Inspection on 05/07/05 for Davigdor Lodge Rest Home

This inspection was carried out on 5th July 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

Davigdor Lodge Rest Home 27/11/08

Davigdor Lodge Rest Home 27/11/07

Davigdor Lodge Rest Home 27/06/06

Davigdor Lodge Rest Home 03/02/06

Davigdor Lodge Rest Home 15/02/05

Davigdor Lodge Rest Home 11/05/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Aldwick House

49 Glendale

The Springs Community

Crossways Community

Belle Vue Country House

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

CARE HOME ADULTS 18-65 Davigdor Lodge Rest Home 56 Tisbury Road Hove East Sussex BN3 3BB Lead Inspector Jane Jewell Unannounced 5 July 2005 11.50 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Davigdor Lodge Rest Home Address 56 Tisbury Road Hove East Sussex BN3 3BB 01273 726868 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) Mr G and Mrs B Rawat Mrs Susan Lyn Dubeau Care Home 10 Category(ies) of Mental Disorder, excluding Learning Disability or registration, with number Dementia (MD), 10 of places Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1.The maximum number of service users to be accommodated is ten (10). 2. Service users should be aged between eighteen (18) and sixty-five (65) years on admission. 3. Service users with a past or present mental health illness only to be accommodated. 4. That the facilities and services provided by the home are accessible to the service users of No 56 only. Date of last inspection 15 February 2005 Brief Description of the Service: Davigdor Lodge is a privately owned residential care home for up to Ten people who have a past or present mental health illness. The registered provider also part owns a further four registered care establishments and supported accommodation within the East Sussex area and has owned and managed Davigdor Lodge since 1992. Davigdor Lodge was originally comprised of two converted Victorian terraced houses No 56 and No 58. In 2002 the houses were separated with No 58 deregistered and now provides supported living accommodation. The home is situated within walking distance of the amenities of Hove town centre and bus routes into Brighton. Accommodation is presented across four levels, lower ground, ground, first and second floors. Resident’s accommodation consists of ten single bedrooms, with one having ensuite facilities. Shared facilities comprising of separate lounge and dinning room plus a rear garden. The homes literature states that one of its aims is to provide a safe homely environment in which residents have as much control over their lives as possible, enabling them to achieve the maximum degree of independence whilst retaining their dignity. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced routine inspection, which was undertaken between 11.50am to 3.30pm. The inspection was undertake by Sue Dubeau (Manager) and there were ten residents living at the home. The inspection involved a tour of the premises, examination of the homes records, discussion with the manager, consultation with three staff on duty and seven residents. The focus of the inspection was to look at the experiences of life at the home for people who live there. Not all residents wanted to participate in the inspection process and this was respected. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection reports. The Inspectors would like to thank the residents, staff and management for their assistance and hospitality during the inspection. What the service does well: What has improved since the last inspection? The vast majority of shortfalls noted during previous inspections have been addressed. This has led to safer practices in medication, increased staffing, improved protection for residents through better recruitment practices, and regular reviews of assessed needs. The environment has undergone some improvements to make a brighter and more attractive surroundings in which to live. This has included further landscaping of the garden and redecoration of some hallways. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 6 What they could do better: Further minor maintenance is needed to ensure that the environment is consistently attractive throughout. The practices of dispensing medicines for administering later needs to be improved to ensure a safe system for medicines is operated. Poor fire safety practices, which are fire doors not closing properly and are being propped open must be addressed as a matter of priority in order to safeguard residents and staff. A training and development plan needs to be put into place to ensure that regular specialist training is made available to staff to enable them to undertake their roles. In response to the draft inspection report, the provided returned to the CSCI an action plan of how they intend to meet the requirements and recommendations made from this inspection. 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. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 and 4 Prospective residents and their representatives have the information they need to make an informed choice about whether to live at the home. No resident moves into the home without having had their needs assessed. Most needs of residents are met by living at the home. EVIDENCE: There is a range of well-documented information about the home and the services it provides, this includes a statement of purpose and service user guide, which are displayed and given to prospective residents, representatives and other interested parties. These documents have been reviewed to reflect changes in the homes practices and services. There are few admissions to the home and there have been none since the previous inspection. When admissions do occur the vast majority are referrals from other establishments within the organisation. There is some movement of residents amongst the organisations services, based on residents needs and wishes. Previous inspections have highlighted that comprehensive assessments are undertaken by the manager for any referrals made. In addition copies of any social care needs assessments are obtained from placing authorities to ensure that a comprehensive picture of needs is established. It was previously recommended that a formal process be introduced to determine permanent residency for internal transfers to the home. This is to ensure that residents are aware of their rights during a trial period at their new home. The manager reported that this has not yet been developed. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 9 Many residents have lived at the home for a number of years and appear settled and clearly benefit from living there. Residents continue to speak positively about their experiences at the home with particular reference to their fondness towards staff and respect for their individual lifestyles. There was appropriate evidence to confirm that the home meets most needs of residents. The manager had identified that the needs of two resident were becoming more complex and had sought additional advice from health care professionals in order to review the level of support the residents now needed. The manager was also advised for one resident to call a review with the placement authority. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8 and 9 The arrangement for planning care are good ensuring that health, personal and social care needs of residents are met. Integral to the ethos of the home is ensuring and respecting resident’s rights to make decisions and that generally there are no specific limits. The home tries to balances the rights of residents to take reasonable risk against any unacceptable risk to themselves or others. EVIDENCE: Three care plans were sampled and these were found to provide staff with a good framework on the assessed needs of residents. They were seen to be regularly reviewed to ensure that any changes in needs and preferences were identified promptly. The standard of daily recording was noted to be good with a clear account of actions and events that had occurred in a style that was respectful and none judgmental. No resident consulted wished to be involved in the development or review of their care plan, but did feel able to access information held about them if they wanted. Staff showed a good knowledge of the assessed needs of residents including how to manage any challenging behaviour in accordance with the individual guidelines contained within care plans. Residents consulted said that the home allowed them to follow their own lifestyle, which was an important element for maintaining their mental health. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 11 Where a resident has expressed their feelings of wanting to move in the past onto more independent living they spoke of being supported to make this decision by staff and provided with various options, but felt that ultimately it was their decision. Residents expressed little interest in being involved in many aspects of running the home that did not specifically affect their individual lifestyle. Instead informal mechanisms are in place to enable residents to have their say in the routines of the home. Namely by regular discussions with the manager who records any feedback given. It was clear that residents feel at ease to express their views on any aspect of the service or changes that they would like. A door alarm has been fitted to one resident’s bedroom to alert staff to them leaving their bedroom at night. This is to help manage the risk of them leaving the building unescorted. The manager confirmed that the residents has agreed to this being fitted and was advised to also obtain their written consent. Smoking remains an integral part of some resident’s lifestyle and comprehensive risk assessments are undertaken to establish what management is needed to reduce the level of risk. Other areas of potential risks are also assessed including aggression, road safety, financial and domestic safety, however, where a risk had been identified this was not always supported by how the risks would be managed. The manager has been required to address this. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15,16 and 17 The home facilitates and ensures that suitable arrangements are made for occupation depending upon the individual preferences of residents. Residents maintain contact with family and friends and with the local community as they wish. The routines of daily living are predominantly determined by the needs and wishes of residents. EVIDENCE: Staff continue to support residents to spend their time usefully, but balance this with the understanding that residents have the choice to become involved or not as they wish. One resident undertakes some work at a local shop and some use a local drop in centre. Staff spoke of organising many individual or group activities, which have not been well attended. All residents consulted continue to say that they prefer to be based at home and make individual arrangements for their occupation. The majority of residents like to congregate in the lounge during the day and socialise with one another and with staff. In house facilities provided include TV, board games and audio equipment. As in previous inspection all residents said that they felt they were suitable occupied. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 13 Some group activities are organised across the organisations services, including day trips to France, visits to local events and places of interest. The manager reported all residents have been offered a holiday with only one choosing to go. The manager said there is a budget for activities so residents do not have to incur the full costs of organised outings. One staff member was particularly knowledgeable about local events and was trying to motivate residents to attend an event at the seafront. Where residents have active family members contact with them is encouraged and supported. Some residents have friends who visit occasionally, others spoke of meeting up with their friends outside of the home. One resident has a partner who visits them daily. As many residents have lived at the home for a number of years or are known to each other via the organisations other homes the residents present as a close cohesive group. Some have formed friendships and one resident said how important other residents were to them. The home balances well the challenges of communal living and ensures that resident’s individual wishes are taken into account if changes to services or routines are needed. Through discussion with residents, staff and examination of records it is clear that resident’s individual routines and lifestyles are respected. During the inspections residents were observed to move around the home freely, choosing which rooms to be in and what level of company they wanted to enjoy. Residents are encouraged to tell staff where and when they are going out but despite this many do not. Restrictions placed on accessing the lounge in order to smoke at night has been reviewed in line with previous requirements and residents are now permitted to smoke in their bedrooms, subject to risks assessment. All residents consulted continue to state that their individual food preferences are catered for. A varied menu is available with residents asked each day their preferred choice of meal. Some residents have fixed food preferences and seldom deviated from this and the cook is innovative in trying to ensure that suitable nutrition is obtained. Although no residents choose to be involved in the preparation of cooked meals, facilities are made available to make hot drinks, snacks, as well as fresh fruit being readily available. Within reason meal times are flexible to suit individual routines. The kitchen was clean and well equipped. Record, required to be kept for food safety reasons were maintained and up to date. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 and 21 Personal support is provided in accordance with residents care plans and in a manner that respects residents dignity and personal preferences. The health needs of residents are well met with evidence of good multi disciplinary working taking place on regular basis. EVIDENCE: None of the residents accommodate need assistance with personal care, instead staff prompt and motivate residents in accordance with their care plan to maintain their personal appearance. Not all residents felt that they needed assistance with their personal appearance and often resented being prompted to have a bath. When this occurs staff said they would provide additional support and encouragement but residents wishes are respected. It was clear that residents are enabled to dress in accordance with their personalities. The home does not provide nursing care. Residents are registered with various local GP surgeries. All residents have access to their psychiatrist or community psychiatric nurse as required or through pre-arranged regular appointments. It was clear through discussion with residents, staff and management that where residents have requested medical input or staff feel additional support is needed then this has been sought promptly. Support is given to attend appointments and staff accompany residents to consultations only upon the invitation of the resident. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 15 None of the residents are assessed as safe to administer their own medication. Residents have a review of their medication a minimum of twice a year or as the needs arise by the visiting psychiatrist. Records of medication showed a clear record of each prescribed medication and when it is administered. Controlled drugs are signed by the resident to indicate that they have received it along with the member of staff who has administered it. It is only the manager who has access to controlled drugs and these are dispensed into pots prior to them leaving shift for the nighttime. There is a need for these medication pots to have lids to prevent spillages and are labelled with the residents name, medication and dosage. Only staff who have undertaken training are permitted to administer medication. It is recommended that a list of staff signatures and initials be developed to assist in identifying who has administered medication and other homes documents. Deaths within the home are very rare. The manager remains mindful of aging issues faced by several residents and has sough additional support on meeting their needs in the future. There is written guidance for staff on what to do in event of a death. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 There is an accessible complaints system with residents feeling able to air any concerns. Staff know what to do if abuse is suspected and the homes practices are consistent with the protection of vulnerable adults. EVIDENCE: There is an accessible complaints procedure for residents, their representative and staff to follow should they be unhappy with any aspect of the service. No complaints has been received or recorded by the home. One resident asked for the complaints book, which had been temporarily removed during redecoration to be put back into the lounge and the manager did this straight away. The inspector observed that residents felt confident to approach the manager with any concerns and the manager listened to and agreed to act upon. Residents said they could also approach any other member of staff with any concerns and felt that they would be dealt with promptly. The home has written policies covering adult protection, which identifies different types of abuse, possible indicators of abusive practices and whistle blowing. A procedural flow chart is used to guide staff on the reporting of adult protection issues. Staff were knowledgeable on what to do if abuse is suspected. In line with previous requirements all existing staff have now undergone training on adult protection. In addition there are policies on the management of challenging behaviour, control and restraint to guide staff on the appropriate techniques to use. Where the manager acts as appointee for residents financial matters then appropriate records are maintained. There are a variety of systems used for residents to access their personal monies depending upon the individuals needs and preferences. This ranges from allowances being distributed in total to daily monies being provided. Although residents felt that their personal Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 17 allowances were not enough all said that they are able to access their monies in accordance with their individual arrangements. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,26,27, 28, 29 and 30 Residents live in a homely environment with their bedrooms personalised in accordance with their lifestyles. Some maintenance issues were in the process of being addressed to ensure that the environment remains attractive to live in. EVIDENCE: The home is situated in a residential road within easy access of local amenities and bus routes into Brighton and Hove. The home is maintained to a reasonable standard and the maintenance issues identified at inspection were in the process of being addressed by the manager. Much effort continues to be made to ensure that in spite of the building being older that it is made as comfortable as possible by regular redecoration and domestic style furnishings being provided. Since the previous inspection some hallways have been redecorated creating a brighter atmosphere. Due to the lifestyles of some residents who smoke there are some signs of wear and tear to the environment through smoking damage. The manager remains vigilant to this and intends to replace some bedroom carpets with wooden flooring to help preserve the appearance of bedrooms. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 19 All bedrooms are provided with locks with nearly all residents having requesting their own key. All bedrooms have been individualised with resident’s personal belongings and are decorated and furnished to a good standard. The manager reported that lockable facilities have been made available to all residents. The lifestyles of some residents and the level of respect and privacy afforded means that some bedrooms could not always be cleaned and kept odour free. Shared space consists of a dinning room, lounge and quiet lounge on the first floor, all are decorated and furnished to create a homely environment. The rear garden has recently undergone further landscaping to create more seating and flora, in addition to the some existing water features and ponds making this a very attractive area for residents to use. There are some external steps leading to a balcony, which are in need of repainting and rendering. The manager reported that they had already instigated this work to be done. A rabbit has recently been obtained at the request of residents and is now housed in the garden. One resident was particularly fond of it and spoke of helping to look after it. There are sufficient number of toilets and bathrooms located around the home including three bathrooms. The ground floor toilet has undergone some refurbishment. The floor around the base of the toilet needs to be sealed to provide an impermeable surface and thus aid effective cleaning. The home is not designated to offer services to people with physical disabilities and the stairs and other access arrangements would make it unsuitable for residents with a permanent restricted mobility. Therefore the use of physical aids is not currently necessary, however the manager is mindful of the level of mobility for some aging residents. Call points are fitted throughout the home for residents to be able to call for assistance if needed, however no residents could recall having ever used it. The home was found to be cleaned to a reasonable standard. There is some written guidance for staff on infection control and communicable diseases. Protective clothing was made readily available to staff. Suitable laundry equipment is available on site. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,34 and 35 Staff have the time to undertake their roles and to spend individual time with residents. The core staff team have worked at the home for many years and residents clearly benefit from the stability of the staff team. Staff have the collective skills and experience to deliver the services that the home offers, however regular specialist training needs to be made available. The homes recruitment practices safeguard residents. EVIDENCE: In line with previous requirements staffing has been increased during the afternoon to ensure that at all times two staff are on duty throughout the day. This includes the manager during the morning. In addition there is a cook who is counted as the second carer in the absence of the manager. At night there is a waking member of staff. Staff consulted said that the staffing structure enable them enough time to undertake their roles as well as being able to spend individual time socialising and talking with residents. There is a core group of staff who have worked at the home for many years and residents particularly benefit from the stability this affords. Due to the close cohesive nature of the home residents are initially wary of new staff but a recent new member of staff has gained the trust and respect of residents quickly. This would appear due to the personal qualities and experiences of the individual recruited. Staff and residents demonstrate positive attachments to each other. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 21 The recruitment documentation was examined for the new member of staff and this showed that good practices were being followed which safeguarded residents. The induction undertaken by them provided a comprehensive introduction into the home and the assessed needs of residents. They were clear on the boundaries of their role and their responsibilities and the manager had already identified future training needs. All existing staff have undergone core training such as adult protection, food hygiene, fire safety and first aid as well as some specialist training in mental health related issues. Since the previous inspection communication training has been undertaken. It was previously required that a training and development plan be developed to identify the specialist training available in mental heath related areas. The providers who largely undertake the training complete a yearly programme of such training, however this has not been completed and therefore specialist training has not been regularly undertaken. It remains essential that this is undertaken as a matter of priority in order to keep staff updated on changes in good practices or legislation and to provide new staff with the specialist knowledge they need to undertake their roles effectively. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,41 and 42 The home is managed in the best interest of residents with a clear sense of leadership provided by the manager. The health and safety of residents, staff and visitors are generally protected by the homes practices with the exception of some fire safety issues that must be addressed as a matter of priority. EVIDENCE: The manager has considerable experience in working with people who have mental health issues and has been manager at the home for a significant number of years. They are currently undertaking a Registered Managers Award and have previously gained qualification in management. They provide a strong sense of leadership and direction and demonstrate a sound working knowledge of the daily running of a home. All persons consulted spoke positively about the manager with particular reference to their approachability. Informal mechanisms are the most successful tool for residents, their representatives to feedback on the home’s services. This is achieved through regular discussions and consultations. Residents were very confident to approach the inspector with their feedback on the home and felt at ease Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 23 talking about their feedback in front of the manager. Other tools used to gage the success of the home in achieving its aims and objectives include regular reviews with placing authorities and recorded visits by the provider, which take the form of an audit of the services. Resident’s feedback cards have in the past been used but these have proved unpopular. Few residents have representatives who are willing to participate in any formal feedback process. Of the records inspected, which are required by regulation for the protection of residents and for the effective running of the home, these were largely up to date and accurate. Although residents continue to stress that they are not interested in what is being recorded about them they felt able to request access to information held about them. The home uses a management consultations procedural manual, which provides a reference guide for health and safety policies and practices of which they are extensive. A record of accidents is maintained however there has been no accidents or incidents recorded since the previous inspection. Some systems to support fire safety are in place, including regular checks and servicing of fire safety equipment, regular fire drills, and training plus a comprehensive fire risk assessment. However concerns are noted over some poor standards relating to fire doors, these were: • One fire door was propped open using non-automatic fire door closure mechanisms. • Several fire doors did not shut flush to the doorframe, and therefore did not offer protection in the event of a fire. • Two fire doors from the a-joining supported living unit were propped open, allowing access from this unit to the home. It has been previously agreed that assess to the home via these fire doors must only be used in the event of an emergency. The manager has been required to address these issues as a matter of priority. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 3 3 2 2 Standard No 11 12 13 14 15 16 17 x 2 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 x 3 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Davigdor Lodge Rest Home Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 x 3 x 3 1 x H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 25 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 9 Regulation 13(4)(b)& (c) 13(3) Requirement That personal risk assessments include the actions needed to manage or reduce identified risks. That night medication dispensed into pots for administering later are provided with lids, are labelled with the residents name, medication and dosage. That the rear external balcony steps are maintained and repainted. That the ground floor toilet flooring is sealed to provide and impermeable surface. That a training and development plan be developed which is linked to the homes statement of purpose, service aims and service users needs and individual plans. (Previous timescales of 30-4-05 not met) That all fire doors can be closed properly. That fire doors are not wedged open using none automatic fire That fire doors from the ajoining supported living unit are not propped open and are only used in the event of an emergency. Timescale for action 30-8-05 2. 20 Immediate 3. 4. 5. 24 27 35 23(2)(d) 13(2) 18(1)(c) (i) 30-10-05 30-8-05 30-8-05 6. 7. 8. 42 42 42 23(4)(a) 23(4)(a) 23(4)(a) Immediate Immediate Immediate Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 26 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. Refer to Standard 4 20 Good Practice Recommendations That a formal process, to determine permanent residency, is established for internal transfers to the home. (First made at inspection of 15/2/05). That a list of staff signatures and initials be developed. Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection 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 Davigdor Lodge Rest Home H59-H10-S14196 Davigdor Lodge V230621 050705 Stage 4.doc Version 1.30 Page 28 - 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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