Inspection on 19/12/05 for Crowborough Lodge

This inspection was carried out on 19th December 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 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

Crowborough Lodge 07/06/07

Crowborough Lodge 13/07/06

Crowborough Lodge 18/05/05

Crowborough Lodge 05/10/04

Crowborough Lodge 01/06/04

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

CARE HOMES FOR OLDER PEOPLE Crowborough Lodge 2 Crowborough Road Saltdean East Sussex BN2 8EA Lead Inspector Merle Blakeley Announced Inspection 19th December 2005 10:00 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 Crowborough Lodge DS0000037605.V250387.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. Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Crowborough Lodge Address 2 Crowborough Road Saltdean East Sussex BN2 8EA 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 302614 Evans Care Ltd Mrs Bernadette Mary Weller Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of residents to be accommodated is twentythree (23) Residents must be older people aged sixty-five (65) years or over on admission One named resident with vascular dementia to be accommodated Date of last inspection 18th May 2005 Brief Description of the Service: Crowborough Lodge provides care and accommodation for up to twenty-three older people who generally do not have a high level of need. The home is a large detached residence with sea views and is situated in a quiet residential area off the A259 main south coast road in Saltdean. Local transport, shops and other amenities are located close by. Accommodation is provided on three floors and there are currently fifteen single rooms and four shared rooms. Communal areas consist of a large and small lounge, dining area, sunroom and a small garden area to the rear of the building. There are current plans to expand the service, as Evans Care Ltd has purchased the adjoining property. Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection took place over a period of four hours on 19th December 2005. The inspection process included a returned pre-inspection questionnaire, eleven service users comment cards, chatting with several residents, a tour of the premises, document reading and informal talks with the proprietor, manager and staff on duty. What the service does well: What has improved since the last inspection? What they could do better: Some of the care plans need to be reviewed and updated on a more regular basis. The information contained in them also needs to be much more comprehensive. Homely remedies need to be recorded in a separate book or quite clearly identified on residents MAR sheets. Staff need to make sure that they read the fire/call bell panel information accurately and that they respond to all call bells efficiently. Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 6 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. Crowborough Lodge DS0000037605.V250387.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 Crowborough Lodge DS0000037605.V250387.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): 1&2 The home has produced a service users guide. Residents are provided with contracts. EVIDENCE: The home has produced a brochure for residents, which includes a service users guide, statement of purpose and terms and conditions. Contracts are provided and are signed by residents. Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 & 10 Overall care plans were up-to-date; however there were some that needed more regular reviews. A separate book needs to be made available to record all homely remedies. Staff were seen to treat residents with dignity and respect. EVIDENCE: Several care plans were viewed during the inspection. Key workers are responsible for updating and reviewing residents care plans and generally they appeared to be informative and up-to-date, however there were several that did not have any recent reviews written up and the information they did contain was very basic. The home needs to ensure that all key workers are provided with training in care planning and that they understand the principles of these important records. Care plans must be comprehensive and relevant and provide a complete history of that persons assessed needs. Medication records were checked and appeared to be in order. Two of the residents self medicate and risk assessments had been carried out on them. The home needs to record all homely remedies that are administered to residents or that residents administer themselves. Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 10 Staff were seen on the day to treat residents with dignity and respect. Residents are called by their preferred name and it was stated that their personal beliefs, religion and cultural needs are also respected. Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 11 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): 12 & 14 A staff member is responsible for the weekly programme of activities. Residents are able to exercise choice and control over their lives. EVIDENCE: A staff member has the role of activities co-ordinator and he is responsible for organising a weekly timetable. At present residents are being offered quizzes, short local walks, regular sing songs, film afternoons and visits to a local pub on Friday. One to One sessions with residents are also held. Residents meetings are held to discuss future activities. At present residents feel that enough suitable activities are being offered. The home feels that it is able to provide residents with choice and decisionmaking. Each persons assessed needs are looked at on an individual basis. Staff will support residents where necessary and many residents have relatives and friends who will also assist them in making important choices and decisions in their lives. All residents are offered choices in regards to meals, activities and how their personal care is carried out. Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has produced a complaints policy and procedure. EVIDENCE: The home has compiled a complaints policy and procedure, which includes all the relevant information about how a resident can go about making a complaint. The home has not received any complaints. Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 13 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): 21, 25 & 26 The home provides suitable bathing facilities. Residents live in a safe environment. The home is clean and tidy and maintained to a good standard. EVIDENCE: The home provides residents with adequate bathrooms and toilets. There are seven bathrooms throughout the home, some of which are assisted. Eleven bedrooms have en suite facilities. Hot water temperatures are checked on a regular basis. Recent records show the temperatures are between 43°C - 46°C. Annual Legionella testing is also carried out. During the last inspection two freestanding heaters were viewed in residents bedrooms and a requirement was made for the home to mount these heaters on the wall. This has been carried out. Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 14 On the day the home was found to be clean and tidy with no offensive odours. The home employs two cleaners over a seven-day period. Overall, the home is maintained to a good standard. Crowborough Lodge DS0000037605.V250387.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): 27, 28, 29 & 30 The home has a stable staff team. Staff are progressing well with NVQ Qualifications. Staff have attended core skills training. EVIDENCE: The home currently employs twenty-seven staff on a full and part-time basis. There are five full-time and seven part-time care staff, three part-time cooks, two cleaners and six teatime helpers. The staff team remains stable and they are providing residents with a good level of care. Residents who were spoken to on the day stated that the staff were friendly and helpful. Staff are progressing well with the NVQ qualifications. Two staff have almost completed NVQ Level 3 and another has almost completed NVQ Level 2. A night staff member is due to commence her NVQ training soon. Staff recruitment files have been updated to include all the information as set out in Schedule 2 of the National Minimum Standards, however the home still needs to include recent photos of each staff member. All staff have now attended training in Adult Protection and they have also completed Fire Training, Manual Handling and Food Hygiene. Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 16 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): 34, 36 & 38 The home carries out suitable financial procedures. Staff supervisions are carried out. The home needs to ensure that staff respond to call bells in a timely manner. The home has installed a new fire alarm system. EVIDENCE: The home carries out suitable accounting procedures. Staff annual appraisals are carried out and staff supervisions are recorded and signed by the manager and staff member. The manager is aware that staff supervisions needs to be held at least six times a year. The home has recently installed a brand new fire alarm system that includes sensors and heat detectors and this conforms to the latest fire safety recommendations of BS5839, which will come into force in April 2006. There is a central panel, which identifies the precise location and nature of any hazard or fault. Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 17 During the inspection the inspector tested a call bell in one of the bathrooms on the second floor. Staff did not appear to respond very quickly and there seemed to be some confusion amongst staff as to where the alarm had been pressed. It took several minutes for a staff member to finally come up to the bathroom. Staff do need to respond to call bells much more quickly and a requirement will be made for staff to receive further training on how to use the call bell and fire alarm system. No other health and safety issues were identified during the inspection. Crowborough Lodge DS0000037605.V250387.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 3 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X 3 X X X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 3 X 3 X 2 Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 19 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. 2. Standard OP29 OP7 Regulation Schedule 2 15(2)(b) Requirement That all staff recruitment files contain current photographs of staff. That all service users care plans are updated regularly and that they contain detailed information relevant to the care and welfare of each person. That all homely remedies are recorded. That staff receive further training on how to respond to call bells efficiently. Timescale for action 31/01/06 19/12/05 3. 4. OP9 OP38 13(2) 13(4)(c) 19/12/05 19/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex 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 Crowborough Lodge DS0000037605.V250387.R01.S.doc Version 5.0 Page 21 - 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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