Inspection on 01/06/05 for Derwent Lodge

This inspection was carried out on 1st June 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Derwent Lodge 19/07/07

Derwent Lodge 17/07/06

Derwent Lodge 10/11/05

Derwent Lodge 06/09/04

Derwent Lodge 16/04/04

Derwent Lodge 30/10/02

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME ADULTS 18-65 Derwent Lodge 11 Beaufort Street Chaddesden Derby DE21 6AX Lead Inspector Jenny Thornton Unannounced 1st June 2005 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. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Derwent Lodge Address 11 Beaufort Street, Chaddesden, Derby, DE21 6AX 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) 01332 347597 01332 347597 derwentlodge@rethink.org Rethink Vena Wesson Care home 16 Category(ies) of Adults registration, with number of places Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Age range of Service users 18 - 65 years. With written agreement of the National Care Standards Commission residents over the age of 65 who meet the registration category may be accommodated. Where residents over the age of 65 are residing in the home consideration is given to the Care Homes for Older People National Minumum Standards. The Conditions of Registration to be reviewed annually. Date of last inspection 7th September 2004 Brief Description of the Service: Derwent Lodge is a care home providing nursing care for up to sixteen people, eight males and eight females, aged 18 to 65 years, with mental health needs. Residents are supported to take part in daily living and social activities, and lead a more independent lifestyle. The home is a purpose built detached bungalow in Chaddesden, close to local shops, facilities and a bus route, and is a short distance from Derby city centre. All bedrooms are single rooms with ensuite facilities. The home has male and female facilities, with seperate lounges (smoking and non-smoking) , dining room and kitchen. The home has a large garden. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was un-announced and took place over three and a half hours. The Inspector spoke to ten residents, two members of staff, and the acting manager. The Inspector looked round areas of the home and examined various records. What the service does well: What has improved since the last inspection? What they could do better: All new staff need to complete foundation training within the first six months. An individual training and development plan needs to be put in place for all staff. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 Page 6 Residents care plans need to include all daily living and social skills, and how they are being assisted to develop these skills. A planned refurbishment programme needs to be provided to ensure that furnishings are promptly replaced when they become worn. 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. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 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 Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 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) 1, 3 The staff team have the necessary skills and experience to meet residents’ needs. EVIDENCE: The statement of purpose had been updated, but did not include the arrangements for respecting residents privacy and dignity, or clearly state that the home is for persons aged 18 to 65 years on admission. The acting manager agreed to amend the statement of purpose to include this information. The acting manager said that the new service users guide and licence agreement was being approved, prior to issuing a copy to residents. Residents had received a copy of the previous guide and licence agreement. No new residents had been admitted to the home since the last inspection. All residents spoken with said they had formed good relationships with staff and considered that their needs were being met. A number of the staff have worked at the home for a considerable time, and the staff team have a good range of skills to meet residents’ needs. Staff related well with residents, and demonstrated a good understanding of their needs. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 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) 6, 7, 8 Improvements have been made to residents care plans to show how their needs are being met, although care plans need to detail all work being done to develop daily living and social skills. Arrangements are in place to ensure that residents are consulted about all aspects of their life and the home. EVIDENCE: Care plans had been updated and were been reviewed at least monthly; residents had signed their care plan and monthly reviews. Two care plans checked had been updated to include a plan of care relating to resident’s daily living and social skills, and how they are being assisted to develop these skills. Care plans were generally detailed but did not include all daily living and social skills, and work being done to develop these skills. Observations and discussions with residents and staff showed that residents are encouraged to make choices and decisions about their lives, and are involved in all aspects of life in the home. Records showed that regular house meetings continue to be held, where residents have a say in the running of the home. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 Page 10 Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 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) 12,13,14, 17 Residents are given opportunities to develop social skills and interests both inside and outside of the home, although care plans need to detail how social and leisure needs are being met. The home provides a good variety and choice of foods, which residents enjoy. EVIDENCE: It was clear from discussions with residents and staff that residents are supported to follow their own interests, and accessed a range of leisure activities. One resident had joined a walking group, which he said he enjoyed. A couple of residents had joined a local gym. One resident was growing vegetables in the garden, and with support from staff was looking to set up a joinery workshop at the home. One resident enjoyed going to concerts of her choice. Residents care plans did not detail the work being done and the progress being made in regards to individual’s social needs. At the time of this inspection, one resident had gone out for the day on a train with a member of staff, a couple of residents had been to town, and two residents were going to the pictures. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 Page 12 Residents said they had discussed various holiday options, and several residents were going on holiday to ‘centre parcs’ shortly. Several residents did not wish to go on holiday, and this was respected. One resident went on holiday with her mother. The majority of residents spoken with said that they attended the local facilities. A new community centre had recently opened and several residents attended this. Residents said they were encouraged to take part in various housekeeping tasks, such as setting the table, making a snack, doing their own washing and ironing, and cleaning their room. Certain residents were unable or refused to participate in housekeeping duties. Staff confirmed that new menus had been introduced, and that residents had been involved in completing these. The menus provided a good variety and choice of foods, based on healthy eating. The majority of residents spoke highly of the meals provided at the home and said that their dietary needs and preferences were met. Residents said that the meals include home cooked foods, which they enjoy. Residents were able to make drinks and snacks for themselves in the kitchen areas, and several residents regularly cooked a meal. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 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) 19 Arrangements are in place to ensure that residents’ health and emotional needs are met. EVIDENCE: It was clear from discussions with residents and staff that resident’s health and emotional needs are well managed; these were set out in care plans. Where possible, residents attended community facilities such as their G.P practice, the hospital or G.P practice for blood tests, and option and dentist. Records showed that residents received regular reviews of their medication and were encouraged to attend regular health checks. Certain residents had declined to attend regular health checks, and this was recorded. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 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) EVIDENCE: The above standards were not assessed on this inspection. Residents and staff spoken with during the inspection said that they found the acting manager approachable, and felt that concerns are listened to and acted upon. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 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) 24, 30 The environment is safe, clean and generally well maintained to ensure residents comfort, although some bedroom furniture needed replacing. Bedrooms contained resident’s personal belongings. EVIDENCE: The home has been open for 3 years and the furnishings and fittings have generally worn well. Staff had identified that certain areas needed redecorating, and that some of the bedroom furniture needs replacing such as the drawers and wardrobes. The Inspector noted that the drawer fronts had come off in one resident’s room; the acting manager said that the drawer had previously been repaired, and needed replacing. The acting manager agreed to carry out further temporary repairs to the drawer. Since the last inspection new bedroom furniture has been provided in two rooms, and a new floor covering had been fitted in one room. The acting manager reported plans to replace further bedroom furniture within this year’s refurbishment budget. The acting manager said that an agreement had been reached for resident’s to buy items of furniture themselves for their bedroom, where requested, and that one resident had recently purchased new furniture. Where residents had purchased their own furniture, this was clearly recorded in their care plan. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 Page 16 Handrails had been fitted in the male bathroom, in response to a resident’s needs. Two garages have been built for storage and general use, and staff were looking to set up this facility as a work base for one resident interested in joinery. Residents considered that the home is kept clean; this was the case at the time of this inspection. The corridor carpets were stained in places; the acting manager reported that the carpets were regularly cleaned. The acting manager said that the maintenance person had recently left, and that interim arrangements were in place to cover general repairs and maintenance work, until a new maintenance person was appointed. The garden areas were tidy, and residents said that they enjoyed spending time in the garden when the weather was warm. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 35 and 36 Staffing cover has been limited over recent months, however the home has continued to maintain an appropriate skill mix and numbers of staff on duty to meet residents’ needs. Staff received a good level of training and support to ensure they have the skills to care for residents, although a foundation-training programme was not in place for new staff. EVIDENCE: The registered manager had been absent from the home since the beginning of April 2005. The manager said that as a result of the manager’s absence and staff changes at the home, staffing cover had been difficult over recent months. The home had vacancies for a qualified nurse and maintenance person; the acting manager said that interviews were due to be held for these positions. The staffing rosters showed that the home’s own bank and regular staff were covering most of the staffing shortfalls, and that some agency care staff were used. The manager said that where possible, the home used the same agency staff that residents were familiar with. Staff and residents spoken with considered that sufficient staff are generally provided to meet residents needs. The staffing rosters for May and June Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 Page 18 supported this, although the staffing cover was limited for reasons previously stated. The staffing rota did not identify the nurse in charge on the 2 June 2005; the acting manager said that this shift had been covered and he agreed to update the rota. The acting manager said that he had updated staff files since the last inspection, to include the required information and documents for staff to work in the home. The Inspector checked the files of three members of staff last employed to work in the home; these contained the required information, except one file did not contain a copy of the person’s application form. The acting manager agreed to obtain a copy of this. Staff said the home provides good training opportunities. Discussions with staff and records showed that staff had attended various training, to ensure that they are trained and competent to do their job. Not all staff had an individual training and development plan. Records showed that care staff recently appointed to work in the home had completed the home’s induction training programme; with the exception of one member of staff . The acting manager stated that the member of staff had completed the induction training, and he agreed to obtain a copy of the programme. The acting manager reported that a foundation-training programme was not currently in place. This was identified on the last inspection report. The acting manager said that the Company had appointed a new training officer, who was setting up a training programme for qualified staff. The acting manager said that all staff had been issued a copy of the standards of conduct and practice set by the General Social Care Council; staff confirmed this. Staff spoken with said that the acting manager was providing a good level of support in the registered manager’s absence. Records showed that regular staff were mostly receiving one to one supervision meetings on a fairly regular basis. Although not all bank staff had received recent supervision. The acting manager acknowledged that due to the qualified nurse situation, there has been some slippage in staff supervision. The manager planned to address this, once qualified staff had been appointed. A date for staff supervision meetings were not always planned in advance, which does not ensure sufficient time, is allocated for supervision. Records of supervision meetings did not include all areas listed in standard 36. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 Page 19 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) 37 Interim arrangements were in place to ensure the home is well run in the registered manager’s absence. EVIDENCE: The registered manager has been absent from the home since the end of March 2005, and the Company had arranged for the deputy manager to take on the acting manager’s role in the manager’s absence. Residents and staff spoken with considered that the home was being well managed, in the registered manager’s absence. The Inspector’s findings throughout this inspection supported this. The acting manager was undertaking an approved management qualification (Level 4 N.V.Q). Records showed that recent staff meetings had been held, and the minutes of the meetings were available to staff. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 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 3 x 3 x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x 3 x x 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Derwent Lodge Score x 3 x x Standard No 37 38 39 40 41 42 43 Score 3 x x x x x x C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 Page 21 Yes 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. 2. 3. Standard 6 14 24 Regulation 15 15 23 Requirement Residents care plans must detail all daily living and social skills, and how they are being met. Residents care plans must detail how social/leisure needs are being met The home must provide a replacement programme to ensure that furnishings are promptly replaced when they become worn. This requirement is carried forward from the previous inspection report. New staff must complete within six months of appointment a foundation-training programme in line with national training requirements.This requirement is carried forward from the previous inspection report. Records must show that all staff have completed induction training within six weeks of appointment Timescale for action 31 August 2005 31 August 2005 31 August 2005 4. 18 35 31 December 2005 5. 18 35 31 August 2005 Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 30 36 36 36 35 Good Practice Recommendations Further action should be taken to remove the stained areas to the corridor carpets Dates for staff supervision meetings should be planned in advance. Staff supervision meetings and records should cover all areas listed in standard 36 All staff should receive recorded supervision meetings at least six times a year All staff should have an individual training and development plan. Training records should provide evidence of training attended, such as a copy of the programme and/or certificate of attendance. Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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 Derwent Lodge C52 C02 S31165 DerwentLodge V230627 010605 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!