CARE HOMES FOR OLDER PEOPLE
Carmel Lodge 576 Harrogate Road Leeds West Yorkshire LS17 8DP Lead Inspector
Michael Smithson Unannounced Inspection 29th November 2005 10:30 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 Carmel Lodge DS0000001433.V265431.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. Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Carmel Lodge Address 576 Harrogate Road Leeds West Yorkshire LS17 8DP 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) 0113 2371133 0113 2682822 Donisthorpe Hall Limited Mr Tapera Robinson Mahachi Care Home 22 Category(ies) of Dementia - over 65 years of age (22) registration, with number of places Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. That the Manager, Mr T R Mahachi, registers to undertake a certified diploma course which relates specifically to adults with a diagnosis of dementia 29th June 2005 Date of last inspection 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 DS0000001433.V265431.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection and was the second inspection for this year. Sight of reports for this and previous inspections are available either at the home or on the CSCI website. This inspection focused mainly on the environment and any outstanding issues from previous inspections. The inspector also spent time speaking to service users and observing the daily routines. The home continues to provide a good service for service users who suffer from Dementia. The staff team appeared skilled and understanding to the special needs of the service users. This helps to create a friendly environment and any possible confrontation is quickly diffused. What the service does well:
The building provides a very good environment for service users. The home is maintained to a very good standard of decoration and hygiene. Good quality fixtures and fittings are available and service users can personalise their bedrooms with pictures, photographs and ornaments. The care documentation was well organised and kept up to date. Individual care plans have been produced which include the identified aims and objectives and provide a record of any progress or deterioration. A friendly atmosphere exists at the home. The service users appeared happy and content. Many were sat chatting or reading the paper. A number were late risers and were still having breakfast. Some of the service users were happily wandering around the building. The staff were busy undertaking the daily routines, however they did take time to spend with service users in and amongst their duties. Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better:
The home is still not achieving the targets for 50 NVQ level 2 qualified staff. One has completed, one is nearing completion and 2 are due to commence. The general organisation of the records of the training provided must be improved. The records of the mandatory training were not up to date. The manager had given the staff the responsibility for keeping their training records up to date. This was clearly not working. The manager must take on the responsibility for keeping the records up to date. Staff supervision needs to be improved and not all staff have had 1 session. The requirement is for 6 sessions a year. The blood sugar monitoring records must be recorded each day. The service user does often refuse to co-operate with the test and no reading is obtained. This must be recorded to keep the records up to date. The medication administration records need to be accurate and kept up to date. Two signatures must always be available following administration of controlled drugs.
Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 Page 7 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 DS0000001433.V265431.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 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 the following standard(s): 3 and 4. Service users and relatives are provided with information to enable them to make an informed choice about the home. All service users are properly assessed prior to admission. EVIDENCE: The records for the last 2 admissions to the home contained a detailed preadmission assessment. The assessments were completed following a domiciliary visit undertaken by the registered manager. This allows the manager the opportunity to talk to the service user and family to provide information regarding the care provided at Carmel Lodge. The assessments include details of a diagnosis of Dementia to determine that the placement would be appropriate and in line with the registration categories. Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 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 the following standard(s): 7, 8 and 9. The health and personal care needs of service users are well met by the staff at the home. The records were informative and up to date. EVIDENCE: The care documentation for 3 service users were checked during the inspection. One was a very recent admission and little information had been recorded. The previous placement had provided very detailed information regarding the service users needs. The manager was taking the opportunity to let the service user settle before finalising the care plan. The other 2 records were very informative and included detailed care plans, medical information and risk assessments. The information is kept up to date by the staff team. One service user was a diabetic and required daily blood sugar level monitoring. A format had been produced to record the information, however there were gaps noted. The service user does often refuse to cooperate with the staff. The staff must remember to record this.
Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 Page 11 A spot check was undertaken of the medications. The home uses a blister pack monitored dosage system provided by a local pharmacist. The medications were well organised and the records were generally kept accurate and up to date. However a small number of discrepancies were noted regarding the signatures of the staff administering the medications. A number of second signatures were also missing from the Controlled Drug records. Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Service users are offered the opportunity to make choices in their daily lives. EVIDENCE: Service users are offered the opportunity to make choices in their daily lives and the home makes sure that proper risk assessments are in place. The service users are free to use many of the areas around the building and there is a security system in place to maintain a safe environment for service users. Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 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 the following standard(s): 16,18 The adult protection and complaints policy and procedure ensures that service users are listened to and are protected from abuse. EVIDENCE: At the last inspection it was noted that the complaints information specific to Carmel Lodge did not provide adequate contact information. A new complaints leaflet has been produced specifically for Carmel Lodge, however the printers have omitted the contact information. A new leaflet has been ordered. More staff have now completed adult protection training. This includes the manager and the senior staff. More training is planned in January 2006. Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 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 the following standard(s): 19,20,21,22,23,24,25 and 26 The premises are very well maintained and are safe. Good levels of specialist equipment ensure that independence is maintained and service users needs are met. EVIDENCE: A full building inspection was undertaken during this visit. The premises were maintained to a very good standard. Good quality fixtures and fittings are provided. The home was maintained to a very good standard of hygiene and cleanliness. The majority of the bedrooms are single rooms although a small number of double rooms are available. All the bedrooms include en-suite facilities. Service users, staff and family have personalised the bedrooms with pictures, photographs and ornaments. All the bedrooms have door locks, however the service users tend not to keep them locked. Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 Page 15 The bathrooms and toilets were kept clean and adequate lifting aids are provided. A shaft lift is in place linking the ground and first floor. The communal areas are well maintained and include objects of interest for service users. The lounge area can open directly to an enclosed rear garden. The home has a good security system to provide a safe environment. The fencing to the side of the building was being replaced at the time of the inspection. This will provide additional security. Only minor issues were noted following the building inspection. These include: Bedroom 2 The door handle was loose and must be repaired. Bedroom 4 The chair in this room is worn and must be replaced. The fire doors are fitted with an automatic closing device. A number of the devices have torn the carpet when closing. This must be rectified and any damage repaired. Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 Page 16 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 and 30. The staffing levels were adequate to meet the needs of the service users. A good level of training has been provided to ensure staff had appropriate skills to meet their needs. However the records need to be improved to provide evidence of the training. EVIDENCE: A good range of training is provided for the staff team. The majority is organised via the organisations main establishment Donnisthorpe Hall. The current staff induction and mandatory training records do not provide adequate evidence of the training provided. The responsibility to complete the records has been given to the staff, however it was clear that they were not keeping the records up to date. The manager must take responsibility for keeping an accurate record of all staff training. The home is still not meeting the target for 50 NVQ level 2 qualified staff. Only 1 of the 14 care staff has completed the course. One is due to complete in December and 2 are due to commence in December and January. Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 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 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, 36 and 38. The home is well run and staff are involved in the decision making process. EVIDENCE: The manager is nearing completion of the Registered Managers Award. A staff supervision programme is in place. The manager and the senior care staff are responsible for completing supervision with the care staff. However all the care staff have not yet had one supervision session. The requirement is for 6 sessions per year. No health and safety issues were noted during this inspection. However one of the training records which were not up to date was the fire safety training record. This must be addressed. Carmel Lodge DS0000001433.V265431.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 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 1 X X Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation Reg 13(2) Requirement The medication administration records must be kept up to date. Two signatures must be provided for administration of controlled drugs. All staff must have a record of training provided. The records must be kept up to date. The fire safety training records must be prioritised. Greater progress must be made to meet the required 50 levels of NVQ level 2 trained staff. The manager must complete the Registered Managers Award. All staff must be provided with the required levels of supervision. Timescale for action 31/12/05 2. OP30 Reg 18 31/12/05 3. 4. 5 OP30 OP31 OP36 Reg 18 Reg 9(1) Reg 21 31/12/05 31/12/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 Page 20 1. OP8 The blood sugar monitoring records should be kept up to date. Carmel Lodge DS0000001433.V265431.R01.S.doc Version 5.0 Page 21 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
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