CARE HOMES FOR OLDER PEOPLE
Conifer Lodge 33 Aylestone Lane Wigston Magna Leicestershire LE18 1AB Lead Inspector
Diane Butler Unannounced 24 May 2005 at 10.00am 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. Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Conifer Lodge Address 33 Aylestone Lane Wigston Magna Leicestershire LE18 1AB 0116 2883170 0116 2883170 na Mrs Kemp Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Anne Crooks Care Home 20 Category(ies) of OP - Old age - 20 registration, with number DE(E) Dementia over 65- 14 of places MD(E) Mental Disorder - over 65 - 3 PD(E) Physical Disability - over 65 - 16 SI(E) Sensory Impairment over 65 - 2 Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: No person falling within category SI(E) to be admitted to the home when three persons of that category are already accommodated within the home No person falling within category DE(E) to be admitted to the home when fourteen persons of that category are already accommodated within the home No person falling within category MD(E) to be admitted to the home when three persons of that category are already accommodated within the home No person falling within category PD(E) to be admitted to the home when sixtee persons of that category are already accommodated within the home No person falling within category MD(E)or DE(E) to be admitted to the home when fourteen persons of that category/combined category are already accommodated within the home Date of last inspection 24th May 2005 Brief Description of the Service: Conifer Lodge is a care home for older persons, providing accommodation and personal care for up to twenty residents. The Registered Provider is registered to provide care in the home for service users with additional needs relating to dementia (up to fourteen places), mental ill health (up to three places), physical disability (up to sixteen places) and sensory impairment (up to two places). The home is situated in Wigston Magna, close to shops and local amenities. Accommodation is on two floors, the upper floor accessed by lift or stairs. There are four lounges available to residents, two of which include dining space. All bedroom accommodation is in single rooms. The home has a small rear slabbed garden area and a decked area to the front of the property with seating and access for service users. Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over five and half hours and commenced at 10.00am on 24th May 2005. The main method of inspection used was ‘case tracking’ which involved selecting four service users and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The Commission for Social Care Inspection is inspecting Conifer Lodge for the seventh time and is in its third year of inspections being inspected against the Care Standards Act 2000. The senior care assistant was most helpful during the inspection process. What the service does well: What has improved since the last inspection?
Since the last inspection the new extension has been opened offering a further six places taking the number of residents that can be accommodated from fourteen to twenty. The accommodation in the new extension offers a further lounge/dining room, bathroom, toilet and six ensuite bedrooms all accessible by a second lift. A new driveway/car park with garden feature at the centre has recently been completed at the front of the home. Staff have commenced further dementia training to ensure that they up to the minute information and knowledge to care for residents suffering with this illness.
Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 6 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. Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4,5 Standard 6 was not applicable at the time of the inspection. Prospective residents are invited to look around the home and are given clear and detailed information about the services offered to enable them to make an informed decision about admission to the home. EVIDENCE: • A revised Statement of Purpose was received from the owner prior to the inspection. This document includes information about the home including details of the new extension, which was recently opened, and the expertise and abilities of the staff working in the home. Four residents files were checked during the inspection. All four files included copies of the resident’s terms and conditions of residency, and three of the four included an assessment of need completed by the manager. • Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 9 • On speaking with a resident who had recently moved into the home, the inspector was informed that they had had the opportunity to look around the home before deciding to move in. Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.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) 7,8,9,10 Residents are currently looked after well in respect of their health and personal care however lack of care plans or risk assessments for some residents could potentially put their health and welfare at risk. EVIDENCE: • Of the four files looked at three of them included care plans. The fourth belonging to a resident who had moved into the home the previous month had yet to be commenced. The care plan belonging to a resident who needed a lot of care did not include all of the actions the staff were expected to carry out. This included regular turning to alleviate pressure to the body. Although not all the care plan documentation was in place it was evident throughout the inspection that the residents care needs were being met. Staff spoken with were all aware of the individual needs of the residents and residents spoken with confirmed their needs were being met. Evidence was seen of GP’s and community nurses visiting, with the Community Nurse and GP visiting on the day of the inspection.
C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 11 • • Conifer Lodge • On checking the daily records belonging to the residents who were case tracked it was noted that a safety risk had been identified for one resident. On checking the residents care plan it was noted that a risk assessment had not been completed with regard to this risk or action taken to minimise the risk until the day of the inspection, some two weeks later. The Procedures for the administration of medication were in order with all paperwork completed appropriately. The contracting pharmacist last checked the homes medication procedures on 31st January 2005 with no issues arising. • Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 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 standard(s) 12,13,14,15 Social activities and meals are both well managed, creative and provide daily variation and interest for residents living in the home. EVIDENCE: • Residents are offered choices on a daily basis. Choices include what to wear, whether to join in activities offered, where to eat meals, when to get up or go to bed or whether to join in church services and communion. Residents spoken with during the inspection explained: “Its homely, marvellous, the staff are more like friends here” “We’ve always got something to do” “I love singing” • • • During the inspection a musical entertainer arrived to offer a sing a long to the residents. All the residents spoken with stated how good the food was. Menus seen were well balanced and varied. The meal served during the inspection was well presented and hot.
C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 13 Conifer Lodge 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) 16,18 Arrangements for the receiving and responding to complaints are sound resulting in satisfactory protection of resident’s rights. Staff awareness of actions to take should any form of abuse be suspected ensures protection of the residents in their care. EVIDENCE: • There is a procedure in place for making a complaint and this is included in the Statement of Purpose document. The senior care assistant on duty at the time of the inspection explained that no complaints had been received since the last inspection in January this year. This statement was supported on checking the complaints book. A service user spoken with stated “I would tell one of the staff if I was not happy”. Staff spoken with during the inspection were aware of what to do should they suspect any act of abuse. A carer recently promoted to a senior care position had yet to be made aware of the Protection of Vulnerable Adults procedure. Knowledge of this would ensure the protection of residents in their care. • Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26 The standard of the accommodation within this home is extremely good, providing residents with an attractive and homely place to live. EVIDENCE: • The home is well maintained and suited to the residents needs. It is decorated and furnished to a standard that creates a comfortable and homely environment. All areas of the home inspected were clean, fresh and well cared for. A new driveway and car park has recently been created at the front of the home and a decked area at the side of the home offers residents a place to sit. The senior on duty at the time of the inspection stated that the enclosed garden to the rear of the home was due to be landscaped in the near future. This will then provide further sitting space for residents.
C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 15 • • Conifer Lodge Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 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 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) 27,29 Staff are employed in sufficient numbers to meet the current needs of the residents. Appropriate procedures for the recruitment of staff are in place to ensure the protection of residents living in the home. EVIDENCE: • There were sufficient numbers of staff on duty on the day of the inspection to meet the current needs of the residents. Staff spoken with confirmed this and felt they were able to care for the residents without feeling rushed. The staff on duty were well aware of the care needs of the residents and had the appropriate training to look after the residents in their care. The files belonging to the two newest staff members were checked. Criminal Record Bureau checks were in place though references could not be located for either staff member. The senior care assistant who was in charge at the time of the inspection stated that they had definitely received some references but could not find them. Through discussion with both staff members it was evident that they had both the knowledge and experience to care for older people. • • Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.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) 31,32,37,38 The home is managed efficiently and appropriate policies and procedures are in place to ensure the continued safety of the residents. EVIDENCE: • The registered manager is currently completing a National Vocational Qualification level four in care and management, and all staff and residents spoken with stated that she was approachable and supportive. It was evident during the inspection that the residents benefit from the ethos, leadership and management that the manager provides. Fire records were in order with the last fire drill being carried out on 5th May 2005.
C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 18 • • Conifer Lodge • • All staff were aware of procedures to follow with regard to infection control and the appropriate protective equipment was being used. The necessary policies and procedures are in place and staff are aware of how to access them. Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 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 3 3 x x x x 3 3 Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.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 7 Regulation 15 Requirement The Registered Person must: 1: ensure that care plans are in place for all service users. 2: ensure all identified care needs are included in the care plan. The Registered Person must ensure that the necessary risk assessments are completed to ensure the safety of the resident and act on the findings. The Registered Person must ensure that two references relating to each staff member are in place Timescale for action With immediate effect on reciept of this report. 2. 8 13 3. 29 19 With immediate effect on reciept of this report. With immediate effect on reciept of this report. 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 18 Good Practice Recommendations It is recommended that all senior staff are instructed/reminded of the proceedure for the Protection of Vulnerable adults and be made aware of the
C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 21 Conifer Lodge 2. 3 Department of Healths guidance No Secrets. It is recommended that the needs assessment completed before admission to the home be completed more thoroughly enabling the assessor to gain a clearer picture of the residents needs and whether these can be met by the staff in the home. Conifer Lodge C51 S1677 Conifer Lodge V228814 240505.doc Version 1.30 Page 22 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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