Inspection on 29/06/05 for Carmel Lodge

This inspection was carried out on 29th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Carmel Lodge 27/01/09

Carmel Lodge 30/01/07

Carmel Lodge 29/11/05

Carmel Lodge 01/09/04

Carmel Lodge 28/04/04

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

CARE HOMES FOR OLDER PEOPLE Carmel Lodge 576 Harrogate Road Leeds West Yorkshire LS17 8DP Lead Inspector Michael Smithson Announced 10 am. 29 June 2005 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. Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Carmel Lodge Address 576 Harrogate Road, Leeds, West Yorkshire LS17 8DP 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) 0113 2371133 0113 2682822 Donishorpe Hall Limited Mr Tapera Robinson Mahachi Care home only 22 Category(ies) of Dementia over 65 (22) registration, with number of places Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 1 September 2004 Brief Description of the Service: Carmel Lodge is owned by Donisthorpe Hall (a company limited by guarantee) which operates under a registered Charitable Trust. The company also operates a larger care home in the area. Carmel Lodge has been open since 1993. It has recently been refurbished and altered in order for the registration to include people with a diagnosis of dementia. Up to twenty-two service users can be accommodated at any one time. Carmel Lodge is a large detached property, which has been extended to provide the current accommodation. The home has a parking area to the front, with double gates to prevent service users walking onto the main road. The front door is operated using a digital device which is only accessible to staff and visitors. The rear of the property is fenced off. A walk way and gardens are available in this area. There is a range of amenities in the locality and the area is well served by public transport. The home has eighteen single and two double bedrooms. All rooms have en-suite facilities. Service users are encouraged to bring their own furniture and cherished items with them. There is one communal lounge, a dining room and three communal bathrooms available for service users. An emergency call system is fitted throughout the home, which is used to summon assistance by service users, staff and visitors. Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit was announced and took place over the morning and afternoon of the 29/06/2005. This was the first inspection for this inspection year. The next visit will be unannounced. Copies of this and previous inspection reports are available from either the home or on the CSCI website. The visit focused on any outstanding requirements from the last inspection, the service user records, discussions with service users, visitors and staff. During the course of the inspection I spoke to 12 service users, 1 visitor and interviewed 2 members of staff. Feedback comment cards were provided and 5 were returned prior to the inspection. The feedback from all the discussions and comment cards was positive. The service users appeared happy and well care for and were able to walk freely around the home. The visitor felt the staff were very patient and skilled in meeting the needs of the service users. What the service does well: The areas of the home seen during the inspection were bright, clean and provided items of interest for service users. A very good range of activities were offered which help to keep service users stimulated. The staff were pleasant, helpful and skilled in dealing with the needs of service users. Any interventions were undertaken in a professional manner which helped to diffuse potentially difficult situations. The mealtime was an enjoyable experience. The tables and the food were very well presented and a choice was offered. Staff were on hand to provide any assistance required and service users were allowed time to enjoy the meal. All the service users were well presented. Time had been taken to choose appropriate clothing and many of the ladies wore small items of jewellery and other accessories. The service user records were detailed and informative. The care plans include identified needs and are regularly up dated. A key worker system is in place Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 Page 6 which allows staff good levels of input into the records and make sure individual needs are identified and are met. What has improved since the last inspection? What they could do better: The staff training records need to be brought up to date and all staff must have a record of the training provided. More progress must be made to achieve the required 50 NVQ 2 qualified staff. The home only has one NVQ 2 qualified member of staff and one currently completing the course. Protection from abuse training must be provided for all staff. Evidence must be provided that this training has been completed. The levels of supervision must be improved. Only one formal supervision session takes place per year. The requirement is for 6 sessions to be held. Evidence of the outcomes of the supervision are not held on the premises making it difficult to follow up on issues raised. Monthly visits do appear to be undertaken by the directors. However monthly reports are not completed following the official Regulation 26 visits. The complaints procedure does not provide clear information for people. The complaints procedure is titled Donnisthorpe and does not refer to Carmel Lodge. The procedure does not include any contact information for either Donnisthorpe or Carmel Lodge. It was suggested that Carmel Lodge should have its own complaints procedure included in the booklet produced for service users and visitors. Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 Page 7 The laundry system must be improved to make sure personal items are returned to the service users. Spare cushions should be provided for the lounge chairs to replace those being laundered. 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. Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 Page 8 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 Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 Page 9 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) 1, 2, 3 and 5. The home ensures that it can meet the needs of prospective residents before they are admitted. EVIDENCE: The statement of purpose and service user guide are available and are regularly reviewed. A simplified version of the information is provided specifically for service users and visitors. Terms and conditions of residency are, organised and held centrally at the organisations headquarters at Donnisthorpe Hall. The documentation was not seen during this inspection. The care documentation for 3 service users was checked. All the records included a detailed pre-admission assessment format. The information helps the manager to determine that the home can meet the needs of service users and would be appropriately placed. Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 10 and 11. The health care needs of residents are met. Care plans provide clear and detailed instructions for staff to follow. Service users are treated with respect and their privacy is upheld. EVIDENCE: Case studies were undertaken for 3 service users. The records were very detailed and included information regarding pre-assessment, health care assessment and monitoring, and a care plan. The care plans all included information which was relevant to the individual service users. Risk assessments had been completed for areas of risk, including manual handling, wandering and behaviour monitoring. A key worker system is in place and guidance is available to assist key workers in completing the care records. During discussions with staff it was evident that they were clear as to their role and were confident they could complete the care records to a good standard. Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 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 Service users are encouraged to be part of the decision making process and make choices about their lifestyle. They are supported to maintain contact with family and friends, and visitors are welcomed at the home. A good, varied and nutritious diet taking into account individual choices is provided at the home. A very good range of activities are provided for service users. EVIDENCE: A very good range of activities are offered at Carmel lodge. The daily activities are displayed on the activities board. During conversations with a visitor, service users and staff it was confirmed that the activities do take place. On the morning of the inspection an organist played for approximately 2 hours. In the afternoon the staff organised a music and dancing session. The activities offered are varied and meet the needs of the service users. Reminiscence therapy and crafts are provided. A reminiscence board in the lounge provides visual items of interest for service users. I joined the service users for lunch and found a very good quality of food was provided. A 3 course lunch is available and service users are offered a choice. The tables were decorative with a good range of utensils provided. The Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 Page 12 mealtime was a positive, leisurely experience where service users were given time to enjoy the meal. Assistance was provided by staff when required. Time was spent with a regular visitor to the home who was very positive about the home. He felt his wife was very well cared for and the staff were pleasant skilled and had a high level of patience. He confirmed he was free to visit at anytime and liked to help his wife take breakfast in a morning. Some concerns were raised regarding the organisation of service users personal laundry. The laundry is now done off premises at Donnisthorpe Hall. The feeling was that since it is not done at Carmel lodge there has been far more instances of laundry going missing. The manager is aware of theses concerns and is monitoring the system to see if improvements can be made. Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 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 and17 The complaints information does not provide all the information required to enable service users and visitors to raise concerns specifically about Carmel Lodge. Adequate training regarding protecting service users from abuse has not been provided for all staff. EVIDENCE: The manager informed me that no complaints had been received since the last inspection in September. I found the complaints procedure confusing. The information is not included in the statement of purpose or the user guide or the handbook. A separate complaints booklet is provided, however it refers to Donnisthorpe and does not include Carmel lodge. The complaints procedure does not include any telephone contact information for the home or the organisation. A detailed adult protection procedure is available. Training regarding adult protection is included in the staff induction. The manager said that further training had been provided, however this was not included in the staff training records. Adult protection has been included in the homes training plan to be completed in August. Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 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. Only 1 of these standards was assessed at this visit. The security of the premises has improved, however further improvements can be made to protect service users. EVIDENCE: A full building inspection was not undertaken during this visit, however the outstanding requirement from the last inspection regarding security of the premises was assessed. The external security has been improved since the last inspection. However the boundary fence to the lounge/dinning room side does require further security. This work is being completed in the near future. The standards of decoration and cleanliness in the communal areas was of a good standard. However a number of cushions were missing from the lounge chairs. Spare cushions should be made available to replace those being laundered. Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 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, 28, 29 and 30. The numbers and skill mix of staff were sufficient to meet the needs of the service users. There are good recruitment procedures in place to protect service users. The training records do not provide evidence of the training provided at the home. EVIDENCE: The staff recruitment records are all organised and held at the organisations headquarters at Donnisthorpe Hall. The manager is involved in the interviews, however does not have sight of the completed CRB check or the 2 references. A spot check of the records was undertaken at Donnisthorpe Hall and the required information was available. The home currently has a vacancy for a part time care worker. The remaining staff team has remained fairly stable. The training records for staff are not kept up to date. A number of the new staff do not have individual training records and some of the existing staff records do not include information on courses attended. The home has made little progress in meeting the required levels of NVQ 2 trained staff. Only one member of staff has completed the courses and one is Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 Page 16 in the process. There is requirement that 50 of the care staff achieve NVQ level 2 before the end of 2005. Interviews took place with 2 of the staff team. The staff had differing levels of experience of the care industry. Both showed a very good understanding of their role and the needs of the service users. They felt the home provided a positive environment for service users and workers. They confirmed they were able to contribute to the day to day running of the home. Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 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 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, 32, 33, 36 and 37. The manager is skilled in many aspects of the day to day running of the home. However some of the required information is held centrally at Donnisthorpe Hall. Where copies of information are not kept at Carmel Lodge this is to the detriment of the running of the home. The recording of the staff supervision provided by the organisation and for the individual staff could be improved. EVIDENCE: The manager is a qualified nurse with a number of years experience running a care home. He is currently undertaking the Registered Managers Award and hopes to complete in October this year. Regular staff meetings are held which allow staff to contribute to the day to day running of the home and future planning. The manager does not complete Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 Page 18 the required numbers of individual staff supervision and appraisal sessions. The staff only receive formal supervision and appraisal once a year. The manager also said that the records of appraisals are held at Donnisthorpe Hall and a copy was not available at Carmel Lodge. To allow the manager to follow up issues raised in the appraisals the information must be kept on the premises. Monthly visits are undertaken by the directors of the organisation, however no written reports are provided. The last report available was from 2002. The organisation must provide a report following each Regulation 26 visit to the home. Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x x STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 3 3 x x 2 2 x Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 Page 20 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 OP16 Regulation Reg 22 Requirement The complaints procedure must improved. Contact information for the home must be included. The home must have its own complaints procedure. Protection from abuse training must be provided for all staff. Evidence that the training has been undertaken must be available. The fencing at the lounge/dinig room side of the buiding must be improved. All staff must have a record of training provided. The records must be kept up to date. Greater progress must be made to meet the required 50 levels of NVQ level 2 trained staff. The manager must complete the Registred Managers Award. A report must be produced following the monthly Reg 26 visits. The report must be available on the premises. Timescale for action 01/08/05 2. OP18 Reg 13(6) 01/10/05 3. 4. 5. 6. 7. OP19 OP30 OP30 OP31 OP37 Reg 23(2) Reg 18 Reg 18 Reg 9(1) Reg 37 Immediate Action 31/12/05 31/12/05 Immediate Action 8. Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 Page 21 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 OP 10 OP 36 Good Practice Recommendations The system of personal laundry should improved. The recommended number of 6 supervision sessions must be completed. The records must be available on the premises. Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Carmel Lodge J52 S1433 Carmel Lodge V226827 290605 Stage 4.doc Version 1.30 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. 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