Inspection on 24/08/05 for Charles Lodge

This inspection was carried out on 24th August 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

Charles Lodge 19/06/08

Charles Lodge 10/08/06

Charles Lodge 17/01/06

Charles Lodge 16/02/05

Charles Lodge 08/09/04

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

CARE HOMES FOR OLDER PEOPLE Charles Lodge 75 New Church Road Hove East Sussex BN3 4BB Lead Inspector James Houston Unannounced 24 August 2005 10.30 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. Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Charles Lodge Address 75 New Church Road Hove East Sussex BN3 4BB 01273 777797 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) 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 (OP), 27 of places Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users to be accommodated is twentyseven (27) 2. Service users will be older people aged sixty-five (65) years or over on admission Date of last inspection 16 February 2005 Brief Description of the Service: Charles Lodge is a care home for older people located in Hove accessed by a quiet drive. The home is a three storey detached building with a passenger lift. The home can accomodate up to 27 residents. The home has a lounge, dining room and additional sun lounge at the front of the home. The home has a level garden around three sides of the building. The home is a short distance away from local shops and connected to other local towns by bus services that run close to the home. Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of the twenty-fourth of August 2005. Before the inspection papers held by the Commission for Social Care Inspection were read, and those standards to be inspected read. The inspection in the home took six hours. A tour was made of the whole premises. The inspector met nine residents, a relative, three staff, the manager and the provider’s group manager. A variety of records including five care plans were read. Twenty-three residents were being accommodated in the home on the day of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 6 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 Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 7 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) 3,5 and 6. The home fully assesses prospective new residents. Residents are encouraged to visit the home before admission to assist them in the decision about whether to enter the home or not. EVIDENCE: Records inspected showed that for prospective residents the manager conducts a detailed needs assessment and that, where available, obtains a copy of Care Management assessment documents. Residents said that they had visited the home prior to admission, or that a family member had done so on their behalf. The manager said that she visits residents in the setting where they are before admission when this is deemed necessary. Emergency admissions are not made. The manager will respond quickly where admission is needed over a short timescale. Intermediate care is not offered. Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 8 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 and 9. Care plans are well drawn up. Aspects of the medication systems need attention. EVIDENCE: Five care plans were examined by the inspector. Care plans contain good general information and risk assessments, and are reviewed regularly. Residents are invited to sign their care plans. The group manager said that a new more comprehensive format is being considered. The home ensures that all staff are trained before administering medication and records inspected confirmed this. The home still needs to ensure that the medication cabinet is an appropriate type for the home. There is now a photograph of each resident on their personal drug sheet. The home must ensure that where residents self –medicate their medications are held securely. Records inspected showed that a pharmacist visits regularly to review the home’s systems. Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 9 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. Social activities could be developed over time. Visitors are made welcome. Food served provides daily interest and variety for residents. EVIDENCE: Residents said that they exercise choice about the routines of daily living such as times of getting up and where they eat. Residents said that they are free to participate or not in any activities organised in the home. There is regular musical entertainment in the home, which residents said that they enjoy. The home has been trying for months to recruit a part time activities organiser, and a staff member has now expressed an interest. The manager said carers take individuals out from time to time and a resident confirmed this. Outings are not organised at present. Residents and a visitor said that visitors are made welcome and offered hospitality. Staff confirmed this. Residents said that they enjoy the food served. Staff said that they go round and ask residents about their menu choices. The home has recently been inspected by the Environmental Health Officer, and all the requirements made have been met and a revisit is expected shortly. Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 10 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The home has suitable arrangements to deal with complaints made to it. The homes’ procedures and processes are designed to protect residents in the event of abuse or allegations of abuse. EVIDENCE: The home has a suitable complaints policy, of which residents said they are aware. The log where complaints made to the home are held was inspected. This was well kept. An amendment to one aspect of recording was recommended. The Commission for Social Care Inspection has received no complaints regarding the running of the home in the past year. The home has a suitable adult protection and whistle blowing procedure. Staff said that they are aware of these documents. Records showed that staff have received relevant training since the last inspection. Further training is planned. The procedures have not had to be invoked for anyone resident at the home. The staff group is currently having training in challenging behaviour. Staff said that they are aware of the home’s guidelines on not receiving gifts from residents. Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 11 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) 19,21,24 and 26. The home provides accommodation to a good standard. Bedrooms are well presented. Bathing and laundry facilities are suitable. EVIDENCE: Charles Lodge is a large detached building in its own grounds. The home is on three floors all served by a passenger lift. There is level access into all areas of the home. The large well-tended garden is accessible to residents who said that they enjoy using it. The home has a staff member who does maintenance and replaced during the inspection three broken toilet light bulbs. One door was found to be wedged open and the manager removed the wedge during the inspection. At the last inspection a requirement was made about the assisted bathing facilities for residents. Facilities have been suitably upgraded, and residents said that they are able to have baths or showers as they wish, with staff assistance as needed. Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 12 Residents said that they like their rooms, and that they are able to bring in their own possessions. A record inspected showed that an inventory of residents’ furniture brought into the home is kept. Residents said that they are able to have keys to their rooms but have chosen not to. The laundry is well sited away from food preparation areas, and is suitably equipped, and with a hot wash cycle. The home was clean and tidy throughout. Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29. A competent staff team meets residents’ needs. The home has robust recruitment policies, but some aspects need completing. EVIDENCE: A rota was available for inspection. The roles of staff were added during the inspection. This showed that three staff are on duty during the day and two staff are on waking night duty. There are sufficient ancillary staff on duty. Residents said that when they have to ring their alarm call the response is swift and helpful. The number and variety of needs means that staffing levels will need to be kept under review over time. Residents and staff said that staff turnover is not high. The manager said that agency staff are not used. The manager and her deputy and senior staff from the provider are on call to staff in the home. Recruitment processes are thorough, but in one case a record of proof of identity had not been retained, and there was no recent photograph of the staff member. References are obtained. Advice was given on the reference format. Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 14 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) 32,33, 35 ,36, 37 and 38. The home has an open atmosphere. Quality assurance processes are in place. Residents’ finances are not handled. Staff supervision needs to be more regular. Records are generally well kept. The health and safety of residents and staff is promoted. Some staff need some core training. EVIDENCE: The manager meets residents regularly individually, and sometimes informally after meals. Residents said the manager is very approachable and one said “she is wonderful”. A recent agenda and notes of a staff meeting were made available to the inspector. Staff said that the manager is open to ideas. The home has a format for approaching its stakeholders about how they consider that outcomes for its residents are being achieved by the home and the manager intends to consult again in the near future. The home’s group manager makes regular visits to the home on behalf of the provider. The home does not hold valuables monies on behalf of residents at present, but the facility to do so exists. Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 15 Staff said that they are regularly supervised. Records inspected showed that for some staff this was not quite at the recommended frequency of at least six times per year. Records are securely kept. Those inspected were generally found to be well recorded. The record of food served (including alternatives) contained several gaps. Policies had recently been reviewed and those read were well written. Residents can access their records but said that to date they had not done so. The home has a range of policies on health and safety. Room assessments have been done for residents’ rooms. A recent fire risk assessment for the premises has just been carried out by an outside body, and the findings will be implemented. Records inspected showed that staff have received recent training in fire safety. Some staff have had First Aid training and Health and Safety Training recently, but recent sessions by external trainers for other staff were cancelled by the trainer. Staff need training in infection control. Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 2 x 3 2 2 2 Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 17 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 9 Regulation 13(2) Timescale for action Ensure that the medication 30 cabinet is an appropriate type for September the home. (Previous timescale of 2005. 31/5/05 not met). Ensure that medications held by 31 August residents who self-medicate are 2005 secure. Obtain all the required 31 August information when recruiting 2005 staff. Record in sufficient detail food Immediate. served. Give core training as needed. 30 November 2005. Requirement 2. 3. 4. 5. 9 29 37 38 13(2) 19(1)(b) 17(2) & Sch 4.13 !8(1) 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. 3. 4. Refer to Standard 12 33 36 38 Good Practice Recommendations Develop activities over time. Seek formally again the views of stakeholders as to how the homes achieves outcomes for residents. Supervise care staff at least six times a year. Address recommendations of the recent fire risk assessment. H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 18 Charles Lodge Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 19 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex BN21 4QT 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 Charles Lodge H59-H10 S58240 Charles Lodge V238871 240805 Stage4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!