Inspection on 24/11/05 for Craigielea Lodge

This inspection was carried out on 24th November 2005.

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

Craigielea Lodge 17/05/06

Craigielea Lodge 15/04/05

Craigielea Lodge 01/10/04

Craigielea Lodge 23/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Craigielea Lodge Lyndhurst Avenue Low Fell Gateshead Tyne & Wear NE9 6AY Lead Inspector Mr Lee Bennett Announced Inspection 09:45 24 Nov 2005,19 Dec 2005 & 4 Jan 2006 th th th 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 Craigielea Lodge DS0000007388.V251235.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. Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Craigielea Lodge Address Lyndhurst Avenue Low Fell Gateshead Tyne & Wear NE9 6AY 0191 482 5823 0191 487 0639 sj@craiglea.fsbusiness.co.uk 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) Gateshead Dispensary Housing Association Limited Patricia Anne Hillary Care Home 33 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (2), Old age, of places not falling within any other category (33), Physical disability over 65 years of age (2), Sensory Impairment over 65 years of age (2) Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Categories MD(E), PD(E) and SI(E) relate to current residents only. Date of last inspection 15th April 2005 Brief Description of the Service: Craigielea Lodge is care home, providing personal care for up to 33 older people. Nursing care is not provided, but District Nursing services can be arranged where necessary. It is a purpose built care home with accommodation provided over two floors, with level access throughout. A lift provides access between the two floor of the home. Adapted bathing facilities have been provided, and there are hand rails fitted to the corridors. There are garden areas to the front and around the home. This includes a paved seating area. The home is situated in the Low Fell area of Gateshead, near to local public transport links. It is also situated near to a wide range of local facilities, including a doctors surgery, a library, shops, pubs and places of worship. Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over 6 and a half hours and was a scheduled announced inspection. The inspection included a separate review and analysis of the pre-inspection questionnaire, and comment cards received from service users and their relatives / representatives before, during and after the inspection. In line with CSCI policy, this report also includes details of any complaints in respect of this care home investigated by CSCI. A tour of the building took place, and a sample of staffing and service users records was inspected. Service users, staff, the registered manager and visitors were spoken with, and the inspector took a meal with service users on the first floor. The judgements made are based on the evidence available to the inspector on the day of the inspection, the pre-inspection questionnaire supplied by the prospective manager and the comment cards completed by service users and their relatives. What the service does well: A relaxed atmosphere is apparent within the home, and staff retain a good rapport with service users. Visitors are made welcome. Service users comments included: • • • “I’m quite happy here.” “I can assure you we’re looked after well.” “It’s a home from home.” A good standard of accommodation is offered for service users, a programme of refurbishment and redecoration continues, and staff work to positively engage service users in activities. Mealtime arrangements include a choice for each meal, and independence in this area is promoted. There is good evidence of work with other professionals, including the GP, social workers, and so on. Care is provided in a discreet manner. Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 Page 6 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. Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 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 the following standard(s): Standards 2 and 6. Each service user has a written contract / statement of terms and conditions with the home, which provides information on the rights and obligations of both parties. This would benefit from review and updating to clarify the arrangements adopted when service users are admitted to hospital or other care setting. Craigielea Lodge does not currently provide intermediate care and rehabilitative services. EVIDENCE: Each service user is provided with a contract, outlining various terms and conditions regarding their occupancy within the home. Where a service user has been placed with the assistance of a local authority their residency is also determined by the detail of the contract between the local authority and the home. Should a person move to the home under a ‘private’ arrangement then they would be supplied with a standard form of contract between the home and service user only. Service user deemed as ‘self-funding’ by the local Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 Page 9 authority can still, if assessed by that authority, be placed under the local authority contract. The Commission for Social Care Inspection received a complaint relating to the contract, and it’s implementation. The Commission has a limited regulatory role in respect of agreements between care homes and service users, and in effect the complaint is a private dispute. Nevertheless, the contract, on inspection, was found to provide no specific detail on the arrangements that apply when a service user is admitted to hospital or other care facility, such as the fee rate applicable, the holding open of accommodation, the continued provision of services, and so on. It is recommended that this be reviewed, and amended in the light of this review. Further advice may be available from the Office of Fair Trading, who have recently published a lengthy report on contracts between care homes and service users. Craigielea Lodge DS0000007388.V251235.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): Standards 7, 8 and 9. Each service user has a care plan in place that, on the whole, reflects their observed needs. This can assist in guiding care practice and ensuring consistency where necessary. Staff within the home liaise with various health care professionals to help ensure that service users’ health care needs are identified and met. Recording practices regarding medication are in need of review, monitoring and to be subject to clear guidance to ensure they consistently reflect current good practice. There is to potential for recording and stock keeping errors to occur where medication administrations are signed off for several service users at once. EVIDENCE: The service users’ care plans that were inspected provide guidance to staff on those need areas observed by the inspector, such as assistance with eating, mobility and anxiety. Guidance in relation to pressure care for a service user assessed as being ‘at risk’ has been developed following a requirement made Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 Page 11 in the last inspection report. Care plans have been periodically evaluated, and daily progress notes are also written up by care staff. Service users’ health care needs are detailed within their care plan files, and any contact with health care professionals is listed within their monitoring records. The input of such professionals (such as the District Nurse) is obtained where necessary, for example to attend to dressing, monitor blood levels and so on. Areas of risk to health (such as a high falls risk), or where care practice can impact on a service user’s health and wellbeing (such as special dietary requirements) are detailed within the service users care plan, to offer guidance to care staff in these areas, and thereby promote service users health and wellbeing. The administration of medication was observed at the main meal time. Three service users were supplied with medication before this was documented. This must be done on a service user by service user basis. This is an outstanding requirement. Craigielea Lodge DS0000007388.V251235.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): Standards 13 and 15. Service users are able to maintain family and other contacts should they wish. This can help ensure they do not become socially isolated. Service users receive a varied and well presented, choice based, menu. This can help promote their general health and wellbeing. EVIDENCE: Visitors regularly call to the home, and all of the questionnaires received from service user’s relatives and representatives indicated that they are welcomed in the home, and that they are able to visit their relative or friend in private. The home has several small communal dining rooms / lounges, should service users wish to meet people in private outside of their own room. Service users are offered choices at meal times, and the lunchtime meal was well presented, nutritious, and served in a congenial setting. Service users commented positively on the meal provided. Craigielea Lodge DS0000007388.V251235.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): Standard 16. A clear complaints procedure is available in the home, which can enable service users’, and their relatives to raise issues regarding the operation of the care home. EVIDENCE: Service users and relatives indicated that, on the whole, they were aware of the home’s complaints process. Of the 23 comment cards received from service users 20 stated that they were aware of who to speak to if they were unhappy with their care. Similarly 17 relatives stated that they were aware of the home’s complaints procedure. 2 were not. Several stated that they had accessed this and the homes own records indicate that 1 complaint have been received during the last twelve months. There has been one complaint regarding the home passed on to the Commission during the past twelve months. See standard 2 above. Craigielea Lodge DS0000007388.V251235.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): Standards 19, 21, 24 and 26. The home is clean, well decorated and maintained. This can help promote a positive image for service users, and ensure they remain comfortable and safe. The service users’ bedrooms inspected are spacious and are furnished to a good standard. This can contribute to their comfort during their stay at the home. EVIDENCE: The service users’ rooms were clean and many contained furniture and possessions personal to the person. They exceed 12 square metres and either have en-suite toilets or toilet facilities near by. A rolling programme of redecoration is in place. Accommodation is provided over two floors, both of which have level access. Adaptations, such as accessible baths and walk in shower facilities have been installed to assist those service users who find it difficult to use standard facilities. Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): Standards 28, 29 and 30. Service users are protected by the home’s recruitment procedures. This can help ensure that unsuitable candidates do not gain employment in the home. Staff have received some training relevant to their job roles. Broader and more frequent training opportunities need to be planned now that they have achieved their NVQ awards in care. This can contribute to their understanding of service users’ needs and competence to undertake their job. EVIDENCE: Staff records indicate that the manager does has not received an ‘enhanced’ Criminal Records Bureau disclosure prior to staff commencing duties. On several occasions staff have commenced duty prior to a POVA first check being received. The reliability of references varied, for example two being written ‘to whom it may concern’, another describing a candidate as ‘unreliable’. There was no evidence that these had been followed up. Some inconsistencies in the employment histories of candidates were also noted. Again there was no evidence that these had been followed up in any way. One member of staff had been recruited without any references, a POVA first check or CRB disclosure being received. The registered manager must ensure that detailed and thorough pre employment checks are undertaken before any care worker commences duty. Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 Page 16 This is a requirement of this report, and will be subject to a specific follow-up inspection. Care staff have received training fire safety and adult protection during 2005. Several have undertaken a course of study to attain an NVQ award in care. A broader range of training is planned for 2006 as the focus of staff development moves on from NVQ work, and this will be monitored during 2006 to judge how this is implemented. The manager has indicated that 50 of the care staff team have attained an NVQ qualification in care, at level 2 or higher. Craigielea Lodge DS0000007388.V251235.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): Standard 38. Health and safety practices in the home keep service users safe. This contributes to the health and welfare of service users. EVIDENCE: The home is kept clear of hazards to the health and safety of service users, visitors and staff. Craigielea Lodge DS0000007388.V251235.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 3 X X 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 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 X 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 Page 19 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 OP9 Regulation 13(2) Requirement The registered manager must ensure that those staff administering medication sign the Medication Administration Record immediately following each medicine administration. This is an outstanding requirement, the previous action plan date for completion being 15/4/2005 The registered manager must ensure that staff commence work only after the receipt of full and satisfactory pre employment checks, including an enhanced CRB disclosure. Timescale for action 14/02/06 2 OP29 19(4) (a to c) 20/12/05 Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 Page 20 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 OP2 Good Practice Recommendations The contract / residency agreement should be reviewed to indicate more clearly the arrangements and responsibilities (such as fee levels, retention of bedrooms, review and assessment arrangement, sharing of information, return to the home, and change of needs) on both parties following an admission to hospital or other care setting. Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Craigielea Lodge DS0000007388.V251235.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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