Inspection on 10/02/06 for Byker Lodge

This inspection was carried out on 10th 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

Byker Lodge 29/11/06

Byker Lodge 03/08/05

Byker Lodge 09/03/05

Byker Lodge 01/10/04

Byker Lodge 19/02/04

Similar services:

Ashlea Mews Residential Home

Eastwood

West Lodge

Arran House

Avenue Community Nursing Home

Cosin Lodge

Farmborough Court

Cragston Court

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

CARE HOMES FOR OLDER PEOPLE Byker Lodge Bolam Way Byker Newcastle upon Tyne NE6 2AT Lead Inspector Anne Brown Unannounced Inspection 10:30 10 February 2006 th 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 DS0000033564.V259033.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. DS0000033564.V259033.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Byker Lodge Address Bolam Way Byker Newcastle upon Tyne NE6 2AT 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) 0191 265 2448 0191 224 2259 angie.gray@newcastle.gov.uk Newcastle City Council Social Sevices Department Ms Angela Mary Gray Care Home 25 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (6), Old age, not falling within any other category (7) DS0000033564.V259033.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 5 beds can be flexibly used to accommodate service users receiving respite care aged 55 to 64 years old, or service users over pensionable age. 3rd August 2005 Date of last inspection Brief Description of the Service: Byker Lodge is a Local Authority home providing care for services users suffering from old age, dementia and mental health problems. The service users are either admitted to the home for respite care or on a short-term emergency basis. All bedrooms have en suite facilities. There are three lounge/dining rooms, small lounges, conservatory and a large secure garden with raised flowerbeds and a water feature. A day centre is attached to the home, which can be used by the service users in the home. There is a range of aids to assist people with disabilities such as hoists, wheelchair access and grab rails throughout the home. The location of the home is convenient for access to the post office, newsagents, general dealers and off licence. There are two social clubs nearby and a public house. DS0000033564.V259033.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over four and a half hours. A partial tour of the premises took place and a sample of care records was inspected along with the fire log book, accident book, maintenance contracts and minutes of meetings held in the home. Discussions were held with the manager and four members of staff. The majority of service users were seen and conversations were held with six service users and one visitor. What the service does well: What has improved since the last inspection? A quality assurance system is being developed by Newcastle City Council. In the meantime the home issues questionnaires to service users to gain their views of the services provided by the home. The manager has achieved NVQ Level 4 in care and management. DS0000033564.V259033.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. DS0000033564.V259033.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 DS0000033564.V259033.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): 2 and 3. Statements of terms and conditions between the service users and the home are in place. Pre-admission assessments are carried out for every service user. EVIDENCE: A copy of the statement of terms and conditions was available on the case files for each service user. This included details of any extra charges. The document is signed by the service user, if they have the capacity, otherwise their representative signs on their behalf. All admissions are made through a single entry point referral process. A sample of case files were examined and all contained a full needs assessment carried out by appropriately trained people. DS0000033564.V259033.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, 8 and 9. The care plans include information to ensure the staff team are well informed about the individual needs of the service users. The service users’ privacy and dignity is respected. The system for dealing with medications is appropriate. EVIDENCE: Six care plans were examined and contained detailed information about personal, health and social needs. The care plans are evaluated regularly and audits are carried out by senior staff. The activities record on two care plans was out of date. A record of appointments with health care professionals is maintained for each service user. The staff on duty were aware of the individual needs of the service users. Comments were made by three service users to confirm that their privacy and dignity is respected. The staff team were observed to be respecting privacy during the inspection. DS0000033564.V259033.R01.S.doc Version 5.0 Page 10 Service users are able to administer their own medications if they are assessed as being able to do so. Lockable facilities are provided in each bedroom. The medication system was examined and found to be in accordance with the pharmacy guidelines. Suitably qualified staff members administer medications and a refresher course has been booked. DS0000033564.V259033.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): 13 and 14. Family and friends are encouraged to visit the home and links with the community are maintained. Service users are encouraged to exercise choice and control in all aspects of their lives. EVIDENCE: The home has an open visiting policy. A conversation was held with one visitor who confirmed they were always made welcome in the home. They said they were grateful for the services offered by the home and the staff were marvellous. The staff escort some service users to the local shops. Service users were choosing where to spend their time in the home. Four service users said they were offered a choice of food at mealtimes. One lady said she would like to do some dusting. The manager confirmed she would facilitate this. DS0000033564.V259033.R01.S.doc Version 5.0 Page 12 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. The home has a satisfactory complaints system in place. Service users are protected from abuse. EVIDENCE: A suitable complaints procedure is in place and complaints leaflets are displayed in the foyer area of the home. One complaint has been received by the home since the last inspection. This has been investigated and satisfactorily resolved. A number of compliments have been received, for example ‘the home went the extra mile’, ‘provided tender loving care without being patronising’, ‘I cannot stress how important the service is’. Policies and procedures for the protection of vulnerable adults are in place and the staff were aware of the procedure to follow if they felt abuse was taking place. The staff team receive training on the protection of vulnerable adults from the manager who has attended a course on adult protection for managers. DS0000033564.V259033.R01.S.doc Version 5.0 Page 13 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, 21, 22, 23 and 26. The home is well maintained, safe, homely and comfortable. Most areas are well furnished and decorated. Suitable lavatories and bathing facilities are provided. Special equipment is provided where necessary. Service users are provided with suitable bedrooms. All areas are clean and hygienic. EVIDENCE: On the day of the inspection the home was welcoming, clean and well maintained. The home is divided into three units, North, South and East and each has its own lounge and dining areas. DS0000033564.V259033.R01.S.doc Version 5.0 Page 14 The carpets in the reception area and corridors were showing signs of wear and tear. A leaking roof had caused damage to the coving in the corridor and caused it to fall off. All bedrooms are single with en suite facilities. Bathing facilities are provided throughout the home and specialist equipment is available. Handrails, hoist and residents’ call system are provided in the home. Bedrooms are pleasantly furnished and decorated. Appropriate facilities are provided. A partial tour of the premises was carried out and all areas were observed to be clean, hygienic and free from offensive odours. Liquid soap and paper towel dispensers have been provided in all en suite facilities and bathrooms to prevent the spread of infection. DS0000033564.V259033.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): 27, 29 and 30. Staffing levels in the home are adequate to meet the needs of the service users. A robust recruitment and selection process is in place. The staff team are trained, skilled and competent to carry out their roles. EVIDENCE: The manager confirmed that staffing levels are being maintained. On the day of the inspection the manager, team leader, one senior care assistant, three care officers, three domestic assistants and a cook were on duty. Mandatory health and safety training is up to date. Sixteen care staff have completed NVQ Level 2 or above and four staff are currently undergoing this training. Specialist training is provided and the manager will be cascading training on dealing with dementia in the near future. The staff on duty were observed to be caring for the service users in a competent and sensitive manner. Good relationships were observed throughout the home. DS0000033564.V259033.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): 32, 35 and 38. The management team are approachable and take their responsibilities seriously. There are systems in place to ensure service users’ financial interests are safeguarded. The staff team promote the health and safety of the service users and staff. EVIDENCE: The staff on duty confirmed that the management team are supportive and approachable. They are committed to providing the best possible care to the service users. Policies and procedures are in place for dealing with the service users’ finances. The staff in the home do not act as appointee or agent for any service users. Money is deposited by service users for safekeeping. A random DS0000033564.V259033.R01.S.doc Version 5.0 Page 17 sample of records and money held was examined. This confirmed that all transactions were appropriately recorded, receipts kept and two signatures retained. Risk assessments are carried out for the individual service users and the premises. All accidents are recorded and monitored on a monthly basis. Fire instruction for the night staff was out of date. Four faulty automatic fire doors had been reported to the Council but have not yet been repaired. A carpet edging in the reception area was loose which could cause a hazard. No other health and safety hazards were observed. DS0000033564.V259033.R01.S.doc Version 5.0 Page 18 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 3 3 X X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 X X 3 X X 2 DS0000033564.V259033.R01.S.doc Version 5.0 Page 19 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2. Standard OP19 OP33 Regulation 23(2)(b) 24 Requirement Plaster coving must be replaced in corridor. An appropriate system must be introduced for quality monitoring. (Previous timescale of 9th May 2005 not met. Automatic fire doors must be repaired. Fire instruction for night staff must be updated. Carpet edging must be made safe. Timescale for action 28/02/06 31/08/06 3 4 5 OP38 OP38 OP38 23(4)(c) 23(4)(e) 13(4)(a) 24/02/06 28/02/06 17/02/06 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. Refer to Standard OP7 OP19 Good Practice Recommendations Record of activities should be up to date. Carpet to be replaced in reception area and corridors. DS0000033564.V259033.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 DS0000033564.V259033.R01.S.doc Version 5.0 Page 21 - 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!