Inspection on 07/06/05 for Danmor Lodge

This inspection was carried out on 7th June 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

Danmor Lodge 23/09/08

Danmor Lodge 06/09/07

Danmor Lodge 05/01/07

Danmor Lodge 04/07/06

Danmor Lodge 03/11/05

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 Gloria Ashwell Unannounced 7 & 29 June 2005 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. Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Danmor Lodge Address 14 Alexandra Road Weymouth Dorset DT4 7QH 01305 775462 01305 781454 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) Danmor Lodge Ltd Mrs Susan Hasler Care home only 27 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two double rooms numbered 10 and 12. 2. One person as known to the CSCI within the category MD may be accommodated. 3. 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. Date of last inspection 20/12/04 Brief Description of the Service: Danmor Lodge has been owned and managed by Mr & Mrs Hasler since 1994. 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 has been recently extended to provide more bedrooms and additional facilities; it accommodates a maximum of 27 service users over sixty-five years of age. Accommodation is on the ground, first and second floors; a passenger lift and the use of ramps enables smooth access, without the necessity to negotiate steps, to all parts of the home. Communal facilities include two lounges, a conservatory, a dining room, two assisted bathrooms, a conventional bathroom and a separate toilet. Danmor Lodge is a ‘non-smoking home’. There is unrestricted street parking outside the home and the garden is laid to lawns with flower borders and at the front of the house is a patio with garden furniture Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was one of the two statutory inspections required in accordance with the Care Standards Act 2000. No complaints against the home have been received or investigated since the last inspection. The inspection took place over two days; the inspector arrived unannounced at 09.45 on 7 June 2005. During that morning she spoke to 13 residents and 3 members of staff. The inspector observed staff interaction with residents, the carrying out of routine tasks and toured the premises, departing at 11.00. A selection of information and comment forms were left with the home for service users. As agreed following the visit on 7 June 2005, the inspector returned to the home at 10.30 on 29 June 2005 and together with the manager/registered providers Mr & Mrs Hasler and their employed personnel advisor considered evidence relating to the National Minimum Standards, as described in this report. Prior to her departure at 13.30 the inspector issued one Immediate Requirements to the home regarding recruitment practise. The duration of the 4 days of inspection was 4 hours and 15 minutes. What the service does well: The home provides good care to residents who are assisted to maintain as much independence as possible and are encouraged to maintain contact with the local community. Meals are appetising and of good quantity and quality. The premises are comfortable, with two lounges and a dining room, and attractive gardens. Staff are kind and helpful to residents. Residents are treated with respect and their privacy is protected. Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 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. Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.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 Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.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) 3 & 6 Standard 6 is not applicable because the home does not provide intermediate care. Prior to admission, the needs of each proposed resident are assessed to ensure the home will be properly able to meet them; the home then writes to the prospective resident confirming the ability to properly care for them. EVIDENCE: The records of a recently admitted resident included details of pre-admission assessment carried out by the manager when she visited the person at home. Because the prospective resident was at the time unwell, two close relatives visited Danmor Lodge and viewed the room in which the resident was to be accommodated. The inspector spoke to the resident who confirmed that pre-admission assessment had been carried out and that relatives had visited the home to view the room. The resident was satisfied with Danmor Lodge and considered the standard of care very good. Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 Page 9 Following pre-admission assessment, if the home decides to offer a place to a new resident, Mrs Hasler writes to the person stating that the home will be able to meet their assessed needs. Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.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 Care needs are described in a written plan of care ensuring staff have information necessary to provide correct care to each resident. The standard of care is good; residents feel well cared for. Medicines prescribed by doctors are safely stored and carefully administered to residents by staff, unless the residents have chosen to store and administer their own medicines. Risk assessment has been recorded for those who selfadminister. Residents are treated with respect, their privacy is protected and staff understand and meet their needs. EVIDENCE: Care records of 4 residents were examined. Care plans are relevant, comprehensive and up to date, and based on the findings of regularly reviewed assessments. Residents feel they are properly cared for; comments included “It’s luxury really; well fed….well looked after”. Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 Page 11 The home uses a monitored dosage system; the dispensing pharmacist provides printed administration charts. The manager said that residents are assessed for their ability to manage their own medicines (at the time of inspection a number were doing this); there was a written record of these assessments. Records indicated that medicines had been accurately administered. Residents are treated with respect and their privacy and dignity is promoted; staff are kind and considerate, and keen to assist residents. Residents are confident they can receive help when needed; comments included “they’re nice staff”, “they’re jolly nice here”, “I wouldn’t want to go anywhere else”. Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.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 The quality of daily life in the home is good with residents assisted to maintain as much independence as possible. Social and leisure activities are varied and suited to the preference and ability of each resident, thereby ensuring residents do not feel bored or lonely. Residents are encouraged to maintain contact with the local community and visits by their friends and relatives are welcomed by the home. Meals are appetising and of good quantity and quality. Most residents take meals in the dining room, some receive them in their bedrooms. EVIDENCE: The inspector spoke to 13 residents; with one exception they expressed satisfaction with the home, including the range of activities, meal provision, staff and premises. One resident said that the food showed “no imagination…boring” but did qualify this by stating that due to ill-health “I’ve rather lost my sense of taste”. Other residents seemed very satisfied with the food, one said “The food is very good here”. The home employs an activities organiser for 15 hours each week. A full programme of activities is available to residents and includes events in the Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 Page 13 home, trips out and visiting entertainers. Destinations during July include Abbotsbury Swannery, Weymouth Sea Life Centre, Monkey World and a visiting circus. Residents confirmed that they were happy with the level of activities and that routines were flexible. Visitors are welcome at any time and residents can go out of the home whenever they wish, and for as long as they wish. One resident regularly visits a Day Centre. On the ground floor there is a dining room where most residents eat; some prefer to receive meals in their bedrooms. Residents select meals in advance, from a planned menu. Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 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 standard(s) 16 & 18 Complaints are managed properly and residents said they are confident their concerns are listened to and taken seriously. The home protects residents from harm and abuse. EVIDENCE: No complaints against the home have been received or investigated since the last inspection. The home has policies and procedures for the protection of residents from abuse or neglect. Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 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 standard(s) 19, 22 and 26 The home is attractive, comfortable and well maintained. The home has been assessed by an Occupational Therapist to ensure it is suitable to meet the various needs of residents. A call system is installed in all resident’s bedrooms and bathrooms enabling them to summon prompt assistance as required. EVIDENCE: Residents bedrooms are suitably decorated and furnished; many residents have brought items of their own furniture and a number have private telephones installed, thereby enabling them to conduct private conversations and maintain contact with persons outside the home. Bedroom doors are fitted with locks of approved type enabling residents to key-lock their bedroom doors for privacy when they temporarily leave the room. Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 Page 16 There are pleasant communal use rooms – a lounge, separate dining room and a conservatory lounge and well maintained gardens. These rooms are suitably decorated and appropriately furnished and the home has a cosy and relaxed atmosphere throughout. An occupational therapist has assessed the premises and in her report states they are suited to the needs of the residents. A call system is installed in all resident’s bedrooms and bathrooms enabling them to summon prompt assistance as required. There is an ongoing programme of refurbishment and upgrading. Since the last inspection 3 bedrooms on the second floor have been registered for use and the conservatory lounge has been newly provided. Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 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 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) 29 Recruitment and employment practices do not reliably protect against risks of unsuitable staff being employed. An Immediate Requirement was issued during the inspection. EVIDENCE: Employment records of two recently employed staff were examined. For one of these persons there was only one reference; POVA/CRB disclosure for both had been obtained after they had commenced employment in the home. However, both applicants were personally known by the registered providers in advance of commencing employment, and worked under close supervision until the CRB disclosures were received. Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 Page 18 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) 38 Equipment used in the home is regularly checked and tested to ensure it is safe to operate. Comprehensive safety assessment of the premises and working practices has been recorded to minimise risks of injury to residents, staff and visitors. Staff are trained to act appropriately in the event of accidental fire in the premises, and fire safety equipment is regularly checked and tested to ensure it will work properly in the event of need. EVIDENCE: Fire Records of periodic routine tests and checks of fire precautions were in good order and a fire safety risk assessment has been recorded. There was written evidence that 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. Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 Page 19 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. Mrs Hasler stated 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 D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 x x 3 x x x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 3 Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 Page 21 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 29 Regulation 19 & Schedule 2 Requirement 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. A similar Immediate Requirement was included in the previous inspection report. Timescale for action 29/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Danmor Lodge D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Unit 4 New Fields Business Park Stinsford Road Poole, Dorset 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 D55 S62426 DANMOR LODGE V228102 020605 Stage 4.doc Version 1.30 Page 23 - 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. 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