Inspection on 25/09/06 for Doddington Lodge

This inspection was carried out on 25th September 2006.

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

Doddington Lodge 20/11/07

Doddington Lodge 07/02/06

Doddington Lodge 02/08/05

Doddington Lodge 24/02/05

Doddington Lodge 03/08/04

Doddington Lodge 09/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Doddington Lodge Doddington Hopton Wafers Cleobury Mortimer Worcestershire DY14 0HJ Lead Inspector Janet Oxley Key Unannounced Inspection 25th September 2006 09:30 X10015.doc Version 1.40 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 Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 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 Older People. 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. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Doddington Lodge Address Doddington Hopton Wafers Cleobury Mortimer Worcestershire DY14 0HJ 01584 890864 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) Chelcare Ltd Suzan Mary Reeves Care Home 41 Category(ies) of Dementia (17), Old age, not falling within any registration, with number other category (24) of places Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: Doddington Lodge is a residential care home, located on Clee Hill in South Shropshire, and is registered to provide care and accommodation for up to 41 elderly people, 17 of whom may have a mental disorder. Accommodation is provided in a large adapted main house and a purpose built extension. The majority of rooms have en-suite facilities and in the main house the three floors are accessed by a shaft lift. Communal rooms are spacious and the home is set in pleasant gardens and grounds. The home is owned by Ms V Cronk, who has over 25 years experience in the residential care home business. On a day to day basis Doddington Lodge is managed by Suzan Reeves, who is fully qualified and has had many years experience. The home makes their services known to prospective service users in The Statement of Purpose and Service User Guide. The inspection report is mentioned in these documents and is given out on request. Fees are reviewed annually and range from £400 - £500. Any additional charges are clearly laid out in the terms and conditions. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: information from the provider, looking at relevant records pertaining to key standards, discussions with residents and the staff on duty, discussion with the Manager, tour of the premises, previous inspection reports, quality assurance process, Fire Authority reports, Environmental Health Office reports and observation of care experienced by people using the service. What the service does well: What has improved since the last inspection? It has to be noted that at this home, management and staff are constantly reviewing all aspects of the service to achieve best practice and maintain a high quality service. A number of areas have been refurbished and redecorated, additional staff have been recruited and the Manager has reviewed and amended the medication systems and the care planning documentation. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 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. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies and procedures that are in place, and have been professionally followed, ensure that the home undertakes all necessary assessments for successful and satisfactory admissions to take place. EVIDENCE: The home has a Statement of Purpose and a Service Users Guide, which includes all the required information for prospective residents. Documentation examined indicated that individuals have a full and comprehensive assessment of their needs prior to admission, which is reviewed and amended as requirements change. Discussions with residents, the manager and staff on duty indicated that the home continues to meet the individual needs of the elderly people living at the home in a professional and sensitive manner. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 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, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The health and personal needs of service users are very well met with evidence of regular review and of good multi disciplinary working taking place on a regular basis. EVIDENCE: It was evident during the inspection from looking at records, inspecting the facilities and chatting to staff and residents that individual health, personal and social care needs were being met. The manner in which the care plans are maintained, continue to be developed and the professional way in which they promote the importance of the compatibility of the service user and their plan, continues to be commendable. Residents were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. Those residents spoken to were complimentary regarding the quality of their lives at the home Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 10 and visiting health professionals continue to praise the management and care standards there. The medication arrears to be stored, recorded and administered satisfactorily and relevant staff have received the necessary training. The Manager has worked with the help and advise of the Primary Care Trust’s Medicines Management Team, Shropshire Partners in Care and the local Pharmacist to improve and develop the policies and procedures that are in place. At the time of the last inspection it had been identified and assessed that the home could no longer meet the needs of one resident, whose mental health had significantly deteriorated and it was considered that the home has worked sensitively and professionally, with the placing authority and relevant professionals, to find an alternative and satisfactory placement for the individual. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The routines of daily living at Doddington Lodge are very flexible and each resident finds the lifestyle experienced in the home meets their individual needs. Many activities take place, there is an open visiting policy and the menu offers a good choice of well balanced and wholesome meals. EVIDENCE: The residents are encouraged and enabled to personalise their bedrooms and have a number of activities arranged for them within the home and outside. These activities are publicised around the home and in the monthly newsletter. Individual needs, likes and dislikes are clearly shown in the care plans and the activities residents participate in are recorded on individual files. Menus, the meal seen and tasted was on offer and that the catering seen to be aiding the more frail manner and the Manager and her and Wellbeing Seminar. Doddington Lodge and discussions indicated that a good diet arrangements were satisfactory. Staff were residents to eat their meal in a sensitive Deputy have recently attended a Nutrition Version 5.2 Page 12 DS0000055436.V297099.R01.S.doc Residents are enabled to exercise choice and control over their own lives as far as they are able and there is a table in the hall with a good range of information for residents and visitors including all aspects of advocacy and legal and financial matters. Visitors are always made welcome, are given all the necessary information on aspects of the home and the welfare of the residents and are included in events in the home. Eg – They are invited to resident meetings and recently joined residents at a Garden Party at the home. Visitors spoken to have always been complimentary regarding the care the residents receive at the home. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are dealt with promptly and professionally and procedures and practices are in place to ensure that individuals are protected from abuse. EVIDENCE: The home has a clear complaints procedure, which is given to residents and their relatives before they move into the home. No official complaints have been received by the home or CSCI since the last inspection. Minor concerns, received by staff at the home, are dealt with in a professional manner without delay. There are resident meetings, a suggestion box, a key worker system in place and the manager and senior staff speak to each resident regularly to ensure that they have no outstanding concerns The home has all necessary documentation in relation to the protection of vulnerable adults and this subject is included in staff training. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is generally good, providing service users with a warm, safe and homely place to live. Necessary improvements have been identified and are in hand. EVIDENCE: The location and layout of the home are suitable for elderly residents. Communal rooms are well equipped and are warm, homely and welcoming. Bedrooms are personalised and suit individual needs and the gardens are attractive and there is a patio area, accessible to residents and their visitors now the extension is completed. Accommodation in the extension is excellent and plans are in hand to refurbish and improve areas of the older part of the home. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 15 At the time of the most recent Fire Officer and Environmental Health Officer’s inspections matters were reported to be satisfactory and advice given by the Environmental Health Officer has been acted upon. It was evident that the proprietor, manager and staff work hard to maintain this environment. At the time of this inspection the standard of hygiene and cleanliness was excellent, a sluicing facility is available and it was reported that all staff have received training in infection control. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a well trained, well supported and committed staff group who are meeting the needs of each individual in a sensitive and professional manner. EVIDENCE: The rotas, ratios of staff on duty at the time of inspection and the number of domestic, laundry, kitchen, administrative and maintenance staff employed indicates that the home exceeds the laid down staff complement. Recruitment at the home is thorough and all elements required by Schedule 2 of the Care Home Regulations are maintained on file. The induction training that staff receive is thorough and 2 staff were complimentary regarding the induction that they had received. The management continue to support staff to undertake their NVQ awards, the minimum ratio of trained care staff well exceeds the minimum requirement, a very good variety of other training has been undertaken and staff on duty indicated that they were very sensitive to the service users needs and disabilities and that their attitudes and practice were monitored and supervised by the Manager and Proprietor. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 17 Recorded staff supervision, staff meetings and appraisals are undertaken in a professional manner and all staff spoken to were complimentary regarding the management approach and the support and supervision they receive. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are clear lines of accountability within the homes management structure and the management approach creates an open and positive atmosphere from which the residents benefit. The home reviews all aspects of its performance through a programme of self review, questionnaires and consultations and meets the requirements of the Fire Officer and Environmental Health Officer. To fully promote the health, safety and welfare of the residents the home must ensure that all staff receive training in Basic Food Hygiene and that hot water temperatures are checked and regulated professionally. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 19 EVIDENCE: Ms Reeves is fully qualified and has many years experience. The Deputy Manager has also completed NVQ4 in care and it was evident that they continue to update their own professional knowledge by attending a number of related courses to the resident group catered for. The manager involves herself fully in the day-to-day running of the home and can relate to all matters pertaining to the National Minimum Standards. The manner in which the manager and staff responded to this inspection indicated that a sound management approach is in place and that staff are committed to achieving best practice and to developing equal opportunities. Equality and diversity for the service users were seen to be promoted throughout the home, within the assessments, care plans and activities. Equality for staff is promoted through opportunities for training at all levels. Sound quality assurance systems are in place and it was evident that the Proprietor and Manager continually monitor and undertake internal audits and seek feedback from all concerned. The home meets the requirements of the Fire Officer and Environmental Health Officer, it was reported that a first aider is on site at all times and the accident records appeared satisfactory. It was reported that all staff have attended heath and safety training and relevant mandatory training however it was identified that one member of kitchen staff had not undertaken Basic Food Hygiene Training. At the time of this inspection a potential hazard identified was that the records and regulating of hot water temperatures to baths requires improvement. Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x x 3 x 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 x 3 x x 2 Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP38 OP38 Regulation 18(1)(C) 13(4)(a) Requirement That all staff handling food receive training in Basic Food Hygiene. That hot water temperatures to all baths be regulated to prevent the risk of scalding and that records be maintained of regular checks. Timescale for action 31/12/06 31/10/06 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 Standard Good Practice Recommendations Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Doddington Lodge DS0000055436.V297099.R01.S.doc Version 5.2 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. 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