Inspection on 15/05/08 for Denmark Lodge

This inspection was carried out on 15th May 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Denmark Lodge 29/04/09

Denmark Lodge 21/05/07

Denmark Lodge 03/03/06

Denmark Lodge 09/11/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Denmark Lodge 38 Denmark Road Gloucester GL1 3JQ Lead Inspector Ms Lynne Bennett Unannounced Inspection 15th May 2008 08:30 Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 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 Denmark Lodge DS0000062183.V360904.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 Adults 18-65. 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. Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Denmark Lodge Address 38 Denmark Road Gloucester GL1 3JQ 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) 01452 311102 www.carehomes.co.uk Cathedral Care (Gloucestershire) Limited ****Post Vacant**** Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st May 2007 Brief Description of the Service: Denmark Lodge is a detached Victorian house, which has been modernised for its current purpose and is adjacent to a sister care home called Denmark House. Bedrooms have en suite facilities and there is a kitchen, dining room and spacious lounge. Outside, there is a large level garden. Both care homes provide care for people with a learning disability and there is access between the properties via patios at the side of the buildings. The home is situated in a residential area and close to all the amenities of Kingsholm in Gloucester. The home has the use of both a car and a people carrier. The weekly fees charged by the home are £820 to £1200. Copies of the home’s Statement of Purpose and Service User Guide are available from the office. Denmark Lodge DS0000062183.V360904.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. This inspection took place in May 2008 and included a site visit to the home on 15th May. The home was first registered in 2005 but this is the first inspection where there has been more than one person living in the home with a full staff team supporting them. There were three people living at the home and they had all moved in earlier this year. The acting manager was present throughout. The Annual Quality Assurance Assessment had not been returned to us (the Commission) prior to the inspection, the acting manager had mistaken the date for return. A copy of this was received after the inspection was completed. Surveys were returned from three people living at the home, two relatives, three staff and six healthcare professionals. Parents of one person were spoken to during the visit. Time was spent talking to people living at the home and observing the care they receive. Two staff were spoken to about the care they provide. A selection of records were examined including care plans, financial and medical records, health and safety documentation, staff files and quality assurance audits. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 6 Seven requirements issued at the last inspection were met. These included reviewing the Statement of Purpose and complaints procedure. All bedrooms now have locks which work and an en suite was added to the ground floor room which was previously an office. A manager was appointed to the home shortly after 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. The summary of this inspection report can be made available in other formats on request. Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Obtaining comprehensive admission information prior to admission will ensure that the home can confirm that it is able to meet people’s needs. Providing people with a copy of their statement of terms and conditions before moving into the home will make sure they have information about the service they will receive. EVIDENCE: The acting manager reviewed the Statement of Purpose and Service User Guide when she was appointed in July 2007. She stated that further changes were needed to these documents to reflect the skills and qualifications of the newly appointed staff group. Changes to our address were made during the inspection. Each person was given a copy of the Service User Guide during their admission that was read through with them by staff. Cathedral Care had assessed each person prior to moving into the home and copies of their care plans and assessments from placing authorities or the health service had been provided. For two people there was comprehensive information from their previous placement and reports from healthcare professionals. There was also evidence that healthcare professionals had been asked to review the environment and make suggestions about adaptations or Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 9 equipment that would be needed. Healthcare professionals commented, “a lot of equipment was recommended before and after the client moved in. All taken on board and the house modified to enable client to move in.” A care plan and assessment for one person indicated that whilst the person considered that they had a severe learning disability the healthcare professionals considered them to have mental health needs. The care plan and assessment had been completed by mental health services. One section indicated the person had a learning disability and mental health needs but not what the prime diagnosis was. The home was not registered to provide a service to people with mental health needs. The acting manager stated that she had sought clarification of the prime needs of the person but had not received a response from the healthcare professionals. After the inspection evidence was provided from a Consultant Psychiatrist that the prime diagnosis was learning disability with schizophrenia. The home must ensure that this information is obtained prior to admission. Healthcare professionals, staff and parents indicated that the person had adapted well to the home and was therefore not seen to be at risk at the present time. People spoken with said they had settled in well and were enjoying living at the home. They had been for visits prior to deciding to move in. One person commented in their survey, “I liked the staff when I came and visited and my room and the home.” Staff confirmed visits to the home were encouraged. Parents commented “visits before discharge from hospital were done, involving people in decorating their room, finding out favourite activities and foods.” Each person had a contract in place between the home and placing authority. The acting manager stated that Cathedral Care was drawing up a statement of terms and conditions for each person. These must be put in place and clearly state the fees payable and any additional costs. Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are being involved in developing their care plans that reflect their aspirations and needs. Plans could be improved by reflecting the diversity and individual expectations of people. Risks are being mostly identified and managed. EVIDENCE: The care for the three people living in the home was case tracked. This involved reading their care plans and assessments, examining their financial and medical records. Talking to them about the service they receive and to staff about the care they provide. People had been involved in developing their care plans with staff. Two people had comprehensive care plans in place, which were based on their initial assessments and information provided by the placing authority and former placements. Care plans were identified with a date for review in six months. Each person had an initial review involving parents or friends, their placing Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 11 authority, healthcare professionals and staff from the home. A record of minutes was kept. Care plans identified a range of emotional, social, physical and intellectual needs. Where hazards were identified the plans clearly noted this with risk assessments being located next to the relevant plan. One person with epilepsy had no care plan specifically in place for this. It was not possible to assess from the plans and risk assessments what was in place to safeguard them from harm. Staff described the processes in place for monitoring the person with their personal care and during the night. These were satisfactory. A care plan relating to community access indicated that one to one support was needed to minimise the risk of injury due to seizure when out and about. Care plans for the third person were being developed with them during the inspection. They had an initial review on the day of the visit where these were discussed. The acting manager stated that she had contacted healthcare professionals seeking further historical information about this person. Staff were observed supporting people following needs identified in their care plans. One person’s eating plan identified the need for specialist equipment and this was provided during the visit. Another person was encouraged to use a walking aid as indicated in their mobility care plan. Care plans did not identify people’s preferences for support from male or female staff. One care plan did not identify a person’s religious beliefs, which had been identified in their assessment. This was recorded for another person. Care plans did not have a current photograph of each person, although the acting manager said that these had been taken and were waiting to be developed. There were no limitations or restrictions to freedoms noted in care plans. People have keys to their rooms if they wish and documents on their care plans indicate where they need support from staff to manage these. House meetings were taking place on a regular basis involving discussions about the home, activities, meals and key workers. A missing person’s procedure was in place and people had a copy of a missing person’s form on their file. Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are able to make choices about their life style and supported to develop life skills. People have the opportunity to participate in social, educational, cultural and recreational activities that reflect their personal expectations. EVIDENCE: Each person had an activity schedule, which had been prepared with them when they moved into the home reflecting their interests and lifestyle choices. It was apparent from talking with people and staff that these schedules were guides only and for some had become out of date. One person was supported initially to carry on attending a day care centre that he had been going to for several years. After a few months he decided he did not wish to attend the centre although an agreement had been reached with them to keep their place open for three months in case they changed their mind. Another person said that they were to going to an evening course at a local college and that they would be attending taster courses during the summer. People had been supported to get to know their local community and Gloucester city centre. Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 13 One person said that they go each week to a local store and post office to collect their allowances. Others said they had tried social clubs and enjoyed going to garden centres, cafes and pubs. People join in with music therapy sessions with people living in Denmark House next door. On the day of the visit one person had a massage. People living at the home said they enjoy using the garden, watching films and listening to music. Staff confirmed that people were trying out activities although some prefer to stay at home. They were providing opportunities for people to gain confidence in a range of leisure and social pursuits. Healthcare professionals confirmed “they have made a great deal of effort to source leisure activities in the community”. Two people said they were really looking forward to a holiday at Butlins. Staff confirmed that this had been their choice. One person’s parents visited with them during the visit and they confirmed they visit each week and were made to feel welcome. Another person said their friend visits regularly. Care plans indicate the level of support needed by people to maintain contact whether by letter, telephone or visits. One visitor commented “they make me feel welcome and because I’m elderly… they meet me at the bus station, without this help I would be unable to visit”. People were being involved in the choice of menu at house meetings. Minutes confirmed that they were informed that alternatives were always available to the main meal. Menus indicated when these had been provided. On the day of the visit people invited us to sit with them for breakfast. This was very relaxed and people were asked for their preferences, each person choosing a different breakfast. They had sandwiches for lunch and a vegetarian lasagne for dinner. Daily diaries occasionally referred to what people had eaten that day. This is good practice providing an individual record for each person. People said that they like to cook and help in the kitchen. One person was planning to bake cakes with a member of staff. Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health and personal care needs are being met helping them to stay well. Their health and wellbeing are promoted by satisfactory arrangements for the safe handling of medication. EVIDENCE: People’s likes and dislikes were recorded in their care plans along with the way in which they wish to be supported with their personal and healthcare needs. Staff were observed treating people with dignity and respect. Daily diaries indicated flexible times for getting up and going to bed. One person likes to stay up late and another likes to occasionally sleep in. Two people needed support with moving and handling around the home. Each has been referred to healthcare professionals for advice about specialist equipment and adaptations. Guidance about the way in which they were to be transferred was in place along with schedules of exercises to be completed on a regular basis. Records were being kept for exercise routines. One person was observed being supported to transfer out of their chair to a walking frame that was contrary to the guidance on their care plan. This could also have put the member of staff at risk of injury. The acting manager said that she would Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 15 remind staff of the correct transfer. She also stated that a new reclining chair had been ordered for the person that would encourage them to be more independent when transferring. Healthcare professionals commented “my client has recently improved in mobility and confidence”, “this client has complex needs and requires a sensitive approach, which is provided” and “staff liaise regularly by telephone”. They also stated that any specialist equipment and adaptations had been provided in consultation with them prior to people moving into the home. Healthcare records were in place that provided evidence of appointments with a range of healthcare professionals. The outcome of each appointment was also recorded on a separate record. One person visited their dentist during the visit and another had a chiropody appointment at the home. This latter appointment was taking place in the lounge. The manager stated that she would immediately address this with them. She said appointments were normally completed in people’s bedrooms. One person’s care plan indicated that a health action plan would be put in place but this had not yet been done. Medication systems were inspected and found to be satisfactory. Staff had completed training in the safe administration of medication. Medication audits were being completed monthly and identifying any changes that needed to take place. Administration records had been completed correctly with handwritten entries being counter-signed by a second person. These records keep a record of the stock in place. Creams were labelled with the date of opening. A letter from seen from the doctor confirming use of homely remedies. Photographs of each person will need to be added to these records. A temperature check also needs to be kept of the cabinet. The manager confirmed that a thermometer had been ordered for this purpose. A healthcare professional said “medication management had been a problem for my client in past accommodation. Staff (at Denmark Lodge) have handled this sensitively”. Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Systems are in place to enable people to express their concerns and they are confident that they will be listened to. Improving the knowledge of staff and the recruitment and selection procedures would safeguard people from possible abuse. EVIDENCE: Each person had a copy of the complaints procedure upon admission and parents and friends indicated that they were aware of the complaints procedure. The procedure stated that this could be produced in a version using text and symbol if needed. No complaints had been received by the home. The manager and staff had received training in the protection of vulnerable adults and discussed their understanding of safeguarding of people. This was satisfactory although they were not all aware of the local procedures. Cathedral Care’s policy and procedure had recently been reviewed and included information about the local adult protection team. The local policy and procedure was kept in the manager’s office. New staff were completing “alerters guide” training as part of their induction programme. The manager and other staff had not recently attended training organised by the local adult protection team. Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 17 Recruitment and selection processes could be more robust to make sure that the necessary checks have been completed prior to employment safeguarding people from possible abuse. (See Standard 34). Staff said that they had attended training in MORE (Management of Response to Emotion) which provides them with an approach to challenging behaviour that uses diversion, distraction and diffusion. Emotional Support and risk assessments were in place for two people, one was being developed for the third. These indicated antecedents, triggers and ways of diffusing situations. Each stated that physical intervention would not be used under any circumstances. Staff spoken with had a good understanding of how to support people who may be upset and were confident that they could manage this behaviour. Financial records were examined and systems were found to be satisfactory. There were regular checks in place with evidence of staff signatures. Receipts were being obtained and cross-referenced with debits and credits. There was evidence that where there had been discrepancies the acting manager had investigated these. Financial risk assessments were in place. Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a home that is clean and well maintained which recognises their diverse needs creating an environment that matches their personal requirements. Specialist equipment is provided to those people who need it. Further work is needed to make sure that a safe environment is provided. EVIDENCE: Since the last inspection the communal areas had been redecorated and issues identified in the last report had been addressed. The overall atmosphere was very calm and homely. People were observed using the spacious lounge, dining room and their own rooms. They said they had been enjoying using the garden in the good weather and that new furniture had been bought for the patio. Two bedrooms were looked at indicating that people were being supported to decorate them according to their interests and lifestyles. One person had brought furniture Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 19 with them. Inventories were on files but had not been completed. One person had a list of clothes they had brought into the home. It was noted that several fire doors around the home were wedged open at the start of the visit. After mentioning this to the acting manager they were immediately closed. Some fire doors have magnetic closures. Some fire doors when shut did not close properly. Specialist equipment such as a stair lift, handrails, bath chair and walking frames were in place. A letter from a healthcare professional indicated that they had completed a full environmental assessment and their recommendations had been complied with. At the time of the visit the home was clean and tidy. The laundry was satisfactory. When initially inspected the cupboard containing hazardous substances was open but this was quickly locked without prompting. Personal protective equipment was available for staff. Communal hand washbasins were provided with liquid soap and paper towels. Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are met by a mostly competent staff team, who have access to an adequate training programme that needs to ensure staff have knowledge about the diverse needs of people living at the home. The qualifications of night staff need to be monitored more robustly to ensure they have the skills needed. Recruitment and selection processes are inconsistent which could put people at risk of possible harm. EVIDENCE: Since the last inspection a dedicated team of staff have been put in place to provide continuity of care to the home. One member of staff had transferred from Denmark House and other new staff appointed. Two staff had a NVQ Award in Health and Social Care and other staff were or will be registering to do their awards. Staff spoken with appeared to have a good understanding of the needs of people living at the home. Healthcare professionals said “ staff respect clients lifestyles”, and “staff respond appropriately to this clients behaviour”. Parents responded, “Staff I’ve met seem very capable”. People living at the home said in their surveys, “I think the staff here are all very Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 21 pleasant” and “I am having the best of care and help”. The AQAA indicated that 4 staff had a NVQ Award. Recruitment and selection files were examined for three new members of staff. There were some inconsistencies in the information obtained. The following issues were identified: • • A full employment history had not been obtained for one person One person had only one reference on their file although the acting manager stated that a second had been seen by her, the application form was also missing • Some references had been requested from people who formerly worked at previous positions rather than from the service directly • Not all files had evidence of identity or a current photograph in place • One person’s last reference indicated reason for leaving as problems with a passport. This did not appear to have been followed up. One person had been employed who was under 18 and there was evidence that a letter had been sent to them outlining the duties they were not able to do. They had signed a copy of this letter. This is good practice. Copies of Criminal Records Bureau checks were examined and the acting manager was informed that these could now be destroyed. The home had a robust training programme in place and the acting manager discussed plans for further training. All new staff had access to the home’s induction which was an introduction to the home, people living there and health and safety. Staff then attend the Learning Disability Qualification with an external provider where they also complete mandatory training and safeguarding training. Staff confirmed that refresher training was being arranged. A training matrix was in place and each member of staff had individual training records. Specialist training in epilepsy, dementia, autism and the Mental Capacity was being provided. If a change in registration is needed to include mental health needs, staff must have the necessary skills and knowledge in this area also. Training records for two night staff indicated that neither had completed mandatory training. Each had attended one course in 2006, one person completing fire and the other first aid. Night staff must have the relevant skills and knowledge to support people living at the home. Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. An improvement in some management functions will make sure that people are living in a well run home which safeguards and protects them from harm. Quality assurance systems involve people living at the home. EVIDENCE: Since the last inspection a manager has been appointed and their application to become registered manager with us had just been submitted. There had been a delay in their Criminal Records Bureau check being processed. The acting manager has completed a NVQ Level 4 in Health and Social Care, the Registered Managers Award, was an NVQ Assessor in Health and Social Care and has a professional trainer award. She said that she had completed the protection of vulnerable adults and Mental Capacity Act training. She had reviewed the Statement of Purpose and Service User Guide since being in post. Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 23 The AQAA was received after the visits to the home. This provided information about what they were doing well and areas for improvement. The DataSet also provided information we had requested about the home. Concerns have been raised about recruitment and selection procedures. These must be more robust if people living in the home are to be protected from possible abuse. Cathedral Care has a quality assurance system in place, which involves people living in the home. People had a copy of the annual survey on their file and there was evidence that one person had started to complete theirs. Regular unannounced visits as part of Regulation 26 were taking place and a record of these were kept in the home. Monthly health and safety and medication audits were being completed. The AQAA confirmed that Cathedral Care had obtained the Investors in People Award. Health and safety systems were inspected. There were inconsistencies in the recording in the following areas: • • • • • Checks on fire equipment and systems were last completed in March 2008 Emergency lighting was done in July 2007 Water temperatures although monitored and appeared to be regularly over 43°C with no evidence of any action being taken to rectify this Portable appliance testing was due to be completed, it was last completed in May 2007 Fire equipment was last serviced in April 2007. Good systems were in place monitoring fridge and freezers temperatures, cooked food temperatures and labelling open food in fridges. The DataSet confirmed that other equipment in the home was being serviced and maintained. Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 2 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 X 2 X 3 X X 2 X Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 25 No 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 YA2 Regulation 43 Requirement The home must obtain information about the prime needs of people being admitted. This is to make sure that their needs can be met and that they are not in breach of their registration. Each person must have a statement of terms and conditions which provides them with information about the fees they pay and any additional costs. This is to make sure they have information about the service they receive. Care plans need to detail how people with epilepsy are supported to manage their seizures. This will safeguard them from possible harm. The ways in which staff reduce the hazards faced by people with epilepsy need to be recorded. This is to protect people from harm or injury. Moving and handling guidance for transfers of people from a chair to walking frame must be followed. So that people are moved safely. DS0000062183.V360904.R01.S.doc Timescale for action 30/05/08 2. YA5 5 30/06/08 3. YA6 15(1) 30/06/08 4. YA9 13(4) 30/06/08 5. YA18 13(5) 30/05/08 Denmark Lodge Version 5.2 Page 26 6. YA23 13(6) 7. 8. YA24 YA24 17(2) Sch 4.10 23(4A) (b) 19(4) Sch 2 9. YA34 10. YA35 18(1)(c) 11. YA42 23(2)(c) All staff need to understand local procedures for safeguarding adults. This is to safeguard people from possible harm. A list of furniture owned by the person living in the home must be in place. Fire doors must be fit for purpose and close securely. This is to prevent fire spreading throughout the home. Prior to employment the necessary documents must be obtained as detailed in the text. This is to safeguard people living in the home from possible harm. Night staff must have the skills and knowledge required to support people living at the home. This is so that people can receive the appropriate help and support they need. Equipment such as electrical or taps and water outlets must be checked and serviced at regular intervals. This is to make sure that people are safe from possible harm. 30/07/08 30/06/08 30/06/08 30/05/08 30/06/08 30/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA17 YA19 YA20 Good Practice Recommendations Individualised meal records should be kept so that the diet of people can be monitored. Health action plans should be put in place for each person. A temperature check needs to be maintained on the drugs cupboard. Photographs of each person need to be included in the medication administration record. Staff should have access to regular refresher training in the safeguarding of adults. DS0000062183.V360904.R01.S.doc Version 5.2 Page 27 4. YA23 Denmark Lodge 5. YA24 Consider fitting magnetic closures/door guards to fire doors which are being kept open. Adjust fire doors so that they when closed they are flush with the frame. The dates of attendance at school and college should be identified on the application form. Mental health training should be provided. Fire records should be kept regularly for equipment, drills and emergency lighting. 6. 7. 8. YA34 YA35 YA42 Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Denmark Lodge DS0000062183.V360904.R01.S.doc Version 5.2 Page 29 - 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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