Inspection on 20/07/05 for Derby Lodge

This inspection was carried out on 20th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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

Derby Lodge 07/11/07

Derby Lodge 26/03/07

Derby Lodge 26/11/05

Derby Lodge 22/09/04

Derby Lodge 13/05/04

Similar services:

Ruskin Lodge

Clover House

Dystlegh Grange

The Good Companions

Springfield Cottage

Cuerden Grange Rest Home

Parkside

Park Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Derby Lodge 2a Blackbull Lane Fulwood Preston Lancashire, PR2 3PU Lead Inspector Lynne Lynch Announced 20 July 2005 9:45am 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 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 Stationary 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. Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Derby Lodge Address 2a Blackbull Lane, Fulwood, Preston, Lancashire, PR2 3PU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01772 718811 01772 716581 Derby Lodge (Preston) Limited Mrs June Nicholson Care Home 23 Category(ies) of Physical disability (20), Physical disability over registration, with number 65 years of age (3) of places Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. This house may accommodate 20 physically disabled adults who may also have a learning disability. Date of last inspection 22/09/04 Brief Description of the Service: Derby Lodge is situated in Fulwood, in easy reach of Preston City Centre and all the amenities that the City has to offer. There are also many services and facilities close by. These include banks, churches, GP surgeries and Preston College. The home provides accommodation for 23 adults who have a physical disability and who may, also have, a learning disability. The home is arranged over two floors and is fully accessible to residents. A passenger lift operates between floors. Much has been done to minimise the institutional appearance of Derby Lodge, the premises are well maintained and there is an ongoing programme of decoration and renewal of the physical environment. The home offers a mixture of accommodation including single rooms, some of which are en suite and flatlets that include a sitting room and kitchen. There is a large car park at the front of the premises and extensive gardens to the rear. During the summer months various recreational activities take place in the garden area. Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced started at 9.45am and took place over 6 hours. The Inspector spoke to the provider, manager and deputy manager, two residents, a member of staff and a visitor. Comment cards were issued. Ten service users, twelve relatives/visitors, one GP and one Health and Social Care Professional returned these. Assessment and care records were examined along with health and safety documentation. What the service does well: What has improved since the last inspection? What they could do better: A training matrix should be introduced to give a clear indication of the staff teams skills and qualifications at any given time. The home should consider ways of ensuring that staff remain aware of policies and procedures ensuring these are working documents. The home should consider developing its means of internal quality assurance to ensure continuing development of the service. Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 Page 6 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. Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 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 standard(s) 2 The home provides an appropriate service, based on professional assessment of need. Resident’s needs are met. EVIDENCE: The home has only had one admission for respite in the last 12 months maintaining the same residents in the home. Two files were viewed and thorough assessments were found to be in place. Evidence on the files showed the manager of the home had visited the person to complete the personal admission form. Specialist health assessments and information from social care professionals were present. The homes assessment covered all relevant areas giving information on mobility, equipment and adaptations required, medication, general health, diet and hobbies. Eight out of ten service user comment cards indicated that the person liked living at the home with two stating they sometimes liked living at the home. One resident said, “Like being here, stay here”. Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 and 9 Residents are well supported by staff to make decisions. The home has good risk management strategies in place. EVIDENCE: During the visit the inspector observed many examples of residents being enabled to make decisions. Minutes from residents meetings showed residents involvement in the running of the home. Several residents had been away on holidays of their choice and one gentleman spoke about the holiday he had been supported to choose. The ten comment cards completed gave good indication that residents were able to make decisions in all areas of their life including having a key to their bedrooms, activities, meals and what is on the menu, what to spend their money on and visitors to the home. One service user showed the inspector his bedroom, which had been redecorated as he had chosen he also had a possum, which enabled him to turn on his television and choose channels. Risk management strategies are in place, which support service users to take considered risks. The home has a disclaimer form in respect of risk which a resident is asked to sign if they wish to undertake an activity or outing against advice. Personal risk assessments for individuals were viewed along with generic environmental risk assessments, which covered main areas, however Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 Page 10 did require keeping under review. Staff spoken to were aware of their responsibility in respect of risks and hazard analysis. Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 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 standard(s) 12,13,15,16 and17 Residents in the home are supported to access the local community on a regular basis. Relationships with family and friends are supported, to ensure that these links are maintained. Menus provide a choice of healthy nutritious meals. EVIDENCE: Residents at Derby Lodge are fully involved in choosing how their time is spent both inside and outside the home. The home has links with the local college; and has provided work placements for some residents. One gentleman volunteers at a local disabled centre and scope shop and another gentleman attends meetings held by REACT to discuss disability issues. The home accesses therapeutic resources for other residents. The interests and hobbies of individual residents are pursued and opportunities for new experiences offered. One resident was recently supported to arrange a birthday party at a local community centre. Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 Page 12 Residents at the home were recently involved in discussions in respect of the local church/community centres development, being asked about disabled access. One resident attends the church independently. Residents at the home have been on holidays both in the UK and abroad. The resident plans these with support from staff. One service user in the home likes his privacy and prefers to go out alone with chosen staff and this is accommodated. The home is currently advertising for an activity co-ordinator to further develop and co-ordinator activities. Indoor activities include relaxation in the quiet room, aromatherapy, reflexology, painting and writing. Eight out of ten residents who returned comment cards felt the home provide suitable activities with two saying sometimes these were suitable. However it was felt that activities should take place more frequently. The home has recently employed a driver/handyperson, which is providing more opportunity for outings in the homes adapted transport. Residents confirmed via comment cards and when spoken to that they could see visitors in private and were supported to visit relatives, with some residents going home nearly every weekend. Relatives comment cards confirmed they could visit in private. Resident’s files contain information in respect of family/friends birthdays. Residents are given choice of food at mealtimes with any issues in respect of menus being discussed at meetings. One gentleman in particular regularly requests alternatives to the menu and the home purchases items such as tripe for him. Menus viewed showed a good choice of healthy nutritious meals with staff always having the flexibility to change these if residents want a take away or impromptu barbeque. Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 Page 13 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 standard(s) None of the above standards were inspected at this visit. EVIDENCE: Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 Page 14 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 standard(s) 22 and 23 Systems are in place to enable residents to voice their opinion and ensure that they are protected from potential abuse. EVIDENCE: The complaints procedure is on display in the home. This is issued to each resident or his or her representative for personal reference. Contact details of local advocacy groups are available to residents. The home has had three complaints from relatives/residents. These were seen to be appropriately dealt with and resolved. The Commission for Social Care Inspection has received no complaints. Comment cards from a social care professional and a GP, confirmed that no complaints had been received by them regarding Derby Lodge. Ten residents who completed comment cards said they knew who to speak to if they are unhappy. Symbol cards indicating whether a person is happy or sad, are available for use for people who are unable to verbally communicate. Eleven out of twelve relatives who returned comment cards said they had not made a complaint. One relative spoken to said if he had any issues they were raised and usually dealt with. The home has a robust abuse policy and procedures. Staff members are aware of the current policy, and one spoken to also confirmed this had been covered in their NVQ. The home has a restraint policy and also has a ‘whistle blowing’ policy, which ensures that all staff are aware of their responsibility to report any issues or concerns regarding care practices within the home. Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of the above standards were inspected at this visit. EVIDENCE: Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Clearer records are required to identify collectively the skills and knowledge of the staff team therefore highlighting omissions. EVIDENCE: The homes manager is a first level nurse. Two second level nurses are employed and 19 care staff. Eight of the nineteen care staff have achieved NVQ qualifications, one at level 3, which brings the home close to achieving 50 of its staff being qualified. The home has a settled staff team, with only three staff leaving employment since the last inspection. Each new member of staff has an induction, which is linked to Skills for Care specifications. The induction covers areas of mandatory training, policies and procedures. Mandatory areas of training including first aid, moving and handling and basic first aid are covered. Specialist training has also been accessed by individuals including training on Diabetes, Epilepsy and the safe handling of medication. The home keeps a general learning file, which contains information on social care issues, conditions and syndromes and information on the Commission for Social Care Inspection. One relative said, “The staff know enough and are skilled enough to support my daughter”. Due to the absence of clear records the inspectors found it difficult to identify what training had actually been undertaken. The manager was advised that Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 Page 17 she needs to be able to identify collectively the skills and knowledge of her staff team; therefore it is felt a training matrix is required. Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 Systems are in place to promote residents safety. Overall the quality monitoring systems are effective and lead to service improvement. EVIDENCE: The manager of the home has an open door policy and is in regular contact with relatives either by telephone or writing. Relatives comment cards confirmed that they are kept informed and nine out of the ten said they were made aware of the inspection. Resident and staff meetings are held in the home and minutes of these were viewed and they reflected opinion being sought. The home viewed comment cards completed in respect of their RDB assessment, for which they received four stars. The home does not carry out any form of satisfaction surveys. Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 Page 19 The home has a thorough Health and Safety policy. Information was given by the registered manager via the pre inspection material indicated that records, which included electrical appliance and wiring safety checks, fire equipment checks and water temperature checks were correctly maintained. All staff cover Health and Safety during their induction and further training is built into the homes training programme. Staff confirmed that they had been enabled to access mandatory heath and safety training, such as moving and handling and first aid. Aids and adaptations are in place to ensure residents and staff safety. All staff are given instruction and guidance relating to the use of specialist equipment at the home. Accident/incident forms were viewed, seen to be completed appropriately and residents are encouraged to sign these. Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Derby Lodge Score x x x x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 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 Regulation Requirement Timescale for action 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. Refer to Standard YA 32 YA 35 YA 40 Good Practice Recommendations 50 of care staff should achieve NVQ Level 2 by 2005 A training matrix should be devised to give a clear indication of staffs current knowledge and skills The home should consider ways of maintaining staff awareness of policies and procedures. Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Unit 1, Tustin Court Portway Preston PR2 2YQ 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 Derby Lodge F57 F09 S9861 Derby Lodge V221681 200705 Stage 4.doc Version 1.40 Page 23 - 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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