Inspection on 19/08/08 for Deerswood Lodge

This inspection was carried out on 19th August 2008.

CSCI found this care home to be providing an Adequate service.

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

Deerswood Lodge 26/02/08

Deerswood Lodge 01/07/07

Deerswood Lodge 22/02/07

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Deerswood Lodge Ifield Ifield Green Crawley West Sussex RH11 0HG Lead Inspector Ann Peace Unannounced Inspection 08:30 19 August 2008 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Deerswood Lodge DS0000068513.V369134.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. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Deerswood Lodge Address Ifield Ifield Green Crawley West Sussex RH11 0HG 01293 561704 01293 561635 deerswood.lodge.manager@shaw.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Shaw Healthcare Ltd Mrs J Mosses Care Home 90 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (50) of places Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of people to be accommodated will be 90 from the age of 60 years. 19th May 2008 Date of last inspection Brief Description of the Service: Deerswood Lodge is a purpose built care home situated in Ifield in Crawley which was opened by Shaw Healthcare Ltd in 2006. The home was built to replace three other homes in the area owned by West Sussex County Council but managed by Shaw Health Care Ltd. The home is registered to provide personal care, support and accommodation for frail older people and older people with Dementia. Resident’s accommodation is provided in nine units on the ground floor and the first floor, each unit has ten bedrooms, all bedrooms have en-suite facilities. Each unit has its own dedicated lounge/diner and all rooms on the first floor can be accessed by a passenger lift. The home has been designed with indoor streets running the length of the building linking units so that residents can get around easily. Additional communal areas are provided. The registered providers are Shaw Healthcare Ltd and the responsible individual on behalf of the company is Mr Jeremy Nixey. West Sussex County Council currently contracts all of the 90 beds in the home. The fees range from £420.00-£520.00 per week. The manager Mrs J Mosses has recently been registered with the Commission. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. A visit to the home was carried out on the 19th August 2008 by Mrs Ann Peace Regulatory Inspector and Mrs J Foley Regulatory Manager and lasted eight hours. The previous visit to the home had been in May 2008 to check whether the home had met the Statutory Requirement Notice issued following an inspection in February 2008. On that visit we found that the requirement notices had been met. We met people in the communal areas of the home and in their bedrooms, we observed residents and staff interactions throughout the day and we spoke to as many residents and visitors as we could to gain an insight into life at the home. We observed that residents were comfortable, relaxed and content in the home and had good relationships with the regular staff who look after residents in a caring, friendly and professional manner. Due to the mental frailty of the some of the residents on the dementia unit we were not able to engage in meaningful conversation with many during the visit but all looked well cared for and were at ease with the staff on duty. Those that could offer an opinion on the elderly frail unit (EFU) were satisfied with the care at the home. Visitors spoken with were also complimentary about the improvements that have been made. Some responses from residents and visitors were the same as the previous inspection where they said they were happy with the care given by permanent staff but were not so complimentary about the care given by agency staff which the home still relies heavily on. What the service does well: Mrs Mosses is a keen and caring manager who is intent in improving the standards in the home. The permanent care staff deliver a good standard of Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 6 care which is evidenced by a good standard of record keeping. Residents and their representatives are positive about the improvements made at the home. Residents are offered nutritious and well-balanced meals in comfortable surroundings and residents on the dementia unit are encouraged and helped in a sensitive manner. What has improved since the last inspection? What they could do better: There must be a safe supportive management structure in the home and staff should be supported and supervised appropriately. New staff should be supervised until they have completed their probationary period. The system of choosing meals to ensure that what has been ordered is what arrives should be reviewed, and when serving food this must be reviewed to ensure safety of staff. The home should ensure that when agency staff are used they are competent to administer medication to safeguard residents. The AQAA told us those improvements the home is planning to make include: • More residents and relatives meetings, and more involvement of residents planning activities. • To maintain recruitment stability and comply with the standards to achieve a good rating. • More training for staff in specialist areas such as nutrition, dementia and challenging behaviour. • Introduce evening social events for residents and their families and friends. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 8 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 Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives are given the information they need to make an informed decision about the home and are able to visit prior to admission. New residents are only admitted following a pre assessment to ensure the home can meet their needs. All residents have full assessment records and an up to date care plan. Intermediate care is not provided at Deerswood Lodge therefore standard 6 does not apply. EVIDENCE: The Statement of Purpose and Service User’s Guide for the home were both available in the foyer of the home and in each of the resident’s room along with the complaint procedure. Prospective residents and their representatives are able to visit the home on a trial basis. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 10 All new resident’s records that were inspected had full assessments of need that related to an up to date care plan, relevant risk assessments had been compiled and equipment that had been identified as being needed was available. Staff have had training so they are confident and competent to be able to look after the residents at the home including those residents suffering from Dementia. Two members of staff on the dementia unit told us that the training they had received about dementia had given them an insight into the particular needs of residents and how to care for them. All residents and relatives spoken to on the day of the visit were complimentary about the permanent members of care staff. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Resident’s health, personal and social needs are set out in a care plan and staff meet their identified needs. Residents are protected by the medication policies and procedures when they are carried out by permanent staff but are not always protected when agency staff are on duty. Staff treat residents with respect and dignity and at the time of their death staff would treat them and their family with care sensitivity and respect. EVIDENCE: Residents receive personal and health support using a person centred approach. Healthcare needs including specialist nursing and dietary Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 12 requirements are clearly recorded in residents care plans. The records give a comprehensive overview of their healthcare needs and what action is needed. The healthcare needs of residents unable to leave the home are managed by District Nurses who attend the home on a regular basis. Records showed us that other healthcare professionals attend to residents as needed. There are communication handover books on each unit and these contained information about resident’s conditions and any changes. Relevant risk assessments are in place and it was noted that when one resident had started to lose weight the GP was informed and advice was sought from other outside health professionals. The advice was recorded and records showed that staff had followed the advice on how best to ensure the resident’s nutritional needs were met and the result was that the resident had started to gain weight. The delivery of personal care is varied to individual needs and preferences and we could see that this was flexible during the visit. Three residents on the dementia unit were late up through choice and having breakfast at 10.30 am. Residents have the aids and equipment they need and these are well maintained to support them and the staff in daily living. Staff have training in matters relating to residents, including aspects of healthcare, and dementia. The home is compliant with the receipt, administration, safekeeping and disposal of medication with the permanent care staff and audits are regularly undertaken. The medication that residents are on is recorded in their care records and also a list of side effects so that staff are aware if there is any problem. However there have been reports of drug errors happening when agency staff are on duty. This investigation is being handled by the manager of the home and the local social services department under the safeguarding procedure. But all the time the home continues to use agency staff who do not follow safe procedures on a regular basis there is a risk to residents. The care plans seen contain information about individuals choices if a resident’s health should deteriorate and the home has policies and procedures to instruct staff in how to manage this. From observation on the day of the visit the staff were respectful and caring in their approach to residents and their relatives so we concluded that if a Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 13 residents was dying the staff would seek support to care for the resident and their families in the home to a good standard. On the day of the visit four visitors were spoken to and all were very positive about he home and the staff. Key workers are allocated so the residents have continuity and a photograph of the resident’s key worker is in the resident’s rooms. One resident told us that they like living at Deerswood and feels well looked after by permanent staff. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The lifestyle experienced in the home matches residents expectations and preferences and they are encouraged to maintain contact with family and friends. Residents are encouraged to exercise choice and control over their lives and they receive a wholesome appealing diet in pleasant surroundings. EVIDENCE: The activity programme in the home has improved since the last visit. The environment especially in the dementia unit has improved so that residents have more stimulation around them and an activity room has been created. Bedroom doors have been personalised with photographs and pictures and residents can choose to have a doorbell if they wish. On the day of the visit street parties had been organised on both floors both in the morning and afternoon, one party was themed around the Olympics and Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 15 residents and staff were seen to enjoy the interaction playing ball games and singing. One resident on the dementia unit was adamant that they did not want to join in and staff were seen to try to involve and persuade them, but did respect their choice to stay and watch television and staff did keep coming back during the party to make sure they were ok. Residents are involved in activities of their own choice although some improvements could be made for example; in the morning on the elderly frail unit, we saw a number of residents playing cards but other residents were just sitting and not included in any activity. This was discussed with the manager during the inspection. Other activities advertised were music /dance, ball games, exercises, bowling and darts. One resident had celebrated her birthday the day before the visit and there had been a party, the balloons and banners were still around the unit. There were numerous photographs of recent outings that residents have been taken on including Snow hill gardens, Tilgate park, strawberry picking and notices also stated that there are outings planned to Eastbourne, Brighton and Worthing. One resident was recently able to attend a Muslim festival in London. Residents are encouraged to maintain contact with family and friends and are able to access community facilities if they wish. A summer fete was planned for the week following our visit and posters were seen inviting the local community to join in. Residents are helped to exercise choice of how they wish to spend their day and during our visit we saw residents get up when they wanted to and their decision was respected by the staff who offered drinks and breakfast when they did get up. In each resident’s room there is a profile of who they are and what they used to do before living at the home, a photograph and a précis of how they like to spend their day. Staff told us about these so we could see that they had been involved in compiling the life history and were noted to respect the choices of residents. The meals have also improved since the last visit and residents have been involved in planning menus. These are also now nutritionally balanced to ensure residents get the nutrition they need. The Regional Catering Manager told us that they are planning to make a recipe book of resident’s favourite meals so that they are always available. We did suggest at an earlier visit that pictorial menus should be made available for residents on the dementia unit; these still have not been done although we were told they are in the pipeline. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 16 We saw residents having difficulty understanding what meals staff were offering to them for the following day it may have been so much easier for them if they could have shown them photographs or pictures. Residents are asked one day what they would like to eat the following day and the list is send to the kitchen. Unfortunately the system for ordering meals has changed and they are not now personalised so the kitchen would not realise if something were missing for a particular resident. This happened on the day of our visit, one resident always has a salad at lunchtime and this was not bought up on the trolley so they had to wait while a member of staff went to the kitchens to request it. We were told that since the system has been changed this does happen a lot. At present the home does not have full time resident cook and is using agency staff, we were told that the home is hoping to recruit an experienced cook in the near future. Also we noted that there could be a health and safety risk when staff are serving up food as they have individual bits of paper all around them with residents choices on them and have to keep referring to them as well as dish up so are constantly turning around with hot food. There can be up to four members of staff congregating around one trolley leaning over each other to serve up so there is a risk to staff. The manager is required to review this unsafe practice as soon as possible. The meals on the day of the visit were shepherds pie with vegetables, sausages, vegetable pie or salad. The temperature of the food was tested before serving to make sure it was the right temperature and this was recorded. The desert was chocolate pudding, yogurts or fruit. Following their meals residents were offered second helpings which some did have. Supplements for those residents who need them were served throughout the day and in nice glasses which staff told us does make a difference to them drinking them. For one resident who needs supplements but does not like the drinks staff froze them and so were able to give the supplements as ice lollies. There were bowls of fruit and other snacks in all of the units for residents to help themselves and on the dementia unit staff were seen to encourage residents to have snacks in between meals, cakes were served during the street parties. Residents are encouraged to sit at the tables for their meals but as seen on the day of the visit their wishes are respected if they want to stay in their armchairs and eat off smaller tables. The units do have a small supply of basic food so that they can make late breakfast or snack throughout the day for residents. Visitors were also noted to be able to make themselves a drink. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 17 Care staff are sensitive to the needs of residents who find it difficult to eat and give assistance with feeding, they did this in an unhurried manner. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and acted on according to the procedure and resident’s legal rights are protected. Residents are being safeguarded by the permanent members of the staff but could be at risk from the continued use of agency staff. EVIDENCE: The home has a complaint procedure that meets the standards and regulations. The procedure is up to date and is displayed on the notice board of the home a copy of it is also in every resident’s bedroom. Staff are aware of the procedure and said they would refer onto the team leader or manager. Complaints are recorded and any action that has been taken, the home has one outstanding complaint which is in the process of being dealt with and we could see from records that action was being taken to address the complaint and write back to the complainant. Residents have their legal rights protected and are able to vote in elections if they wish. The home advertises how residents or their representatives can contact advocacy services, and staff told us that they could contact an advocate for residents if they were unable to do it themselves. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 19 There are policies and procedures for safeguarding residents and staff are trained in the procedure, staff when spoken to do understand about the issues and the procedure that should be followed. There had been one safeguarding alert in March 2008 related to a resident’s care which Social Services found partially substantiated following an investigation. Since then there has been a change of management at the home and standards of care have improved. At the present time the registered manager Mrs Mosses has reported numerous alerts relating to medication errors made by agency staff. The home has picked these errors up through permanent staff members noticing and through the internal audits of the home. In all cases GP’s have been informed and no resident came to harm. These have all been reported to Social Services who with Mrs Mosses are dealing with the agency concerned under safeguarding. This is ongoing and unfortunately although the home are recruiting staff to permanent positions until they are fully staffed they are still having to use agency staff which is putting residents at risk. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, well-maintained, comfortable, clean and well-furnished environment and have access to indoor and outdoor facilities, although the garden outside the dementia unit could be improved. There are sufficient toilet and washing facilities and specialised adaptations are available in the toilets and bathrooms and resident’s bedrooms are well decorated and furnished. Some improvements have been made in the accommodation for residents suffering from Dementia to maximise their potential and stimulate them. EVIDENCE: The home is a newly purpose built home and there is a car park to the front. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 21 Communal gardens surround the home and we are told that these are used regularly weather permitting. We did discuss with Mrs Mosses that the garden that the dementia unit looks out onto could be made more stimulating for the residents as there is just trees and grass. We were told that this had been recognised and that the home was hoping to start up a gardening club and a poster advertising this was seen The home has a swipe fob facility for entry into the home and the dementia unit for security. All areas of the home are nicely decorated and furnished and all areas are clean. The standard of décor and furnishings is high and there are music systems, televisions, pictures and ornaments in each unit. Each unit contains a lounge/dining room with a small kitchen area to the end of each. Kitchens have a microwave for heating up meals and hot milk for drinks and dishwashers have been provided on the units. Communal spaces are well furnished with plenty of chairs for residents. All units had the televisions on or music playing during the visit. There are accessible assisted toilets near to the lounges, and good bathroom and toilet facilities with specialist baths, handrails, raised toilet seats, hoists and other specialist equipment in place. Bedrooms are very comfortable and attractive and have been personalised with belongings and small pieces of service user’s own furniture. All have en suite facilities. Pipe work and radiators are guarded and the temperature of the water is tested to prevent scalding accidents. An indoor street runs the length of the building linked to wings and facilities, additional communal areas are situated at the end of the ‘street’. All bedrooms on the first floor can be reached by a passenger lift. The layout of the home allows for small clusters of residents to live together and many activities are arranged on the streets. We did note that on the dementia unit the street is wider so residents had more space and there was a relaxed atmosphere. On the Elderly frail unit during the street party the residents were quite crowded and when staff were trying to get wheelchairs through there was a problem although staff were trying hard to manage. Since the last inspection there have been many improvements on the Dementia unit, there is more stimulation around especially on the ‘street’. Resident’s bedrooms have also been personalised to make them more familiar. There was a selection of doorbells in the street that residents could use and try Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 22 out and we were told that if a resident wanted one on their door they could have one. There were some pictorial signs around for toilets and bathrooms but these are on bits of paper stuck to the wall. As these are needed on a permanent basis they should be a better quality and more robust. There is a designated smoking room for residents. Health and safety records and the quality audit showed that safety checks are carried out at specified intervals. There is a separate day-care facility, which caters for people living in the community. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is sufficient staff on duty to meet the identified needs of residents and residents can have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. However there continues to be a high reliance on agency staff which is affecting the quality and continuity of care especially in relation to medicines. Staff are receiving the relevant training but need structured supervision and support. EVIDENCE: Since the last inspection the manager Mrs J Mosses has been registered with CSCI as Registered manager for the home. There has also been a recent successful recruitment drive for staff although there are still vacancies which need to be filled to reduce the use of agency staff. Two of these vacancies are for unit managers, we were told that unit managers had been recruited and they were due to start the week following our visit. Also there are a number of staff working in the home who are waiting Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 24 for another of Shaw Healthcares home to open and then they will move on which may upset the continuity of care for residents. Training in the home has improved and training records showed that all staff had received either induction (if they were new) or mandatory training for established staff. We were concerned that because of the increased number of new staff not all were not having the support and supervision they needed to show they were confident or competent in their roles this was discussed with Mrs Mosses at the end of the inspection. The recruitment procedure meets statutory requirements and the National Minimum Standards. Due to vacancies which we were told numbers 146 hours the home still finds it necessary to use agency staff, however there have been a number of recent safeguarding alerts due to medication errors being made by agency staff and all of the time there is a high use of agency staff this is affecting the individual care of residents. Staff on duty on the day of the visit were positive about the home and seemed to enjoy their jobs. The residents on both units were at ease with them and there was a friendly and caring atmosphere. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,37,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager Mrs Mosses is qualified and competent to run the home but does need a robust management structure to support her in the running of the home. The outcomes for residents have improved and in the majority of cases it is run in their best interests. New staff are not always being appropriately supported or supervised. In the majority of cases the health safety and welfare of residents is promoted and protected. EVIDENCE: Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 26 Since the last inspection Mrs J Mosses has been registered with the Commission as The Registered Manager for Deerswood Lodge and Mrs Mosses is presently undertaking the Registered Managers award. We did discuss the necessity for Mrs Mosses to have training in Dementia care and Business Planning due to the size of the home and the residents accommodated. This was bought to the attention of the regional manager and Mr Nixey, The Responsible Individual for Shaw Healthcare during our visit. Since Mrs Mosses has been in place at Deerswood it is noted that she has worked very hard to raise standards in the home and there have been general improvements both to the atmosphere in the home and with the way the staff work. There is more of a team approach which we could see is benefiting residents. Residents and their visitors were all positive about the home and the improvements made. Social Care Professionals who the Commission has been in contact with also said they have noticed improvements. As yet Mrs Mosses has not got the advantage of having a secure management structure in place to support her, although we were told that two new unit managers were due to start in the near future. A deputy manager has been in place since the home opened. The emphasis must be on supervision and support for staff especially new staff as we noted that some new staff who are still undergoing induction were not being adequately supported or supervised. There is a quality assurance system in place and we were shown recent surveys that had been completed by residents or their relatives. In some cases suggestions had been made in the surveys of how to improve things but there was no records to indicate that the home had taken these on board and considered them. Mrs Mosses was advised to record where action has been taken from the suggestions in the surveys and where it had been acknowledged to the resident or representative. Meetings are held for residents and relatives and we were told that at a meeting following the last inspection the inspection report was discussed openly and residents and relatives told how the home intended to improve standards. Policies and procedures are available and in most cases updated. Health and safety requirements are being met and records available to evidence this. Records seen are up to date and kept securely to comply with data protection. Policies and procedures are in place to protect resident’s financial interests and these were inspected in detail at the last inspection. Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 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 3 18 2 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 2 3 2 Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 29 STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) 2 OP36 18(2) 3 OP31 9 (2) (b) i 4 OP38 13.4 (c) Timescale for action The registered person shall make 30/09/08 arrangements for the safe administration of medicines to residents by any staff working in the home. The registered person shall 30/09/08 ensure that persons working at the care home are appropriately supervised. The registered person shall 31/12/08 ensure that the registered manager undertakes relevant training in Dementia care. The registered manager shall 30/09/08 ensure that the welfare of residents and staff are promoted and protected by reviewing the system for handling and serving food. Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Deerswood Lodge DS0000068513.V369134.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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