Inspection on 26/11/05 for Derby Lodge

This inspection was carried out on 26th November 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 found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Derby Lodge 07/11/07

Derby Lodge 26/03/07

Derby Lodge 20/07/05

Derby Lodge 22/09/04

Derby Lodge 13/05/04

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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 Mrs Lynne Lynch Unannounced Inspection 26th November 2005 12:30 Derby Lodge DS0000009861.V256022.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 Derby Lodge DS0000009861.V256022.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. Derby Lodge DS0000009861.V256022.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Derby Lodge Address 2a Blackbull Lane Fulwood Preston Lancashire PR2 3PU 01772 718811 01772 716581 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) 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 DS0000009861.V256022.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. This house may accommodate 20 physically disabled adults who may also have a learning disability. 20th July 2005 Date of last inspection 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 DS0000009861.V256022.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced, started at 12.30 pm and took place over three hours. At the time of the inspection there were 22 people resident within the home, however not all were in the building as some of the service users were on home visits or out shopping. The inspector spoke with one member of staff, five service users and the deputy manager on duty for the home. Some of the people living at the home have specific communication needs and therefore discussion with these individuals was limited. Care records, staff recruitment records and some of the written policies were viewed. Medication recording, storage and administration were evidenced and a full tour of the building was conducted. What the service does well: What has improved since the last inspection? The home now has a clear training matrix and staff training continues to be actively promoted. One service user spoken to advised, that staff had placed a sensor on his wall, which bleeped when anyone entered his room, he was pleased with this. A health check reference chart is now in place, which enables staff to monitor health input received by individuals. Several bedrooms have been redecoration as per service users requirement. The home has a rolling programme of maintenance and renewal. Derby Lodge DS0000009861.V256022.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. Derby Lodge DS0000009861.V256022.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 Derby Lodge DS0000009861.V256022.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): None of the above standards were assessed at this inspection. EVIDENCE: Derby Lodge DS0000009861.V256022.R01.S.doc Version 5.0 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 the following standard(s): 6 Care plans are in place, are regularly reviewed and give clear direction for staff. EVIDENCE: Care plans are in place for each resident. Three files were viewed. Each person has a named staff member as their care coordinator who takes the lead in reviewing needs and care plans. Files show that regular reviews take place. The manager explained that they hope to further develop these care plans and focus on goals for each person. Care plans include risk assessments and specific detailed guidance directing staff as to how elements of care should be delivered and specific likes and dislikes of the person. E.g. takes sugar in hot drinks. The information is wide ranging covering areas such as family details, diet preferences, activities preffered, communication needs and a very useful section describing what makes me sad or happy. Staff clearly get to know individuals very well and were observed throughout the day communicating with people and giving appropriate support. One service user spoken to said that staff were very good and listened to what he wants. He said that he told staff when he wanted to go to bed and that he felt staff supported him well Derby Lodge DS0000009861.V256022.R01.S.doc Version 5.0 Page 10 when hoisting him from his chair to his bed. Files are very well organised, with information easy to find. Derby Lodge DS0000009861.V256022.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): None of the above standards were assessed at this inspection. EVIDENCE: Derby Lodge DS0000009861.V256022.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): 18,19 and 20 Personal care is provided in the way individuals prefer. Good systems and practices are in place, which ensure that health care needs are met. Medication within the home is managed well. EVIDENCE: Personal and health care needs of the people at the home are clearly documented. Very clear guidance is available for staff with much personal detail included. This includes information regarding equipment to be used e.g. prefers bath or shower table, the persons skin type and preferred toiletries which were evidenced in use. Many of the people at the home have specific health needs. Records show good contact with other professionals such as district nurses, GP’s and Chiropodists. All visits for health appointments are clearly recorded and advice given was evidenced in care plans. Good records are kept and staff understand the importance of this. Despite many of the people in the home having complex health staff encourage people to get out and about and lead active social lives. On the day of the inspection people were on home visits and out shopping. One gentleman said “I went to my exercise club last night, it keeps me fit”. Advice given by physiotherapists was on display in one persons room and the gentleman confirmed he was encouraged to follow this. Derby Lodge DS0000009861.V256022.R01.S.doc Version 5.0 Page 13 Medication in the home is well managed. Prescriptions are seen and then sent to the pharmacy. All medication is booked in and signed for. The majority of medications are in a monitored dosage system; those that aren’t are clearly marked with opening dates being recorded on items such as eye drops, which have a short life span. Administration records were completed satisfactorily. One lady self medicates and has signed a disclaimer form. Good records are maintained for medication being transferred from the home. Medication being returned to the pharmacist is recorded and signed off by the pharmacist. Patient information leaflets are kept in the home on file. Five of the staff team have completed medication administration training with another senior staff due to access this in January. Derby Lodge DS0000009861.V256022.R01.S.doc Version 5.0 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 the following standard(s): None of the above standards were assessed at this inspection. EVIDENCE: Derby Lodge DS0000009861.V256022.R01.S.doc Version 5.0 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 the following standard(s): 24, 29and 30 The home provides service users with comfortable surroundings with suitable equipment in place to maximise their independence. EVIDENCE: A full tour of the building was conducted. The home has a continuous maintenance and renewal programme. Several of the people in the home have had their rooms redecorated since the last inspection. All the work has been done under the direction of the service users. All bedrooms are specifically personalised some with pop or football decorations and contain many personal items. Specialist equipment was seen in the majority of bedrooms to maximise people’s independence and maintain skills. Several of the service users have possum systems which enable them to control their own environment e.g. to turn on lights, operate TV’s, videos, DVD’s etc. One gentleman spoke about the planned redecoration for his room advising that he had chosen the colour scheme and carpet and curtains to match. The home offers a quiet lounge, dining room, games room and a garden area. The bedrooms are spacious, and the flatlets offer all facilities. The home is accessible to local amenities, and is on main public transport routes. The manager and proprietors continue to make improvements, to ensure a homely non institutional appearance. The premises are fully accessible to all service users, and are served by a passenger lift. CCTV protects the front entrance of the building, and an Derby Lodge DS0000009861.V256022.R01.S.doc Version 5.0 Page 16 intercom doorbell is in use. Heath and safety audits have been compiled covering the building and equipment used, staff members are made aware of health and safety issues during their induction and ongoing training. All required repairs are dealt with swiftly. The home appeared to be clean and well maintained. The laundry facilities at the home are designed to control risk of infection. The home has policies and procedures for the handling and hygienic disposal of waste. Cleaning staff were on duty during the inspection. Derby Lodge DS0000009861.V256022.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 The policies and procedures for the recruitment of staff on this occasion did not provide safeguards for the protection of service users and potentially placed service users at risk. EVIDENCE: The inspector examined three staff files and found in the main that the recruitment procedures had been followed with application forms, satisfactory references and signed Criminal Record declarations. However one staff member had been allowed to commence work under supervision without her Criminal Records Disclosure (CRB) being submitted. The manager explained that three members of staff had left giving very little notice, causing a staffing crisis. The manager does not advocate the use of agency staff and felt it was better to start the member of staff under supervision. The manager was advised that this was not acceptable. The completed CRB was submitted the following day as planned. Derby Lodge DS0000009861.V256022.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above standards were assessed at this inspection. EVIDENCE: Derby Lodge DS0000009861.V256022.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 X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Derby Lodge Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000009861.V256022.R01.S.doc Version 5.0 Page 20 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 YA34 Regulation 19 Requirement All staff must be CRB checked prior to employment Timescale for action 26/11/05 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. Refer to Standard YA32 Good Practice Recommendations 50 of care staff should achieve NVQ Level 2 by 2005 Derby Lodge DS0000009861.V256022.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way 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 DS0000009861.V256022.R01.S.doc Version 5.0 Page 22 - 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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