Inspection on 21/05/07 for Denmark Lodge

This inspection was carried out on 21st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 7 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 15/05/08

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 08/07/2008.

CARE HOME ADULTS 18-65 Denmark Lodge 38 Denmark Road Gloucester GL1 3JQ Lead Inspector Ms Lynne Bennett Key Unannounced Inspection 21st May 2007 09:45 Denmark Lodge DS0000062183.V337154.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.V337154.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.V337154.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 To be appointed Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th July 2006 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 shares use of both a car and a people carrier with Denmark House. Although the homes are next to each other the main objective is that the two homes will function independently. The weekly fees charged by the home are £859 to £1200. Copies of the home’s Statement of Purpose and Service User Guide are available from the office. Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. 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. This inspection took place in May 2007 and involved a visit to the home on 21st May. At the time of the inspection the home did not have a registered manager and there were no people living at the home. The home was being temporarily managed by the registered manager of Denmark House. She was present throughout the visit and able to supply records and information about the service. References to a registered manager throughout this report refer to her. Staff working at Denmark Lodge have been relocated to Denmark House until people move into the home. A discussion was held with one member of staff whose substantive post is at the home. Records examined included policies and procedures, health and safety records, quality assurance systems and staff records. A walk around the environment was also completed. A random inspection in December 2006 confirmed that sixteen outstanding requirements had been met by the home. No further requirements were issued at that inspection. What the service does well: What has improved since the last inspection? A quality assurance system is in place which will involve people living at the home. Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Denmark Lodge DS0000062183.V337154.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.V337154.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 and 5. 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 who may wish to live in the home have access to information about the service and are fully assessed before deciding whether to move in. EVIDENCE: The home has a Statement of Purpose and Service User Guide which have been reviewed recently. These will be given to people as they are referred to the service. These documents will need to be reviewed when a new manager is appointed and to reflect amendments to the complaints policy and procedure. Since the last inspection the person living at the home has been supported to move to a service which is better able to meet their needs. The registered manager discussed the ways in which she and the team had supported this person through the move to ensure consistency and continuity. She stated that the parents had contacted her to pass on their thanks for a smooth transition. Referrals have been received by the home. The registered manager acknowledged that she has completed a full assessment and obtained Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 9 information from the placing authority. Copies of the assessment tool used and the admissions policy and procedure were examined. Clear guidelines are in place to ensure that sufficient information is obtained and put in place prior to admission. She confirmed that visits to the home would be encouraged and that she and staff would visit people in their present placements. A service agreement is in place for use with people wishing to move into the home. Denmark Lodge DS0000062183.V337154.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): People who use the service experience excellent/good/adequate/poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This outcome group was not inspected on this occasion. Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 11 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): People who use the service experience excellent/good/adequate/poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This outcome group was not inspected on this occasion. Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 12 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): People who use the service experience excellent/good/adequate/poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This outcome group was not inspected on this occasion. Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 13 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. Amendments to the complaints procedure will ensure that people will be confident of the process of how to make a complaint. This needs to be produced in accessible formats enabling them to voice their concerns. Systems are in place to protect people from possible harm due to accidents or abuse promoting and safeguarding their best interests. EVIDENCE: The home has a complaints policy and procedure in place. The complaints procedure examined did not contain a contact address or telephone number for the registered provider. There was also no indication of timescale for a response from the registered provider to the complainant. No alternative formats of the complaints procedure are available. The registered manager said that a complaints and compliments folder is in place. No complaints had been received prior to the person moving out of the home. There is a policy and procedure in place for the safeguarding of adults. The registered manager confirmed that staff have access to abuse training as part of the Learning Disability Award Framework training and their NVQ Awards. Staff have also completed training in the protection of vulnerable adults provided by an external trainer. The home does not have any information about local procedures for the safeguarding of adults. Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 14 Staff receive training in challenging behaviour and physical intervention. The registered manager confirmed that policies and procedures in the management of challenging behaviour have been changed to reflect this training. This document was available for examination and had been reviewed with the training providers in April 2007. Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 15 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 and 30. 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 will be moving into a home which provides a safe environment and accommodation of a high standard. EVIDENCE: At the time of the visit areas of the home were being re-decorated maintaining the high standard of accommodation. Fixtures and fittings were of a good quality. The following issues were identified as needing action: • • • • A broken television cabinet needs to be replaced doors need to be fixed onto the wardrobes toilets on the first floor are badly stained the lock to a bedroom door on the first floor is broken Since the last key inspection the office has been changed into a ground floor bedroom and the office has been moved into one of the bedrooms. If this Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 16 arrangement is proposed to continue then en suite facilities must be added to the ground floor room. Systems were in place for the day to day maintenance and upkeep of the property. The maintenance person confirmed their responsibility for health and safety checks, flushing water through the systems and redecoration of the home whilst it is empty. At the time of the visit the home was clean apart from the issues identified. Hazardous products were stored securely. Colour coded mops and buckets were in place. Communal toilets and wash basins were provided with paper towels. Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 17 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): 35 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. The needs of people who may live in the home will be met by a staff team who have access to training enabling them to acquire the knowledge and skills to meet people’s needs. EVIDENCE: Three members of staff have been redeployed at Denmark House whilst the home is empty. One person was spoken to confirming that they have access to training and refresher courses where needed. Training records verified that courses in protection of vulnerable adults, fire, manual handling, epilepsy and autism have been completed in the last twelve months. No new staff have been appointed since the last inspection. The registered manager confirmed that an induction programme has been set up for the home which is complemented by staff attending the Learning Disability Award Framework foundation course. Staff will also have access to a NVQ programme. Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 18 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): 37,39 and 42. 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. The service will benefit from having a registered manager in post to further develop key processes and systems within the home. A safe environment is maintained promoting the safety and welfare of people who may wish to live there. EVIDENCE: There is presently no manager at the home. The registered manager of Denmark House confirmed that the position has been advertised and that interviews have been arranged. In the interim period the registered manager is responsible for the management of the home. Key documents such as the statement of purpose and complaints procedure need to be reviewed. Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 19 A quality assurance system has been developed for use in the home. A copy of the audit being used for Denmark House was available for examination. The registered manager confirmed that people living at the home and their representatives would be involved in this process. Unannounced visits by the registered provider will be arranged as soon as people are admitted to the home. Health and safety systems are in place to ensure that fire equipment, water temperatures, portable appliance tests and boiler servicing are completed whilst the home is empty. The home has recently had inspections from environmental health and the fire service which were satisfactory. A fire risk assessment for the home was completed by an external company in 2007. Staff confirmed that their mandatory training is updated as required. Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 20 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 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 2 X 3 X X 3 X Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 21 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 YA1 Regulation 6 Requirement Amendments and changes to the Statement of Purpose and Service User Guide will provide people with up to date information about the service being provided. Where a complaint is made the registered provider must inform the complainant within 28 days of what action they will be taking. The complaints procedure must be produced in a format appropriate to the needs of people living at the home. Toilets must be kept clean to prevent the risk of infection. Bedrooms doors must have locks which function to ensure that people can have privacy and security for their belongings. Bedrooms must provide en suite facilities as stated in the Statement of Purpose and in accordance with the home’s registration. A manager must be appointed to manage the home. Timescale for action 21/08/07 2. YA22 22(4) 21/08/07 3. YA22 22(2) 21/08/07 4. 5. YA24 YA24 23(2)(d) 23(2)(c) 21/08/07 21/08/07 6. YA24 16(1) 21/08/07 7. YA37 8(1)(a) 21/08/07 Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 22 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 YA22 YA23 Good Practice Recommendations The complaints procedure should include reference to the registered providers contact details. Staff should be aware about the local adult protection procedures. Denmark Lodge DS0000062183.V337154.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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.V337154.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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