Inspection on 03/08/05 for Byker Lodge

This inspection was carried out on 3rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 10/02/06

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 3 August 2005 10.00 rd 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 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. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Byker Lodge Address Bolam Way Byker Newcastle upon Tyne NE6 2AT 0191 265 2448 0191 224 2259 angie.gray@newcastle.gov.uk Newcastle City Council Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Angie Gray CRH 25 Category(ies) of DE(E) Dementia - over 65 (12) registration, with number MD(E) Mental Disorder over 65 (6) of places OP Old Age (7) Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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. Date of last inspection 9/3/05 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 placed in the home for respite care or on a short term emergency basis. All bedrooms have en suite facilities. There are three lounge dining rooms and kitchen, small lounges, conservatory and a large secure garden with raised flower beds 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 deal and off licence. There are two social clubs nearby and a public house. Nearby are St. Peters Basin Marina and Newcastle Quayside. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over six and a half hours. A partial tour of the premises took place and a sample of care records were 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 eight members of staff. The majority of service users were seen and conversations were held with four service users and two visitors. Two questionnaires were returned by the service users and six were returned by relatives/visitors. What the service does well: What has improved since the last inspection? The benches and units have been replaced in the small kitchen areas on each unit and the carpets have been replaced in three bedrooms. These were requirements made at the last inspection. It was also recommended that net curtains should be placed at the windows overlooking the car park. These have been provided. The National Minimum Standards require at least 50 per cent of the staff team achieve NVQ Level 2 by 2005. The number of staff who have achieved NVQ Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 Page 6 Level 2 or above has increased since the last inspection from 37 per cent of the staff team to 79 per cent. The manager is now registered with the Commission. 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. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 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 standard(s) 2, 3 and 5. Statements of terms and conditions between the service users and the home are in place. Detailed pre-admission assessments are carried out and where possible new service users are invited to visit the home prior to admission to ensure their individual needs can be met. EVIDENCE: A copy of the revised statement of terms and conditions was available for inspection. 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. Six case files were examined and all contained a full needs assessment carried out by appropriately trained people. Service users admitted for respite care are offered the opportunity to visit the home prior to admission but this is not always possible for emergency admissions. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 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 standard(s) 7, 8, 9 and 10. The care plans include all the necessary information which helps ensure that the staff team are well informed about the needs of the service users. The service users’ privacy and dignity is respected. The medication procedure and system were appropriate. EVIDENCE: Six care plans were examined and were well organised and up to date. They contained detailed information about the personal, health and social needs. Each service user is allocated a key worker. The staff team on duty were observed to be aware of the needs of the service users. Regular meetings are held in the home where service users are asked their opinion on the services offered in the home. There are currently no service users who are able to administer their own medications. Lockable facilities are provided in each bedroom should a service user be capable of holding medications. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 Page 10 The medication system was examined and found to be satisfactory. However, the key to the medication system is not held on the person in charge of the shift. Suitably qualified staff administer medications and drug audits are carried out on a weekly basis. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 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 standard(s) 12, 13 and 15. A wide range of activities take place both inside and outside of the home according to the individual preferences of the service users. Family and friends are encouraged to visit the home and links with the community are maintained. Menus are varied and nutritional and a choice is available. EVIDENCE: A list of activities taking place both inside and outside of the home was provided for inspection. The staff stated that most activities are planned but some need to be spontaneous due to the nature of the service. The service users can also participate in activities taking place in the day centre attached to the home. On the day of the inspection a mini bus had been booked to take some service users on a trip to South Shields where they had enjoyed a pub lunch. Some service users were enjoying walking around the garden. One service user was agitated and a member of staff had escorted her to the garden to look at the flowers to help her feel better. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 Page 12 The staff on duty confirmed that they often escort some service users to the local shops. Two visitors were present during the inspection and one service user was entertaining their visitor in one of the small lounges. The questionnaires returned by relatives all confirmed that they were able to see their relatives in private and confirmed they were consulted about their care. Four weekly menus are in place and these are reviewed on a regular basis. The staff were observed to be offering a choice of meal at lunchtime and second helpings were offered by the staff. The food was well presented and the portion sizes were ample. The meal was relaxed and unhurried and the staff were sensitive to the service users’ needs. The dining room tables were appropriately set with condiments, napkins and flowers. Where possible meal times are flexible and one lady was observed to be having breakfast at 11 am. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 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 standard(s) 16 and 18. Complaints are addressed appropriately and 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. Two complaints have been received by the home since the last inspection. These have been investigated and satisfactorily resolved. A record of compliments is also available. 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 existing staff team have received formal training on the protection of vulnerable adults and new staff members have been booked on the course. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 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 standard(s) 19, 20, 25 and 26. The home is well maintained, safe, homely and comfortable. All areas are well furnished and decorated. A pleasant garden is available and this is attractive and accessible. 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. No unpleasant odours or health and safety hazards were noted. Service users and relatives were observed to be enjoying the garden that is well maintained, attractive and a handrail has been provided around the parameter. One member of staff has been nominated to be the contact person with the Infection Control Nurse and will cascade any necessary information to the staff team. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30. Staffing levels in the home are adequate and the staff are trained, skilled and competent to do their jobs and to meet the needs of the service users. The staff team are committed to offering a high standard of care to the people using the service. EVIDENCE: Staff rotas were examined and showed that staffing levels are being maintained. On the day of the inspection there were adequate numbers of staff on duty to deal with the needs of the service users. The staff confirmed that they received regular mandatory training and specialist training to deal with the individual needs of the service users. They were observed to be caring with the service users in a competent and sensitive manner. Good relationships were observed throughout the home. One visitor commented that the staff were very good and wished their relative could remain in the home on a permanent basis. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 35 and 38. The home is well run and the management take their responsibilities seriously. The manager ensures that the home is run in the best interests of the service users and there are systems to ensure their financial interests are safeguarded. The staff team promote the health and safety of the service users and the majority of risk assessments are in place. EVIDENCE: Since the last inspection the manager has become registered with the Commission and is currently undergoing training to obtain the Registered Managers Award. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 Page 17 Service users are consulted in all aspects of the day to day running of the home and this information is recorded in minutes of meetings. There is no formal system to follow up any comments made. 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. Monies are deposited in the by service users for safe keeping. A random sample of records and monies were examined. This confirmed that all transactions were appropriately recorded, receipts kept and two signatures retained. The staff receive regular training in health and safety issues and all accidents are recorded and monitored on a monthly basis. Risk assessments are carried out on the premises by staff in the home on a regular basis. A fire risk assessment is carried out by a member of staff from Newcastle City Council on an annual basis. This should be carried out on a regular basis according to the recommendations of the fire safety officer. Up to date maintenance certificates were not available for the fire alarm, emergency lights, hoists and electrical appliances. The manager stated that these would need to be obtained from the Civic Centre but confirmed the tests had been carried out. No health or safety hazards were observed during the inspection and staff sign to confirm they receive regular fire instruction. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x x x 3 x STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 x 3 x 3 x x 2 Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 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. Standard 3 Regulation 13(2) Requirement Key for medication cupboard must be kept on the person in charge of the shift in accordance with the pharmacy guidelines. Manager must achieve NVQ Level 4 in care and management or the equilavent. An appropriate system must be introduced for quality monitoring. (Previous timescale of 9th May 2005 not met. Regular fire risk assessments must be carried out and copies of maintenance contracts must be forwarded to CSCI. Timescale for action 03/08/05 2. 3. 31 33 19(2)(b) 24 31/12/05 30/9/05 4. 38 23(4) 31/8/05 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 33 Good Practice Recommendations Introduce a system to ensure comments made at service users meetings are followed up. Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection 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 Byker Lodge v232068 b53-b03 s33564 byker lodge v232068 030805 stage 4.doc Version 1.30 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. 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