Inspection on 04/07/06 for Danmor Lodge

This inspection was carried out on 4th July 2006.

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

Danmor Lodge 23/09/08

Danmor Lodge 06/09/07

Danmor Lodge 05/01/07

Danmor Lodge 03/11/05

Danmor Lodge 07/06/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Danmor Lodge 14 Alexandra Road Weymouth Dorset DT4 7QH Lead Inspector Val Hope Unannounced Inspection 4th July 2006 10:10 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 Danmor Lodge DS0000062426.V302543.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. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Danmor Lodge Address 14 Alexandra Road Weymouth Dorset DT4 7QH 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) 01305 775462 01305 781454 Danmor Lodge Ltd Mrs Susan Hasler Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Two double rooms numbered 10 and 12. One person as known to the CSCI within the category MD may be accommodated. Only ambulant persons who are able to understand and react to emergency situations including evacuation of the premises may be located in rooms numbered 24, 25 and 26, on the second floor. One person as known to the CSCI within the category DE(E) may be accommodated. 3rd November 2005 4. Date of last inspection Brief Description of the Service: Danmor Lodge has been owned by Mr & Mrs Hasler since 1994. Mrs Hasler is the Registered Manager in charge of the day to day running of the home. It is a detached property, set in its own grounds/gardens situated close to local shops and a short bus ride from the town centre of Weymouth. The home is registered to accommodate a maximum of 27 service users over 65 years of age. Accommodation is on the ground, first and second floors; a passenger lift and the use of ramps enables smooth access to all parts of the home without the necessity to negotiate steps. Communal facilities include two lounges, conservatory, dining room, 2 assisted bathrooms, a conventional bathroom and a separate toilet. Danmor Lodge is a non-smoking home. The garden is laid to lawns with flower borders and at the front of the house is a patio. There is unrestricted street parking outside the home. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken on Tuesday 4th July 2006. The total time spent on this inspection was 5.5 hours. The purpose of this inspection was to assess the home’s compliance with key National Minimum Standards for Older People. Mrs Hasler the registered manager was on holiday at the time of the inspection, the inspector was assisted throughout the duration of the inspection in a positive and professional manner by the two Deputy Managers employed by the home. Additionally, the inspector toured the premises, examined records and spoke with 14 residents and 2 other members of the staff team. It was ascertained that the named person as specified in Condition 2 to the homes registration has vacated the premises, arrangements will be made to issue a new certificate. Two residents have been accommodated within the home whose care needs are outside the category for which the home is registered; any repeated breaches of the Care Standards Act 2000 will result in the instigation of legal action. What the service does well: What has improved since the last inspection? The inspector was unable to note improvements as this was the first inspection since the home was allocated to her caseload. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 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. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 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 Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 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): 3, 4 and 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Prior to admission the care needs of prospective residents are assessed; evidence that the home confirms in writing that the home is able to meet their assessed needs, was not available for inspection. The service had failed to ensure that the needs of each person admitted into the home were in line with the categories of care, for which the service is registered. Danmor Lodge is not registered to provide intermediate care. EVIDENCE: There was evidence that pre admission assessments of need had been undertaken prior to admission into the home. Records were not available to evidence that prospective residents had been advised in writing that the home was able to meet their assessed needs. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 9 It was noted that one assessment document had no name on it and the resident admission checklist had not been completed, making it difficult for the home to evidence that due care and attention had been paid to assisting the resident to become orientated and settle into the home. There was evidence that two people had been admitted into the home whose care needs fall outside the service’s categories of registration. One person is still accommodated therefore the home must apply for a variation to their registration. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 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): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Care plans would benefit from further expansion to more accurately reflect the care delivered, ensuring and demonstrating all care needs are routinely met. The systems for the administration of medication are satisfactory with clear arrangements in place to ensure service users medication needs are met. Residents are treated with respect, their privacy is protected and staff understand and meet their needs. EVIDENCE: The care records of four residents were examined. Discussion with staff found that they are very knowledgeable about residents care needs. Each resident had a care plan in place in a file in the office; a summarized short term care plan is kept within each residents room as a working document readily available for staff to refer to. Care workers are alerted to changes made to care plans through the handover process at the end of each shift. The content Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 11 of care plans varied in the standard of detailed instruction given to staff as to how specific care needs were to be met. Discussion with residents and staff and examination of records found that care plans did not in all cases accurately reflect the care provided, in two instances more care was being delivered than was recorded in the care plan. A general lack of essential detail was noted throughout care records [care plans/needs assessments/risk assessments] ie lack of residents name, date of the document and signature of the author of the document [see standard 37]. Main file care plans are reviewed on a quarterly basis and the short term plan on a monthly basis. It is recommended that the record of reviews is dated and initialled by the reviewer instead of a ‘tick’ against the month. Risk assessments were in place and these would benefit from further expansion it is recommended that staff undertaking risk assessments receive training in this discipline. Residents are enabled to access NHS services and hospital appointments and domiciliary visits of health professionals were recorded appropriately. Satisfactory policies and procedures relating to medicines are in place. Staff who have responsibility to administer have received training in the Administration of Medication. The medication trolley was well organised and tidy; the records of administration of medication were up to date, legible and appropriately signed. Residents said they feel respected and that care tasks are undertaken in a way that ensures they are able to retain dignity. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 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): All the above were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social, cultural and recreational activities are dependent on individual preferences and the resident’s capacity for involvement. The activities provided by the home meets the expectations of residents. Residents are supported in maintaining contact with their friends, family and the community. A wholesome varied diet is provided, meals are appetising and of good quantity and quality, assisting with the promotion and maintenance of health. EVIDENCE: The inspector spoke to 14 residents; the vast majority expressed satisfaction with the home’s services, including the range of activities, meal provision, staff and premises. A full programme of activities is available to residents and includes events in the home, trips out and visiting entertainers. Residents confirmed that for the most part, they were happy with the level of activities and that routines were flexible. Residents confirmed that their visitors are made welcome and that they are encouraged to maintain their links in the local Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 13 community. The majority of residents take their meals in the ground floor dining room however, some prefer to take meals in their bedrooms. Residents select meals in advance, from a planned menu. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 14 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are managed in accordance with the home’s complaints procedure and residents said they are confident their concerns are listened to and taken seriously. The home has policies and procedures in place designed to protect residents from harm and abuse. EVIDENCE: Most of the residents spoken with said that they feel able to complain to Mrs Hasler or members of staff and know that she will make efforts to resolve any problems. Comments received were varied and included: “If I have anything to complaint about I feel able to tell someone”, “I don’t like to rock the boat so I say nothing”, “When things go wrong they try to put things right, you can’t ask for more than that”, “I am settled here and if I had a problem I would tell Mrs Hasler I’ve no complaints so far” and “It is hard to please a lot of people all at the same time, they try very hard to make it as comfortable as possible and if I had any complaints I feel they would put things right”. The home has policies and procedures for the protection of residents from abuse or neglect. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 15 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): 19, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The standard of the environment within this home is good providing residents with an attractive and homely place to live. For the most part a good standard of cleanliness and hygiene was evident, providing pleasant surroundings for residents. EVIDENCE: The fire door on the first floor landing was found to be damaged and failed to close shut therefore an immediate requirement relating to this was made. Rooms are pleasantly decorated and furnished, residents are able to bring their favourite possessions and rooms were well personalised. With the exception of two rooms no unpleasant odours were detected and a good standard of cleanliness and hygiene elsewhere had been achieved. The replacement of two Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 16 mattresses, the source of the odour of stale urine in two rooms identified to the Deputy Managers, must take place as a matter of priority. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 17 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, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service Recruitment and employment practices designed to minimise the risk of unsuitable staff being employed are not being consistently implemented. EVIDENCE: Staffing levels at the time of the inspection were appropriate for meeting the care needs of the residents accommodated. It was not possible to assess standard 28 in the absence of the registered manager as the deputies were unable to access records to demonstrate compliance with the standard. Examination of records relating to new recruits found that the recruitment process was insufficiently robust, proper checks had not always been undertaken prior to commencement of work. One record did not demonstrate any further investigation or record the rationale for appointing after receiving an unsatisfactory reference. Shortfalls were identified in record keeping relating to staffing for an example the induction record relating to one person did not contain the post, start date or staff signature to confirm induction training had been received. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 18 The records were unable to demonstrate that all new staff had received induction training at the commencement of employment. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service The management arrangements of the home support good care practices for residents. Organisation of some administrative tasks need to be better defined to ensure residents benefit from an efficient administration. The home does not manage the finances of any resident. EVIDENCE: Mrs Hasler is the registered manager, she has two deputy managers to assist her in the day to day running of the home. It was ascertained that to date sufficient time has not been allocated to them in order that they can ensure they are able to undertake the duties as identified in their job descriptions comprehensively. Subsequent to the inspection and prior to production of the report Mrs Hasler confirmed that this has been rectified, additionally evidence was provided to demonstrate that a quality assurance survey of residents views had been undertaken in May. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 20 However, Mrs Hasler stated that she had not provided residents, relatives/friends, health professionals and GP’s with surveys/comment cards the Commission sent to the home for distribution as she had thought it “inappropriate to ask people to fill in again after such a short period of time, however they can be asked again in approximately six months time”. In effect, this decision failed to offer residents, their relatives and other interested parties courtesy and the dignity of deciding for themselves whether they wished to give their views and make comments regarding this service directly to the Commission. The inspector had however, sent comment cards directly to Care Managers and Placing Officers who have had dealings with the home. The comments received demonstrated that a good working relationship with professionals responsible for placing and overseeing care provided by the home has not been established and maintained. Examples of those comments are contained within the Summary of this report, as are comments received from residents. A general lack of essential detail was noted throughout care records [care plans/needs assessments/risk assessments] ie lack of residents name, date of the document and signature of the author of the document [see standard 7]. The home does not manage the personal finances of any resident although there are facilities for the temporary storage of monies and valuables which residents no longer wish to personally hold. Fire Records of periodic routine tests and checks of fire precautions were in order and a fire safety risk assessment has been recorded. Fire safety training has been provided to all staff at the required frequencies and staff to whom the inspector spoke confirmed they had received recent fire training. The home has recorded comprehensive Health & Safety risk assessment of the premises and working practices to identify potential risks and introduce measures to manage/reduce them. The Commission has been previously shown evidence of compliance with the Water Supply (Water Fittings) Regulations 1999 and evidence of safety of the gas and electrical installations. It was reported that at all times there are staff on duty in the home with knowledge of how to deal with accidents and health emergencies. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 21 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 x 2 1 X x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 Standard No Score 16 3 17 x 18 3 1 X X X X X 3 2 STAFFING Standard No Score 27 3 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x x x 2 3 Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 22 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 OP4 Regulation 4, 12, Schedule 1(6) Requirement The registered person must submit an application for variation to accommodate a resident whose needs are not in line with the home’s categories of registration as stated in the home’s statement of purpose. The service must not admit any resident whose care needs are outside the category for which the home is registered. Timescale for action 31/07/06 2 OP7 15 3 OP19 23 [This requirement has been met.[ The registered person must 31/08/06 ensure that each care plan accurately reflects the delivery of assessed care needs. The registered person must 04/07/06 ensure that the fire door on the first floor landing is repaired as a matter of priority. [Prior to production of this report the Registered Manager confirmed this requirement was met.[ The registered person must ensure that two mattresses DS0000062426.V302543.R01.S.doc 4 OP26 16[2] 31/07/06 Danmor Lodge Version 5.2 Page 23 [identified to the home] are replaced. [Prior to production of this report the Registered Manager confirmed this requirement was met on 6/7/06.[ There must be evidence that the home operates a robust recruitment procedure. New staff must not commence work in the home without evidence of suitable CRB and POVA disclosure. Not met from the previous inspection. The registered person must ensure that care records accurately record the persons name, date and signature [where necessary] of the person making entries . 5 OP29 19 & Sched 2 31/07/06 6 OP37 17 Schedule 3 31/07/06 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 Refer to Standard OP7 OP7 OP29 Good Practice Recommendations It is recommended that the record of reviews is dated and initialled by the reviewer instead of a ‘tick’ against the month. It is recommended that staff undertaking risk assessments receive formal training. Upon receipt of an unsatisfactory reference, the home should be able to demonstrate the rationale for selection and appointment where applied. Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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 Danmor Lodge DS0000062426.V302543.R01.S.doc Version 5.2 Page 25 - 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!