listened to and taken seriously. Residents are protected from abuse. EVIDENCE: No complaints have been received by the Inspector or at the home. At the beginning of the inspection the Manager informed the Inspector that an incident had taken place on the Sunday, 2 days prior to the inspection visit, the Manager had completed the investigation and paperwork and this was given to the Inspector, the relevant authorities have been informed and may result in am Adult Protection meeting. The Resident is being reassessed on Friday 27th January 2006 and the Manager is to keep the Inspector informed of the outcome. The Inspector was satisfied that the home had acted quickly and appropriately in dealing with the issue. Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 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 the following standard(s): 19,20,21,25,26 Residents live in a safe well-maintained environment. Residents have access to safe and comfortable indoor and outdoor communal facilities. Residents have sufficient and suitable lavatories and washing facilities. Residents live in safe, comfortable surroundings. EVIDENCE: The Inspector walked around the home and found the décor and furniture to be in good condition and Residents were living in a safe environment. The home has plenty of communal space that is easily accessible to the Residents. The home has 4 bathrooms and 8 toilets,1 shower and 1 en-suite room, all of the rooms have a wash basin. The home has a number of wheelchairs and walking frames to assist Residents with walking difficulties. The Residents live in safe comfortable surroundings that are pleasant, clean and hygienic. Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 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 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 needs are met by the numbers and skill mix of staff. Residents are in safe hands. Residents are supported by the homes recruitment policy and practices. Staff are trained and competent to do their job. EVIDENCE: The Manager told the Inspector that the home has a committed, stable and dedicated staff team that delivered excellent care, they also have access to a good training program. The manager has in discussion with the Senior staff implemented a new rota for them, this allows for 2 days off the care rota so that they can carry out staff supervision and update paperwork. Since the last inspection staff have had training in; Infection control; Bereavement and loss; Manual Handling; Ageing Process; Stroke Care; Medication and continuing NVQ’s. The Cook and kitchen staff are attending a Certificated Healthy Eating course. The Manager spoke to the Inspector about the need to go through the staff files to ensure they are in line with the Care Home Regulations 2001 as these were lacking at the last inspection. Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 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 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): 31,32,33,36,37,38 A person that is fit to be in charge manages the home. Residents benefit from the leadership and management of the home. The home is run in the best interests of the Residents. The staff are appropriately supervised. The health, safety and welfare of Residents and staff are promoted and protected. EVIDENCE: The Manager has been in post since the beginning of November 2005, during this time the Manager has had full staff team meetings, 3 senior team meetings and night staff meeting. The Manager has also covered care shifts including both early and late duties. The Manager has implemented a staff supervision program to ensure that all staff will have a minimum of 6 supervisions a year, they are also in the process of starting a key-worker system. The Manager is in the process of changing the Statement of Purpose and Service User Guide to reflect the changes being made. The Inspector was aware that the Manager had only been in place for 8 weeks at the time of the inspection and they were still in the process of consulting with all staff and
Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 Page 15 assessing and prioritising issues they felt needed to be addressed. The Inspector was confident that the Resident and staffs health, safety and welfare were being promoted and protected. Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 Page 16 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 X X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X 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 3 3 X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 Page 17 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 OP1 OP29 Good Practice Recommendations The Manager keeps the Statement of Purpose and Service User Guide updated with the changes being made. That the home has all the documentation or copies of the original information required in Schedule 2 of the Care Homes Regulations 2001. Blackburn Lodge LSC DS0000037875.V279132.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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