Inspection on 19/06/08 for Charles Lodge

This inspection was carried out on 19th June 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Charles Lodge 10/08/06

Charles Lodge 17/01/06

Charles Lodge 24/08/05

Charles Lodge 16/02/05

Charles Lodge 08/09/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Charles Lodge 75 New Church Road Hove East Sussex BN3 4BB Lead Inspector Jennie Williams Unannounced Inspection 19th June 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 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. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Charles Lodge Address 75 New Church Road Hove East Sussex BN3 4BB 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) 01273 777797 01273 777797 Gloria.Draper@njch.co.uk Nicholas James Care Homes Ltd Mrs Gloria Elizabeth Draper Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users to be accommodated is twenty-seven (27) of which a maximum of fourteen (14) can have a dementia type illness. Service users must be older people aged sixty-five (65) years or over on admission. 10th August 2006 Date of last inspection Brief Description of the Service: Charles Lodge is a care home registered for twenty-seven (27) places for residents, of either gender, aged sixty-five (65) years or over on admission. The home is registered for personal care only and can accommodate a maximum of fourteen (14) residents with a dementia type illness. No nursing care is provided at the home. The home is not registered to provide nursing care. District nurses will supply nursing input when needed. The home is part of the Nicholas-James Care Homes Ltd company, who own numerous care homes throughout England. The home is located by a quiet drive and is situated within a residential area in Hove. There is limited car parking available at the home. There are local amenities in the area and there is nearby access to public transport. Residents accommodation is located over three floors that are all serviced by a passenger shaft lift to ensure residents are able to access all areas of the home. There are seventeen (17) rooms for single occupancy, of which fourteen (14) have en suite facilities. There are five (5) double rooms, of which all have en suite facilities. The Registered Manager confirmed that all rooms are used as single occupancy unless people have made a decision to share. The home has a lounge, dining room and additional sun lounge at the front of the home. There is garden area within the grounds that residents are able to access. There are suitable numbers of assisted bathing facilities and communal toilets located throughout the home to meet the needs of residents. Fees range from £314 to £575 per week. Additional fees are: hairdressing, chiropody, personal toiletries and newspapers/magazines (at cost). This information was provided to the CSCI on the 19 June 2008. Additional information regarding additional costs is provided in the Service Users Guide. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. It should be noted that following recent CSCI consultation, it was identified that service users prefer to be called people who use services. It was confirmed that the home uses the term residents or service users. For the purpose of this report, people who use the service will be referred to as residents. This unannounced site visit took place over seven and a half hours on the 19 June 2008. Evidence obtained at this site visit, previous information regarding this service and information that the CSCI have received since the last inspection forms this key inspection report. This report includes information from an Annual Service Review (ASR) that was undertaken on 15 January 2008. This ASR used information that was provided in the Annual Quality Assurance Assessment (AQAA) that the home sent to the Commission. Five residents were briefly spoken with throughout the site visit. All residents eating in the dining room at lunchtime were met and advised to let the Inspector know if they wished to speak with her individually. Ten surveys for residents to complete were sent to the home, of which eight were returned. Five of these were completed independently, whilst all others identified that they were completed with support from friends/relatives. Care plans were not viewed in detail as there were no shortfalls noted at the last inspection. Specific areas of care were viewed in eight care plans. Ten surveys for staff to complete were sent to the home prior to the site visit, of which eight were received. Staff on duty at the site visit were provided with an opportunity to speak with the Inspector, however they confirmed that they had completed a survey. Four staff files were viewed. A tour of the environment was undertaken and some individual rooms were viewed. Medication procedures were inspected. The quality assurance system was discussed and complaint records were viewed/discussed. There were twenty residents residing at the home on the day of the site visit. What the service does well: The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. The pre admission process ensures that only residents whose needs can be met at the home are admitted. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 6 Staff practice reflects a good understanding of residents’ personal and healthcare needs, which ensure that needs are met. Residents’ lifestyle within the home is generally their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. Residents are provided with varied nutritional meals and are provided with choice to ensure their preferences are catered for. Residents feel comfortable to complain, reassuring them that they are being listened to and that action will be taken, if necessary. Residents live in a homely environment and are provided with comfortable indoor communal facilities. Residents’ needs are being met with the number and skill mix of staff on duty. The home is generally run in the best interest of residents. Comments received from current residents living in the home include: ‘ Very nicely situated home, could not be nicer place’, …the staff give us the support we need with kindness and cheerfulness’ and ‘ good, simple home cooking, good adequate portions and a good variety of dishes’. What has improved since the last inspection? What they could do better: The documentation in place for some people does not fully reflect the level of care provided and there is a risk that care may not be consistently provided. Clear risk assessments must be in place for all residents and provide guidance for staff on how to reduce the risk, ensuring the safety of residents. These must be dated, signed and regularly reviewed. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 7 Medication procedures need to be more robust to ensure residents and staff are safeguarded. Advice needs to be sought and confirmation obtained that the controlled drugs cabinet is suitable and installed correctly to ensure compliance with current guidelines. Ensuring all staff receive regular training in Safeguarding Adults will better protect residents and staff and ensure any allegations are dealt with correctly. Robust recruitment procedures need to be followed to ensure service users are safeguarded and evidence that staff have the skills and experience necessary for such work. An effective quality assurance and quality monitoring system should be developed and implemented to ensure that the home is run in the best interest of residents and assist in evidencing that the aims and objectives of the home are being met. Health and safety procedures need to be more robust to safeguard residents’ health, safety and welfare and to ensure the home is free from hazards. The Registered Manager must consult with a fire safety officer to ensure that there is an adequate fire safety procedure in place to ensure the health, safety and welfare of all people within the home. This includes regarding all staff participating in fire drills. Any minor shortfalls noted at the site visit, of which no requirement or recommendation has been made, have been highlighted throughout the report of which the Registered Manager confirmed she will address. These areas will continue to be monitored throughout the inspection process. 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. The summary of this inspection report can be made available in other formats on request. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 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 Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 & 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has information available for prospective residents/representatives on the facilities and services provided to make an informed decision if their needs can be met at the home. The pre admission process ensures that only residents whose needs can be met at the home are admitted. EVIDENCE: The home has a Statement of Purpose and Service Users Guide that is available at the home and provides prospective residents/representatives with information about the services and facilities provided at the home. The service needs to ensure that the contact details for the CSCI in the Statement of Purpose complaints information is updated with the current contact details for the Commission. This information has been updated in the Service Users Guide. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 10 The home is registered to accommodate residential people and people who may have a dementia type illness. The Registered Manager confirmed she keeps in mind the needs of existing residents when assessing any prospective resident. The Registered Manager confirmed that there is no designated accommodation for people with dementia and all residents within the service will intermingle with each other. This has not been a problem to date. The one resident that currently has a dementia type illness is relocating to be nearer their family. Staff are undertaking detailed training in providing care for residents who have a dementia type illness. The Registered Manager undertakes an assessment of prospective residents whenever needed. If one is not undertaken, she obtains a comprehensive assessment from social services on which to base her decision. It was discussed that wherever possible she should still undertake an assessment herself due to the home being their business and to satisfy themselves that the individuals needs reflected are accurate and can be met. There was a social service assessment in place for the individual being admitted on the day. The Annual Service Review undertaken identified that the AQAA stated that the pre admission assessments have been improved. On discussion with the Registered Manager she was unable to identify what had been amended. The Registered Manager confirmed that there was no one residing at the home from any minor ethnic community, social/cultural or religious groups with any specific needs or preferences. Seven of the resident surveys received identified that they received enough information about the home before they moved in so they could decide if it was the right place for them. Written comments identified that relatives had visited the home prior to them moving in. Some residents spoken with and written comments identified that some residents came for a period of respite and decided to remain living at the home on a permanent basis. One comment was ‘Wonderful place to live – I would recommend to anyone to live here.’ The Registered Manager confirmed that it is identified in the contract that the first four weeks of residency is a trial period, to ensure that the individuals needs can be met at the home and the home meets the individual’s expectation. There is no dedicated accommodation to provide intermediate care, however respite is provided if there is a spare room available. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff practice reflects a good understanding of residents’ personal and healthcare needs, which ensure that needs are met. The documentation in place for some people does not fully reflect the level of care provided and there is a risk that care may not be consistently provided. Medication procedures need to be more robust to ensure residents and staff are safeguarded. EVIDENCE: Care plans viewed reflected that needs were identified and had set outcome goals in place, however there was no guidance in place for staff on how to meet these needs. Head office of the organisation has commenced sending detailed care plans to the home that provide guidance for staff on action to take to meet these needs. The care plans viewed identified that they have pre-populated information on them and staff at the home must ensure these are personalised to the individual, to ensure a person centred approach to care Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 12 is promoted. The Registered Manager confirmed that she has not been informed on how to use these care plans and had just been told by head office to put them in the resident’s files. An example of this was that there was a continence care plan in place that was not relevant to an individual. No requirements or recommendation has been made in relation to care plans as there is action being taken to address the shortfalls. It was observed that there is not a consistency of documentation within residents care plans. Discussions were had with the Registered Manager that it will assist staff to provide continuity if all residents files contained the same format of information. On viewing daily notes, it was observed that some staff were writing ‘all care given as per care plan’. Daily records are a good source of evidence to show that care is being provided, as detailed in the care plan, however the term All care given is not helpful or adequate, especially when care plans do not reflect accurately all needs. Daily records when well written, help ensure a consistent approach and good quality of care for residents. It is in the homes interests to be able to show what they have done, along with providing the evidence on which to base the monthly review and to record that they are following the assessment of needs. A risk assessment in place for pressure care identified that an individual was at high risk. The risk assessment was not dated and there was no information to identify what action has been taken or what staff need to do to reduce the risks. Risk assessments need to be dated and reviewed on a regular basis. Risk assessments must be in place for areas of daily living such as; nutrition, the use of door locks, self-medicating etc. It was confirmed that care plans are updated on a monthly basis, however discussions were had with the Registered Manager that care plans should be used as a working document and kept up to date as an individuals needs change. Examples of this were shared with the Registered Manager where some new needs of individuals were not reflected within the care plan, to provide clear guidance for staff on action to take to address the needs. The Registered Manager confirmed that most residents/representative do not wish to be involved in their monthly reviews and documentation is commencing to be put in place to reflect those who choose to be involved or not. Residents receive input from health professionals whenever the need arises. Residents are able to continue seeing their own GP wherever possible. Seven of the resident surveys received identified that they always receive the medical support they need. A written comment was ‘the GP is always informed when I am unwell, and arranged for a visit from a dentist and optician’. Records are maintained of visiting professionals. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 13 Seven of the residents surveys identified that they always receive the care and support they need. A written comment was ‘….the staff give us the support we need with kindness and cheerfulness’. Six of the staff surveys identified that they are always given up to date information about the needs of the residents, two identified they are usually kept up to date. It was confirmed that there are policies and procedures in place for all aspects of dealing with medication. The content of these were not read. Records are maintained of all incoming and outgoing medicines received into and leaving the home. Medication Administration Records (MAR) charts viewed identified that medication is generally being signed for at the time of administration. Photos of the individuals are kept with the MAR charts to assist staff in identifying residents. Staff administering medication have all received training for this procedure. It was observed that where it is prescribed for one or two tablets, staff should be identifying how many they have administered. It is recommended that all handwritten prescriptions are double signed by staff who have received medication training to ensure residents and their colleagues are better safeguarded from errors occurring. On one MAR chart, it was identified that staff were writing the code for ‘refused and destroyed’, however on observation it was noted that these tablets were still in the blister packs. Clear records must be maintained so a clear audit trail of all medicine received and administered at the home is available. Where a medicine had been prescribed for daily use, it was not clear if this was being administered or not. It was confirmed that it was administered ‘as needed’ (PRN). This was not the prescription on the MAR chart. For where creams/lotions have been prescribed there was no information available as to where and when this should be used. No information was within an individuals care plan in relation to this. Although different issues have been identified with medication shortfalls, this is the third inspection of which a requirement has been made relating to shortfalls in medication procedures. Controlled drugs checked identified that accurate records were being maintained. The Registered Manager needs to obtain confirmation that the controlled drugs storage cabinet is compliant and attached to the walls in line with current guidelines. The screws used to attach this cabinet to the wall were standard and could easily be removed. Residents are provided with an opportunity to self medicate, however the home must ensure that there are clear detailed risk assessments in place for those wishing to do this. This is to ensure that they are capable of this and that they and other residents are safeguarded from this procedure. Guidance needs to be in place as to what aspects of self-medication the individual is responsible for. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyle within the home is generally their own choice and residents are provided with sufficient stimulation to fulfil their interests and needs. Residents are provided with varied nutritional meals and are provided with choice to ensure their preferences are catered for. EVIDENCE: Residents spoken with confirmed that their routines of daily living are to their own choice and preference. Residents were observed to move freely within and out of the home throughout the site visit. It was observed throughout the site visit that the atmosphere was relaxed and residents were able to do things at there own pace. A written comment from residents was ‘The bathing and showering facilities are good and very little limitation in timing’. The majority of resident survey and residents spoken with confirmed that there were usually enough activities available for them to take part in, if they choose to. Some identified that they prefer to remain in the own rooms, and staff respects this. Staff undertake the duties of facilitating activities for the Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 15 residents. There is an advertisement on the notice board advising residents of community and social events that are due to take place if they choose to be involved. There are no visiting restrictions at the home. A written comment from a resident stated ‘I am very happy here and there is always a warm welcome for my visitors’. One resident commented to the Inspector ‘I haven’t any relatives in the world and this is my home. Looked after very well here.’ Residents were observed to be enjoying their lunchtime meal. It was confirmed that a choice in meals is provided. There is a notice board that displays what meals are being provided for the day. It is recommended that a list of residents’ likes/dislikes/allergies in relation to food be provided to the cook to ensure that peoples’ preferences are taken into account. It was confirmed that the cook is familiar with the preferences of the residents currently residing at the home. Surveys received identified that five people always liked the meals provided at the home. Written comments ranged from ‘Meals are served with ruined by overcooking with watery, mushy, tasteless, worthless vegetables…., to ‘very good cook’ and ‘the food is always excellent’. One survey identified that the home had been accommodating with their meals when they had a period of requiring additional assistance. The Registered Manager confirmed that there is currently one resident who requires a soft diet and all the ingredients for the meals are liquidised together. They had not thought to liquidise ingredients individually. The Registered Manager must discuss this with the resident and tried in order to assist in the meal being presented nicer and the individual being able to enjoy the individual tastes and flavours of the food. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents feel comfortable to complain, reassuring them that they are being listened to and that action will be taken, if necessary. Ensuring all staff receive regular training in Safeguarding Adults will better protect residents and staff and ensure any allegations are dealt with correctly. EVIDENCE: There is a complaints procedure available at the home that all people have access to. Records of complaints identified that the home takes any concern seriously and takes action to address these. Complaint records identified that any the home has received had been related to the environment, that the maintenance person addressed. An example of this was a drawer handle missing. There is a new complaints form that the home has implemented to assist them to monitor/record complaints in more detail. All resident surveys received identified that the individuals knew how to make a complaint with seven confirming they always knew who to speak to if they were not happy about anything. All staff surveys received identified that they knew what to do if someone raises concerns about the home. The Registered Manager confirmed that she undertook Safeguarding Adults training some years ago. It was recommended that she look into accessing Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 17 training designed for managers to attend to ensure she is kept up to date with current guidelines. Staff have received training in Safeguarding Adults, however it was identified that some staff have not undertaken this training since 2005, whilst others received training in September 2007. The Registered Manager confirmed that she will be ensuring that staff will receive Safeguarding Adults training on an annual basis and will arrange updates for those that are out of date. No requirement or recommendation has been made in relation to this, as action will be taken to address this shortfall. This will continue to be monitored throughout the inspection process. There have been no Safeguarding Adults alerts made since the last inspection. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents live in a homely environment and are provided with comfortable indoor communal facilities. EVIDENCE: The home is located down in a residential are within Hove. It is located at the end of a private road. The sign at the end of the driveway identifying where the home is cannot be read. The Inspector had trouble locating the home and the Registered Manager confirmed that visitors often ring to locate the home, as they are unable to find it. This needs to be addressed. A written comment from residents was ‘ It is in a quiet location but accessible to shops etc.’ The registered provider has previously applied for building permission to provide an extension on the home. The Registered Manager informed the Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 19 Inspector at the site visit that an application for building an extension is again being submitted to the local authority. The CSCI has previously expressed concerns to the registered provider regarding these proposals, as the extension will take up the communal external area that is currently used and enjoyed by residents living at the home. On tour of the environment, it was observed that the home is generally well maintained and residents live in a homely environment. Some areas require some additional attention. These include, some radiator guards to be installed, ensuring radiator guards are secured to the wall, cleaning of extractor fans and ensuring they all work. There was a hot water tap noted to not be thermostatically controlled. This was in an area that residents have access to, however it was confirmed that residents do not use the sink and there was no one currently at the home of risk from this. No immediate requirement was left in relation to this as the Registered Manager confirmed that she would ensure this was addressed. It was advised that risk assessments be put in place for the interim period. The Registered Manager confirmed that they have thought about the use of signage throughout the home to assist is orientation of those residents who may have a dementia type illness. This will be implemented as and when the need arises. There is no written programme for refurbishment and the Registered Manager confirmed that rooms are redecorated as and when needed. Seven resident surveys identified that they always find the home fresh and clean. There were no offensive odours noted on the day of the site visit. Attention needs to be made to ensuring under the bath hoist seats are kept clean to promote infection control. Hand towels were noted to be in use in some communal areas, as well as paper towels. These areas should be restricted to the use of paper towels only to assist in infection control. There is no sluice machine provided at the home and it was confirmed that commodes in use are emptied down the toilet and bleached. Staff must ensure that full protective clothing are used when emptying commodes and it is recommended that the home seek advice from the Health Protection Agency in regards to good infection control practices when no sluice facilities are available. The home has a contract with a company for disposal of clinical wastes. Residents have expressed the wish to have a birdbath in the garden. The home is planning to have a fete to raise funds for this. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ needs are being met with the number and skill mix of staff on duty. Robust recruitment procedures need to be implemented to ensure residents are safeguarded. EVIDENCE: Feedback from residents identified that they were complimentary about the staff working at the home. Six of the resident surveys identified that they felt that there were always staff available when needed. One written comment was ‘there is sometimes a shortage of staff around meal preparation and bed times. Five staff surveys identified that they felt there is always enough staff on duty to meet the needs of residents; with three identifying there is usually enough staff on duty. The Registered Manager confirmed that there a four care staff working in the mornings, three in the afternoons and two care staff that work a waking night. The Registered Manager confirmed that she keeps staffing levels under review. The Registered Manager is on duty during the weekdays and is additional to the numbers above. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 21 The home employs 20 care staff; of which 9 have achieved NVQ level 2 in care or above. A further four staff have just commenced this training. Staff files viewed identified that more robust recruitment procedures must be implemented to ensure residents are safeguarded. Ensuring application forms are fully completed will assist in addressing some of the shortfalls, such as gaps in employment, reasons for leaving etc. Of the four files viewed, it was noted that three of the staff members had commenced employment without a Protection of Vulnerable Adults (POVA) first check or full Criminal Record Bureau (CRB) being obtained. One of these members of staff only had one reference in place, which was not signed or dated to identify when it was completed or who it was from. Staff surveys identified that they receive training that are relevant to their roles, helps them to understand and meet the needs of residents and keeps them up to date with new ways of working. The Registered Manager confirmed that all new staff undertake an in house induction programme. It was discussed with the Registered Manager that she ensures that this complies with the Common Induction Standards as set by the Skills for Care. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is generally run in the best interest of residents, however further work on monitoring the service will assist in evidencing that the home meets its aims and objectives. Health and safety procedures need to be more robust to further safeguard residents’ health, safety and welfare. EVIDENCE: The Registered Manager ensures she keeps herself up to date with current practices and attends training sessions that are provided to staff. She has completed her Registered Manager Award course, but has not undertaken any National Vocation Qualification training. She should consider undertaking NVQ Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 23 level 4 in care as recommended in the National Minimum Standards. The Registered Manager confirmed that she receives support from head office of the organisation whenever required. The ASR undertaken identified that they intend to have a deputy manager undertake NVQ level 4 in care and the Registered Manager Award courses. The Registered Manager confirmed that as part of the quality assurance and quality monitoring system within the home, surveys are provided to residents twice a year to obtain their feedback on the care and services provided at the home, ensuring that it is run in a way that meets their expectations. Resident meetings are held every six months. It was confirmed that there is no formal system in place to obtain feedback from relatives/visitors, staff or visiting health professionals. Staff are provided with an opportunity to have an input into the service at staff meetings. Surveys returned by residents are shared with the staff. The system in place is currently different from what the home advertises in their Statement of Purpose. Discussions were had with the Registered Manager on ways that their quality assurance system could be further developed and ways in which the results of their quality assurance surveys be displayed or shared with all people who have an interest within the home, including external stakeholders. Health and Safety checks are undertaken on a monthly basis, except fire alarms are checked weekly. It was confirmed that an external company undertook a fire risk assessment of the home in September 2007. The Statement of Purpose identifies that a full fire drill is conducted monthly. On discussion with the Registered Manager, she confirmed that fire drills have not been undertaken with night staff. Management must seek advice from a local fire officer to ensure that this complies with current guidelines. Some door guards in use on fire doors were not being used effectively or working efficiently. The Registered Manager confirmed that this has been identified and action is being taken to address this shortfall. Regulation 26 reports undertaken by a designated person within the company was available for inspection. These monthly visits assist the company in monitoring their service and ensuring it is meetings it aims and objectives. The home continues to send ‘notifications’ to the CSCI as legally required. The home does not hold any personal allowances. Residents maintain their own finances or have made their own arrangements if they require assistance. Other health and safety shortfalls noted at inspection have been highlighted throughout the relevant sections of the report. Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 13(4) (b&c) Requirement That clear risk assessments are in place for all service users and provide guidance for staff on how to reduce the risk, ensuring the safety of the service user. These must be dated, signed and regularly reviewed. That safe procedures for the safe handling and administration of medicines are followed at all times to ensure service users and staff are safeguarded. That advice be sought and confirmation obtained that the controlled drugs cabinet is suitable and installed correctly to ensure compliance with current guidelines. That robust recruitment procedures are followed to ensure service users are safeguarded and evidence that staff have the skills and experience necessary for such work. That an effective quality assurance and quality monitoring system is developed and implemented to ensure that the DS0000058240.V365293.R01.S.doc Timescale for action 31/07/08 2. OP9 13(2) 17(1)(a) 31/07/08 3. OP9 13(2) 15/10/08 4. OP29 19 Schedule 2 31/07/08 5. OP33 24 31/08/08 Charles Lodge Version 5.2 Page 26 6. OP38 23(4)(e) 7. OP38 13(4) home is run in the best interest of service users and that the aims and objectives of the home are met. That following consultation with a fire safety officer that there is adequate fire safety procedures in place to ensure the health, safety and welfare of all people within the home. This is particularly in relation to fire drills. That the home undertakes a comprehensive environmental health risk assessment to ensure the home is free from hazards. 15/08/08 15/08/08 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 OP9 Good Practice Recommendations That all handwritten prescriptions are double signed by staff who have received medication training to ensure residents and their colleagues are better safeguarded from errors occurring. That a list of residents’ likes/dislikes/allergies in relation to food be provided to the cook to ensure that peoples’ preferences are taken into account. That the home seek advice from the Health Protection Agency in regards to good infection control practices when no sluice facilities are available. 2. 3. OP15 OP26 Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Charles Lodge DS0000058240.V365293.R01.S.doc Version 5.2 Page 28 - 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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