Inspection on 07/02/06 for Doddington Lodge

This inspection was carried out on 7th February 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 25/09/06

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 HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Doddington Lodge Doddington Hopton Wafers Cleobury Mortimer Worcestershire DY14 0HJ Lead Inspector Janet Oxley Announced Inspection 7th February 2006 09:30 X10029.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.V270232.R01.S.doc Version 5.1 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 and 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. Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 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 Mrs 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.V270232.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2005 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. Doddington Lodge has for many years provided a community resource, for advice, day care and home care services and the local community fully support and endorse its purpose and function. 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 qualified and has had many years experience. Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection reviewed key standards only as the home is currently considered to be performing well and thus warrants the application of a reduced methodology. The inspection was announced and commenced at 9.30am. It included observing activity within the home, inspecting the premises, looking at records and case tracking and talking to 8 staff and 4 visitors. The Manager and staff on duty were welcoming and helpful throughout the inspection. It was found that the National Minimum Standards assessed had been met, with a number exceeded, and that the overall quality of care provided was good. All residents appeared happy, content and very well cared for and those who were able expressed complete satisfaction with their quality of life at the home. Visitors, relatives and all visiting professionals have also expressed satisfaction with the service and care the service users are receiving and have been complimentary regarding the management and care practices at the home. 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. Since the last inspection a well appointed extension has been completed to provide 6 en-suite bedrooms, a dining room, lounge and conservatory, kitchenette, bathrooms and a sluice. Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 Page 6 The manager, who was appointed and subsequently registered with the CSCI in October 2005, has reviewed all aspects of the service and has developed, amended and improved documentation and many recording systems. 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.V270232.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. 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.V270232.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are 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. 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 Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 Page 10 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 and visiting health professionals continue to praise the management and care standards there. The medication was seen to be stored, recorded and administered satisfactorily and relevant staff have received the necessary training. At the time of this 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 was working sensitively and professionally, with the placing authority and relevant professionals, to find an alternative and satisfactory placement for the individual. Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All 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. Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 Page 12 Menus, the meal seen and tasted and discussions indicated that a very good diet was on offer and that the catering arrangements were satisfactory. Staff were seen to be aiding the more frail residents to eat their meal in a sensitive and professional manner. Residents are certainly 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 included in events and are given all the necessary information on aspects of the home and the welfare of the residents. Visitors spoken to have always been complimentary regarding the care the residents receive at the home. Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) 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. Concerns and complaints are dealt with promptly and professionally and robust 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. Four complaints have been received by the home since the last inspection. All have been investigated, resolved and recorded in a professional manner. One complaint, regarding the noise from a machine administering oxygen, had been received by the CSCI however on investigation this was not substantiated. Minor concerns, received by staff at the home, from residents, are dealt with in a professional manner without delay. There are resident meetings, a suggestion box and the manager reported that she speaks 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.V270232.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) 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 The standard of the environment within the home is very 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 now an additional patio area, accessible to residents and Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 Page 15 their visitors now the extension is completed. 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 and on completion of the extension a sluicing facility was made available. Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All. Residents are supported by a well trained 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 3 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.V270232.R01.S.doc Version 5.1 Page 17 Recorded staff supervision, staff meetings and appraisals are undertaken in a professional manner. Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) 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, 32, 35 and 38. 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 regularly 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, promoting the health, safety and welfare of the residents. Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 Page 19 EVIDENCE: Ms Reeves is fully qualified and has many years experience. It is evident that she continues to update her own professional knowledge by attending a number of related courses to the resident group catered for. The deputy manager has almost completed NVQ4 and the 3 seniors and the team leader have completed NVQ3. The manager involves herself fully in the day-to-day running of the home and can fully 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. Sound quality assurance systems are in place and there was evidence available to indicate the proprietor and manager ensure, so far as is reasonably practical, the health, safety and welfare of service users and staff. All staff have attended a health and safety course and relevant mandatory training was reported to be up to date. At the time of this inspection no potential hazards were identified and all records required are maintained in a professional manner. Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 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 3 2 x 3 3 4 x 5 x 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 ENVIRONMENT Standard No Score 19 3 20 3 21 x 22 x 23 x 24 3 25 x 26 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No Score 31 4 32 4 33 4 34 x 35 3 36 x 37 x 38 3 Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 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. 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. Refer to Standard Good Practice Recommendations Doddington Lodge DS0000055436.V270232.R01.S.doc Version 5.1 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.V270232.R01.S.doc Version 5.1 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. 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!