Inspection on 09/11/05 for Denmark Lodge

This inspection was carried out on 9th November 2005.

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 4 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 21/05/07

Denmark Lodge 03/03/06

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 Peter Still Unannounced Inspection 9th November 2005 14:00 Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 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.V257266.R01.S.doc Version 5.0 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.V257266.R01.S.doc Version 5.0 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 383888 www.ccarehomes.co.uk Cathedral Care (Gloucestershire) Limited Mr Patrick Joseph Boyle Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection None 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. Each resident has their own bedroom 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 access between the properties is via patios at the side of the buildings. The home is situated in a residential area and close to all the amenities of Gloucester. The home has use of both a car and a people carrier. Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two hours. Although the home is registered to accommodate seven residents, currently there is one resident living at the home. There was some communication with the resident, who appeared to be content and settled with staff, who were providing constant one to one care. The senior member of staff for the home and a care assistant supported the inspection. A previous inspection had been arranged for Denmark Lodge but since there were no residents accommodated, it was cancelled. This was therefore the first inspection of this home since registration was granted. A tour of the building was completed and a number of records reviewed. The care home is being established and a number of requirements and recommendations need to be addressed. What the service does well: What has improved since the last inspection? No previous inspection Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 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. Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 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.V257266.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Assessment of individual needs and the development of a care plan support a resident. EVIDENCE: The daily diary and file for one resident was reviewed and showed up to date review. The current care plan is basic and the key worker is currently developing the plan, which will include short, medium and long-term goals. The Key Worker intends to provide a monthly review from this December and a copy of the new recording format was provided for the Commission file. Prior to completion of the document, it is expected that it will include a heading so that it can be distinguished from other forms. The resident file contained forms for completion concerning seizure and it appeared that none had been recorded. However these were found in another part of the file. An index and clear sections to the file is needed so that staff can easily find the documentation. It is unfortunate that there is currently only one resident at Denmark Lodge. The resident prefers to have time with other residents, which is recognised and the resident spends time at Denmark House, where meals are also provided. The provider is looking forward to further residents being admitted and is working towards this. It is understood that the funding authority is no longer providing a named representative and advocacy will need to be considered. The funding authority Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 Page 9 is providing access to a duty member of staff, where this is needed. This arrangement should be considered further and also any ongoing professional agency support. Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Staff develop understanding of a residents needs to support decisions that improve quality of life. EVIDENCE: The care plan has vital importance in ensuring this standard is met and it is being developed. During the short time a resident has been accommodated, staff have found ways of understanding the resident so that likes and dislikes are known. An example concerned a preference of transport and the choice offered enabled a resident to make a decision, important to them. Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Activity is being developed to enhance positive experiences. EVIDENCE: A range of activity is being provided and more is being planned. Trips out in the people carrier was the preferred form of transport. Other activity includes enjoying contact with staff, books, music, open countryside and kicking a ball. Swimming is also an important activity but unfortunately due to slow response for provision of personal equipment from agencies, this is not currently taking place. Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Staff find ways of ensuring needs are understood and preferences are supported in the way the resident wishes. EVIDENCE: Staff know likes and dislikes and find ways of providing support. A personal care activity of dental hygiene was described to provide evidence that staff have considered a personal need, have looked at taking very specific steps to help the individual and provided record keeping so that staff can work consistently in the way the resident wishes. Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Staff work to understand communications so that needs can be met. Residents will be protected from abuse by staff engaging in further training. EVIDENCE: The development of comprehensive care plans will support staff to gain on going clarity to ensure needs of a resident are understood and acted upon. This was acknowledged and work is in progress. Evidence was observed that staff were well aware of a residents needs and responded well. A resident was seen to be happy with the way staff were responding. Further training, concerning signs and forms of abuse, whistle blowing and of the critical steps to take, should be considered within the staff training programme. A member of staff had some difficulty in remembering their training and was not immediately clear about the policy and procedure they had studied. Two members of staff felt that further training could be of benefit. Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 29, 30 Residents enjoy a comfortable and clean home, which is being developed as needs are identified. Hot surfaces may present a risk to resident’s safety. EVIDENCE: The home was well furnished and comfortable and a resident’s bedroom had been painted to a colour of the resident’s choice. A laminated and colourful panel was being considered for the bedroom. Staff should be commended for working hard to ensure curtains provided a homely feel and privacy in a resident’s bedroom. Radiators were not provided with covers and may present a risk to residents. Risk assessments were seen, including guidance to keep material away from them, however no reference was seen concerning risk to residents and a requirement will be made that risk assessments be reviewed and radiators covered where they present a risk. A door to the laundry could be locked from the outside and this should be reviewed to ensure staff could not be locked into the small room. The kitchen was not in use for provision of meals since these were being taken at Denmark House. It is understood that this is only occurring because the resident of Denmark Lodge enjoys being with other residents for meal times Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 Page 15 and not eating on their own. A door has come off from one of the kitchen units and needs to be replaced. Documentation concerning COSH and cleaning chemicals was seen to have a review date of August 2004 and a review was not seen. A requirement will be made to review all documentation concerning the health, safety and welfare of residents and staff. The manager should also ensure that documentation relates specifically to Denmark Lodge. Specialist equipment is not provided. The home was considered to be clean. Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 Staff training is progressing to ensure the home has suitably qualified staff. EVIDENCE: Staff had undertaken a wide range of training opportunities. The manager holds the Registered Managers Award; the senior member of staff holds an NVQ Level 3 and the other member of staff on duty during the inspection, hopes to complete the NVQ Level 2 award within the next six months. NVQ training has been difficult for staff due to changes in assessors from the local collage provider and this has caused a delay in completion of course work. Further training concerning adult protection would be helpful to staff. The home currently has two night staff and three day staff. Support is also provided from Denmark House. One resident currently accommodated is being provided with one to one direct care during the waking day and a monitor is used during the night to alert staff of a potential need. Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 The service has been running for three months and is being developed. The health, safety and welfare of residents will be protected by attention to documentation and aspects of the running of the home. EVIDENCE: The policy and procedures file held a significant amount of information. It was found to be difficult to work through and should be reviewed. It may be better to put some information into other clearly labelled and indexed files, with section tabs. Weekly water temperature checks documentation was reviewed and last completed in September. A requirement will be made to review all environmental testing and checks to ensure they are all properly maintained. The hot water was hand tested in a resident’s bedroom and considered to be satisfactory. Only work place risk assessments concerning radiators were available and there should be a review of the work place to see if others are needed. Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 Page 18 It is understood that no reportable incidents have occurred, which require notification to the Commission and others, under Regulation 37. It was understood that documentation about this was held in a locked cabinet. This documentation must be available to staff so they can immediately report a matter effecting the well being of a resident. A requirement will be made concerning this. The senior member of staff was aware of steps to take. The provider is required to undertake unannounced visits to the home every month and provide both the manager and commission with a copy. A requirement will be made that these must commence. Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 2 X X X Standard No 22 23 Score 2 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X X X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Denmark Lodge Score 3 X X X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 2 X DS0000062183.V257266.R01.S.doc Version 5.0 Page 20 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 YA42 Regulation 37 Requirement Ensure all staff have access to and know how to report events, which affect the well being of residents. The provider must conduct monthly, unannounced visits to the care home and provide a report to the manager and commission. Review Standard 42.1 to 42.9 and ensure that all records are being maintained and checks are up to date. Also that documentation is clearly labelled and easily accessible to staff. Provided further risk assessment of radiators to ensure that hot surfaces do not present a risk to residents. Provide covers to radiators where there is any risk. Timescale for action 19/12/05 2 YA43 26 31/01/06 3 YA42 13 24/02/06 4 YA24 23 24/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000062183.V257266.R01.S.doc Version 5.0 Page 21 Denmark Lodge 1 2 3 4 Standard YA24 YA23 YA24 YA3 5 6 YA6 YA32 7 YA41 Repair kitchen unit door prior to the kitchen being used to prepare meals. Provide further staff training concerning adult protection. Review the safety of the lock on the door to the laundry to ensure staff cannot be locked inside. Review the decision of the funding authority not to provide a named person to support a resident. Review the need for an advocate. Review the ongoing external professional agency support to ensure this is being fully provided. Continue to develop the care plan for a resident It is recognised that staff could not have done more to ensure NVQ training is provided and the awards are obtained and the manager should continue to support staff as they complete their training. Resident files should be easy to refer to and an index with clear section tabs would help. Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Denmark Lodge DS0000062183.V257266.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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