Inspection on 29/04/09 for Denmark Lodge

This inspection was carried out on 29th April 2009.

CQC 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

Denmark Lodge 15/05/08

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 27/06/2009.

Key inspection report CARE HOME ADULTS 18-65 Denmark Lodge 38 Denmark Road Gloucester GL1 3JQ Lead Inspector Ms Lynne Bennett Key Unannounced Inspection 29th April 2009 09:30 Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Denmark Lodge DS0000062183.V375121.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 dalewcathcare@msn.com www.carehomes.co.uk Cathedral Care (Gloucestershire) Limited Mrs Dale Williams Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (code LD) The maximum number of service users who can be accommodated is 7 Date of last inspection 15th May 2008 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 base fees charged by the home are £817. An additional charge of £10 is payable towards the cost of the home’s transport. Copies of the home’s Statement of Purpose and Service User Guide are available from the office. Denmark Lodge DS0000062183.V375121.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 April 2009 and included one visit to the home on 29th April by one inspector. The registered manager had returned the AQAA (Annual Quality Assurance Assessment) to us (The Care Quality Commission) prior to the inspection although we had not received it. A copy and proof of posting was given to us during the visit, indicating that the AQAA had been completed in March 2009. This provided considerable information about the service and plans for future improvement. We received surveys from 1 person living in the home, 4 staff and health care professionals. We talked to 3 people using the service, and asked staff about those peoples needs. We also looked at the care plans, medical records and daily notes for these 3 people. This is called case tracking. We spent time observing the care provided to people living in the home and spoke to staff on duty. We conducted a tour of the building and looked at a range of records including staff files, quality assurance audits and health and safety systems. 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? Eleven requirements issued at the last inspection were complied with. These included making sure that the person admitted met with the registration requirements of the home. Each person was provided with a statement of terms and conditions. Care plans provided details about how to support a person with epilepsy. Moving and handling risk assessments and guidelines were in place. Staff had completed training in the safeguarding of adults. Inventories were in place for people. Servicing of electrical equipment and Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 6 checking water outlets was being done. All documents required by us before appointing staff were in place. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Denmark Lodge DS0000062183.V375121.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.V375121.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Satisfactory admission arrangements are in place that includes an assessment of people’s needs. Information about the home is regularly reviewed to make sure that people living in the home and wishing to move in have access to up to date information. EVIDENCE: The Statement of Purpose and Service User Guide had been reviewed to reflect changes to the service and were accessible to people living in the home. These were supplemented with a brochure about the home for people wishing to move in. At the time of the visit there were three people living at the home. There had been no new admissions since the last inspection. Previously a comprehensive assessment had been completed by the home and copies of assessment of need and current care plans obtained from placing authorities before inviting people for visits to the home. Each person had a copy of their terms and conditions indicating any additional fees which were payable. These had been reviewed in September 2008 and people had signed their copies. Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are being involved in developing their care plans that reflect their aspirations and needs. Risks are being managed which should safeguard them from possible harm. EVIDENCE: At the time of the visits people’s care plans were being reviewed, some had been completed and others were being reproduced. There was evidence that they had been reviewed every few months or sooner as changes occurred. Evaluation sheets were in place. Each person had a copy of their assessment of need and care plan supplied from their placing authority in 2008. Reviews for this year were being arranged. The registered manager said these documents were used as the basis for developing support plans and we verified that this was the case. Support plans were in place for a range of physical, intellectual, social and emotional needs. These were written in plain English and gave the Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 10 reader a clear summary of how the person wished to be supported. People had signed their plans. Where risk assessments were in place the support plan indicated this and a copy of the risk assessment was included with each plan. Where changes had occurred plans indicated this and there was evidence that they were being amended. People were observed being supported in line with their identified needs and staff spoken with had a good understanding of people’s needs and how to minimise risks. For instance one person’s eating and drinking support plan indicated that their food should be cut up small and they should use adapted cutlery. Observation of a meal time confirmed this was happening. Daily notes were being kept as well as monitoring forms for epilepsy, continence and accidents or incidents. Each person had a communication support plan in place indicating how they express themselves and how to interpret their verbal and non verbal behaviour. Guidance was provided to staff on how to enable people to express themselves. Support plans made reference to the support people may need in relation to making decisions and being able to consent to treatment or medication. Where appropriate these indicated where a best interests meeting may need to be held. There were no restrictions to people’s liberty or freedom around the home. A keypad to the kitchen was not being used and people were observed using the kitchen to make themselves snacks and drinks. One person has a wheelchair and was noted to use a lap belt to prevent them from falling out. It is advisable that the home records this as a form of restraint and provides evidence of the rationale for this. A person was observed using a recliner chair with remote control. They were given the control to activate the chair and called staff when they wished to go to their room, change position or use the toilet. Risk assessments were in place which had been reviewed. They provided guidance about the hazards people may face and how to minimise these. They enabled people to be as independent as possible. A missing person’s procedure was in place, with individual profiles and current photographs. Denmark Lodge DS0000062183.V375121.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): This is what people staying in this care home experience: 11, 12, 13, 14, 15, 16 and 17. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Opportunities to participate in social, educational, cultural and recreational activities are affected by staffing levels. People are supported to maintain contact with their families. They are offered a range of freshly produced meals giving them choice about their diet. EVIDENCE: Outcomes for people in standards 12 to 14 are poor. Each person had an activity schedule in place indicating how they should be supported to access the community, in house activities and follow their religious beliefs. Support plans were inconsistent in the recording of people’s religions; with their front sheet indicating that they were non practicing and support plans noting how they were supported to follow their religion. Two people said they regularly Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 12 went to church each week. Their daily notes confirmed this. There was no evidence that people were being supported to access community activities on a regular basis and they were not having the opportunity to participate in educational interests, training courses or employment. One person said they were thinking about attendance at a summer school at a local college. The daily records for people were sampled for a three week period in April 2009 and they indicated that for two people there were 7 occasions when they were supported to access the community. This included 3 visits to church. Otherwise their time was spent in the home watching television, listening to music, helping with household tasks such as cleaning and vacuuming and laying the table. They had a massage at the home twice a month and one person said they really enjoyed this. One person said they had been to the pub for lunch and out to a social club. They said they liked to go out for a ‘Cappuccino’ and to visit garden centres. Another person living in the home goes out and about independently without staff support, which dairies indicated they did most days. People had taken holidays last year and said they were planning trips away for later in the year. Rotas indicated that during the period sampled the staffing levels were reduced to one member of staff on shift on 19 occasions. One person said (without prompting), “haven’t got enough staff, I think we should have more staff here” and when a staff member left the house to go to the other home, a person said, “are you coming back?” During the visit staffing levels were maintained at 2 carers per shift and people were supported to go into town for a drink in the afternoon. They had spent the morning in the lounge watching television or helping to prepare lunch. Another person was getting ready to meet their family later in the day. The registered manager and staff confirmed that staffing levels over the past few months had affected the activity schedules of people living in the home. Surveys also raised concerns about staffing levels. The AQAA did not refer to these concerns. Daily notes indicated that people were being supported to maintain relationships with their family, who visited the home or were telephoned regularly. All people had keys to their rooms which some people chose to use. Inventories of personal belongings were in place. People were observed choosing where to spend their time and with whom, using communal areas and their rooms. One person said they enjoyed doing the vacuuming and were observed helping to lay tables ready for lunch. One person said they occasionally took a dog for a walk although they did not have any pets at the home. Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 13 A four week rota was in place for meals with a hot meal being provided at lunch time and a snack at tea time. People said they liked the food and were observed tucking into Gammon, mash and vegetables. They were provided with the necessary adapted cutlery and crockery where necessary. Meals were being freshly prepared and fresh fruit was available for snacking. Denmark Lodge DS0000062183.V375121.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s health and wellbeing are being met helping them to stay well. There are some improvements in the administration of medication that need to be implemented to safeguard people from the risk of error or possible harm. EVIDENCE: People’s likes and dislikes were recorded in their support plans which gave clear guidance about how they wished to be supported with their personal care needs. Personal care support plans indicated people’s preferences about the gender of staff providing their personal care. The needs of one person had changed and they needed two staff to support them with some of their personal care especially when this involved moving and handling tasks. There was evidence that the relevant health care professionals had been involved in the assessment and supply of equipment to help people with moving and handling. Staff were observed using new equipment which Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 15 promoted the person’s independence when transferring from chairs whilst also promoting safe practice. The appropriate risk assessments were in place. As mentioned one person requires support from two carers with some moving and handling tasks. Two people had new motorised scooters and staff were supporting them to trial these in the safety of the garden before going out into the community. Risk assessments were being developed. Each person had a Health Action Plan which was being developed with the relevant health care professionals. A summary sheet was in place providing a summary of appointments with health care professionals including Doctors, Dentists, Opticians, Chiropodists and the local Community Learning Disability Team. A record of the outcomes of each appointment was recorded. Where people were supported with their mental health needs there was evidence of a Care Programme Approach being in place. Health care professionals commented that sometimes advice was sought from the ‘wrong direction’ and greater awareness was needed of whom to contact for Mental Health, Learning Disability or health/physical concerns. The changing needs of one person were being monitored in respect of possible dementia. Systems for the administration of medication were examined and found to be satisfactory. A monitored dosage system was in place and staff had received training in the safe handling of medication from the pharmacy and an open learning course. Medication audits were being conducted each month. Medication administration records for March and April were examined. There was some inconsistency in handwritten entries. These need to be signed and countersigned as correct by staff. Staff indicated that secondary dispensing of medication does not take place when people take social leave. Some homely remedies were being kept and there was evidence that the home had consulted with the Doctor about their use. Stock control of medication was in place and stock was returned to the pharmacy each month. A signature list was in place for all staff administering medication. Each person had a medication support plan indicating that they needed support with their medication. There were no records in place to confirm that they had given consent to staff to administer their medication. Patient information leaflets were in place but the British National Formula was out of date (2006). People were having access to medication reviews. Denmark Lodge DS0000062183.V375121.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People using the service experience good quality outcomes in this area. We have made this judgement using a range of 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. The systems in place should safeguard people from possible harm or abuse. EVIDENCE: The home has a complaints policy and procedure which was accessible to people living in the home. Our details on this were being revised. The AQAA indicated that no complaints had been received. The home did not have a complaints or compliments folder. People spoken with said they would talk to staff or the manager if they had concerns. Their surveys also confirmed this. During 2008 there had been 6 house meetings which were recorded, providing the opportunity for people to talk about the service they would like to receive. There was no evidence that these were still taking place this year although the AQAA indicated this was the case. Staff had completed training in the Protection of Adults with the local team at Gloucestershire County Council and had completed an open learning course. There was information in the office about ‘No Secrets’ and the local procedures. Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 17 People had an Emotional behaviour risk assessment and support plan in place which identified any support they may need when anxious or angry. Guidelines clearly stated how to support people, what triggers to look for and what action to take to diffuse or distract people. Staff were observed putting this into practice during the visits. All plans indicated that physical intervention was not acceptable and staff confirmed that this was not used. Staff had completed training in M.O.R.E. (Management of Response to Emotion). Records were being maintained and support provided from the appropriate healthcare professionals. Each person had a financial support plan identifying the support needed to manage their personal finances. Records were kept for day to day expenditure with receipts cross referencing expenditure. Savings accounts were also in place for each person and the registered manager confirmed they audited this regularly. Denmark Lodge DS0000062183.V375121.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a home that is safe, 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. EVIDENCE: The registered manager confirmed that the home had a day to day maintenance plan in place. This was examined which highlighted communal areas to be ‘touched up’ and bedrooms to be redecorated. There was evidence that the latter was being done. Communal areas and hallways will need some attention in due course to attend to wear and tear on walls. Peoples’ rooms were decorated to reflect their interests and lifestyles. They said they were happy with the facilities they had. Health care professionals commented that a “homely environment” was provided. The bathroom (Room 5) needs attention Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 19 to the lino floor which appeared to have some water damage. The lock on the door was very stiff and needs to be repaired. Where needed specialist adaptations and equipment had been provided around the home. One person showed how they used the chair lift to access their room. Staff were carrying their tripod up and down the stairs. It was suggested to minimise risk of injury that an additional walking frame be provided to remain permanently upstairs. Personal protective equipment had been provided around the home including in communal toilets and hand wash basins. Hazardous products were stored securely and data sheets were in place. Staff had completed training in infection control and good infection control measures were observed to be in place. Denmark Lodge DS0000062183.V375121.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples’ needs are met by a competent staff team, who have access to a satisfactory training programme that provides staff with knowledge about the diverse needs of people living at the home. Staffing levels may put people at risk of possible harm and leave staff unable to meet people’s needs. EVIDENCE: New staff were completing an induction programme within the home and then completing a Learning Disability Qualification. The registered manager confirmed that once completed they would progress onto a National Vocational Qualification (NVQ) Award in Health and Social Care. The AQAA indicated that 57 of staff had a NVQ award and that a further 28 were working towards their awards. This is excellent practice. Discussions with staff confirmed they had a good understanding of the needs of the people they support. They were observed treating people with dignity Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 21 and respect. Health care professionals commented that staff were “open and honest.” People living in the home and staff had indicated that at times the staffing levels fell below the scheduled level of 2 care staff per shift. Rotas and dairies for a three week period confirmed that on 19 shifts a member of staff had been relocated to work in Denmark House. Shifts were split into early and late shifts with some staff working long days. The result of this was that for some shifts staff were lone working. As mentioned previously one person now needs two members of staff for some moving and handling tasks and this could potentially put them at risk of harm. Community activities were also being affected. When levels of staff fall below the scheduled 2 per shift we must be informed under Regulation 37. Staff meetings had been taking place every two months in 2008. There were minutes for one meeting on file held in January 2009. There were no staffing vacancies at the home. One new member of staff had been appointed since the last inspection. Their recruitment and selection file confirmed that all records required by us had been received before appointment. Where there were gaps in the employment record these had been queried and records completed to provide a full employment history. Evidence of identity and a current photograph were in place. The registered manager was advised not to keep copies of birth certificates in line with Data Protection recommendations. A training matrix was in place and staff confirmed access to refresher training via open learning packages. Copies of test booklets and certificates of completion were on file. Additional training in Mental Health, Person centred planning, safeguarding, equality and diversity, coping with aggression and death, dying and bereavement were also available. Some training was being sourced through external training providers. The training matrix identified future training needs. This included Mental Capacity Act and Deprivation of Liberty safeguards and Dementia training. The registered manager said that she was trying to find training in Dementia and Downs Syndrome. A supervision schedule was in place indicating they would take place every two months. Last year staff had received up to 4 sessions over the year. Staff had a supervision session in January 2009. The registered manager said that annual appraisals were being planned. Denmark Lodge DS0000062183.V375121.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A number of areas identified throughout this inspection would benefit from the presence of the manager to fulfil their managerial role and improve the experience of people living in the home. The quality assurance system does not give people feedback about planned improvements to the service they receive. Systems are in place to maintain and monitor the health, safety and welfare of people. EVIDENCE: The manager had been confirmed by us as the registered manager for the home after the last inspection. Since January 2009 she has been managing two services, Denmark Lodge and Denmark House in the absence of a manager in the latter home. She said she occasionally spends time at Denmark Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 23 Lodge but was mostly based at Denmark House. Staff confirmed this. She supplied a copy of the AQAA to us during our visit. This did not indicate the current problems experienced in the home due to staff working in Denmark House and the demands on her time. Shortfalls identified in this report were a direct result of pressures on Denmark Lodge from the other home impacting on the wellbeing of people living at Denmark Lodge and the quality of the service they were receiving. Staff commented in their surveys that she was accessible and approachable and competent in her role. Supervision sessions and staff meetings appear to have suffered as a result of the registered manager’s additional duties. She was attempting to review care plans and risk assessments at the time of our visit. Although a person centred approach to care appeared to be in place she was struggling to make sure that this was delivered given the constraints on staffing levels. There are no people living in the home who are subject to the Deprivation of Liberty safeguards. The organisation had been awarded the Investors in People Award in 2007. A quality assurance system was in place which included monthly unannounced visits to the home by the provider, surveys from people living in the home and medication and health and safety audits. There was evidence that action was taking place as a result of this feedback but there were no formal means of recording an improvement or action plan from this quality assurance system. Systems for the monitoring of health and safety were observed to be in place. There were regular checks for fire, food hygiene and water systems. The fire risk assessment stated that this was valid until April 2008 and although the registered manager had reviewed this document it should be reviewed by a competent person. The AQAA confirmed that equipment and utilities had been serviced. Documents in the home verified this. A visit by Health and Safety from Gloucestershire County Council in 2008 indicated that their recommendations had been complied with. Denmark Lodge DS0000062183.V375121.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 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 4 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 3 12 1 13 1 14 1 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X Version 5.2 Page 25 Denmark Lodge DS0000062183.V375121.R01.S.doc Are there any outstanding requirements from the last inspection? No 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 YA7 Regulation 13(7) Requirement The registered person must make sure that where restraint of any form is used, records are maintained for this, describing the rationale for this restraint. This is in respect of the use of lap belts in wheelchairs. This is to safeguard people from possible abuse. The registered person must make sure that people living in the home are supervised appropriately, and provision is made for access to education/activities. This is to make sure the home promotes their wellbeing. The registered person must make sure that the floor in the bathroom and the lock to the door are fit for purpose. This is to safeguard people from possible risk of injury or harm. The registered person must make sure they inform us when staffing levels fall below the scheduled level of 2 per shift. The registered person must make sure that at all times appropriate numbers of staff are DS0000062183.V375121.R01.S.doc Timescale for action 30/05/09 2 YA14 12(1) 30/05/09 3 YA24 23 30/05/09 4 YA33 37 30/04/09 5 YA33 18 30/04/09 Denmark Lodge Version 5.2 Page 26 6 YA37 10 7 YA39 24 working in the home to meet the needs of people living there. This is to make sure that their needs and wellbeing are being met. The registered person must 30/05/09 make sure that the registered manager is present to carry on the management of the home competently. The registered person must 30/06/09 produce a report to reflect the outcomes of the quality assurance system and any action taken. This is to provide feedback to people involved in this process of any action taken. 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 4 5 6 7 8 Refer to Standard YA11 YA20 YA20 YA20 YA22 YA29 YA34 YA42 Good Practice Recommendations There needs to be a more consistent approach to the recording of people’s religious beliefs. Handwritten entries on medication administration records should be signed and countersigned by staff. Consent to have medication administered by staff should be in place. An up to date copy of the British National Formula should be obtained. A complaints folder should be set up. Consider providing an additional walking frame at the top of the stairs with the chairlift. Copies of birth certificates should not be kept. The fire risk assessment should be reviewed by a competent person. Denmark Lodge DS0000062183.V375121.R01.S.doc Version 5.2 Page 27 Care Quality Commission South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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