Inspection on 15/12/05 for Down Lodge

This inspection was carried out on 15th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Down Lodge 26/09/08

Down Lodge 06/09/06

Down Lodge 28/06/05

Down Lodge 18/01/05

Down Lodge 22/09/04

Down Lodge 16/03/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Down Lodge 11 Sturges Road Wokingham Berkshire RG11 2HG Lead Inspector Amanda Longman Unannounced Inspection 15th December 2005 10:00 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 Down Lodge DS0000011397.V272117.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 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. Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Down Lodge Address 11 Sturges Road Wokingham Berkshire RG11 2HG 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) )118 978 6484 Mr Graham Richard Casselden Mrs Sandra Rose Taylor, Mr M J Taylor Mrs Sandra Rose Taylor Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: Down Lodge is a care home for 16 older people. It is situated in a residential road, close to Wokingham town centre. The home is situated over 2 floors with a stair lift providing access to the first floor. Fourteen rooms are single occupancy, with one room currently being shared. There is a communal lounge/dining room which provides access to an enclosed lawned garden. Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out during a visit to Down Lodge. The inspector met with The Care Manager, Miss Eloise Taylor. A tour of the premises was undertaken. The inspector spoke with several residents and was able to take lunch with them. Three service users were interviewed in detail. Staff members were spoken with and two were interviewed. Policies and procedures were looked at; three service user files were examined as were three care worker files. This was a positive inspection, with all the requirements of the previous inspection being met. Down Lodge is a happy and homely establishment where service users feel supported and are encouraged to maximise their independence by committed and caring staff. What the service does well: What has improved since the last inspection? All the requirements made at the previous inspection have been actioned appropriately. The Statement of Purpose has been revised and provides all the required information. The manager has applied for registration with the Commission for Social Care Inspection and the induction process has been improved and documented. New service user files are consistently completed and systematically ordered. Diabetic service users have been given information to enable them to access free chiropody services. Surface temperatures of unguarded radiators are monitored. The laundry has been improved. The quality assurance process has been improved to enable analysis of results. Down Lodge DS0000011397.V272117.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. Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 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 Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 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): 1, 3 and 6 Prospective service users have the information they need to make an informed choice about where to live. Service users do not move in to the home without having their needs assessed and being assured these will be met. Standard 6 was due to be assessed but was judged not to be applicable. EVIDENCE: The home’s Statement of Purpose and Service User Guide were examined. The Statement of Purpose, sub titled “A Mandate for Choice”, has been updated and contained all the required information including the trial period and the complaints procedure. Evidence was seen that copies of the updated Statement of Purpose had been supplied to service users’ families. The Service User Guide was examined and found to contain up to date and appropriate information. The information could be enhanced by the addition of service users’ views of the home. An up to date certificate of registration is displayed in the entrance hall of the home. The home has recently introduced a new system of service user files, three files were examined and showed full and detailed assessments covering all the required areas. The home does not offer intermediate care. Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 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(part) and 10 The health, personal and social care needs of service users are very well set out in individual care plans. Service users health care needs are met and service users are treated with respect. EVIDENCE: The three files examined showed detailed short term and long term care plans. They contained appropriately detailed risk assessments, which included trigger factors and measures to be taken to minimise risk. Risk assessments were signed and gave a clear review date. Evidence was seen on the files that care plans are reviewed monthly to ensure short term care plans remain appropriate and that detailed six monthly reviews are held with the service user and their family. Health care needs were deemed to have been met at the previous inspection with the exception of enabling diabetic service users to access free chiropody. The files belonging too the three diabetic service users currently resident at the home showed letters had been sent to the service users or their families detailing this service, with appropriate contact numbers. Two so far had replied stating they wished to continue with the current service offered by the home. Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 Page 10 The home has in place an appropriate policy and procedure covering the privacy and dignity of service users and this is reflected in the home’s Statement of Purpose. Evidence was seen that this area is covered in induction training and staff spoken with demonstrated appropriately knowledge. The inspector observed staff assisting service users in a respectful manner, whether it was assisting with care, such as toileting or lunch, or engaging in activities such as playing cards, or generally interacting with service users. Interviews with three service users, held in private, confirmed that they were satisfied that they were treated with respect and their dignity and privacy were maintained. Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 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): No standards were inspected in this section on this occasion. EVIDENCE: Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 Page 12 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): No standards were inspected in this section on this occasion. EVIDENCE: Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 Page 13 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): 23, 25 and 26 Service users’ rooms suit their needs, they generally live in safe, comfortable surroundings, but some attention to emergency lighting is required. The home is clean, pleasant and hygienic. EVIDENCE: The home is an older converted house. A tour of the home revealed rooms to be of varying sizes, but all adequate in space. One twin room exists and is occupied by service two service users who are happy to share. Privacy is provided by a curtain. At the previous inspection a requirement was made to monitor the surface temperatures of radiators and it was recommended that these should not exceed 43 degrees Celsius. Records were seen showing that these temperatures are now regularly monitored and do not usually exceed 43 degrees. The manager informed the inspector that an inspection had been undertaken by the fire service on 9 December 2005 but she had not yet received the report. A copy of the report was sent to the inspector after the inspection. This indicated some attention to emergency lighting is required to fully meet standard 25. Shortfalls in standard 26 identified at the previous Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 Page 14 inspection were seen to have been addressed. The laundry has a new impermeable floor covering, hand cleansing facilities are provided in the laundry and dedicated hand washing facilities are appropriately close by. Mop heads are washed and hung up to dry. Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 Page 15 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): 29 and 30 Whilst the home’s recruitment policy and practices do not directly put service users at risk, improvements are required to ensure service users are fully supported and protected. Staff are trained and competent to do their jobs. EVIDENCE: The home’s recruitment process was examined, as were three staff files. Staff files were well organised and contained most of the information required by Schedule 2 of The Care Standards Act. Two references were contained on each file but these were not always robust. Some were obtained on a pro-forma, which did not allow for authentication and one was addressed “To whom it may concern”, and therefore not specific to the role being applied for. The declaration of fitness was not separately signed on the application forms and not all application forms contained a full employment history. The homes recruitment process needs to be modified to address these issues. The home has a well documented induction procedure, which care workers sign to confirm they have received induction. Evidence was seen that understanding is then tested by the manager to confirm competence. Training records on the staff files examined were detailed and up to date. Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 Page 16 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 and 38 The home is currently managed by the Care Manager and an application to register her as the home’s manager has been appropriately submitted. The home is run in the best interest of its service users and the health and safety of service users and staff are promoted and protected. EVIDENCE: Documentary evidence has been received to confirm that the current registered manager, who is also one of three owners of the home is leaving the business at the end of 2005 and the process to register the current Care Manager as the manager of Down Lodge is almost complete. The most recent quality assurance survey was examined which looks at satisfaction with care and choice within the home. Forms are signed and dated by the service user or their relative. They are summarised by the manager and followed up appropriately, for example increasing the number of baths per week. An analysis in percentage terms had been undertaken by the manager. Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 Page 17 A summary report to compare standards to the home’s Statement of Purpose would be beneficial. Residents meetings are undertaken approximately three monthly and the last two minutes were seen. These covered likes and dislikes, planning such as for the Christmas party. It would be helpful to place the agenda on the service users’ notice board for items to be added. Evidence was seen that the manager takes steps to ensure the health, safety and welfare of service users and staff. Training was seen to be provided in moving and handling, fire safety, first aid, food hygiene and infection control and understanding of induction training is tested (see standard 30). Records showed that appliances are suitably serviced, and water and surface temperatures are appropriately monitored. Records of accidents or incidents were seen to be appropriately recorded. However a recent inspection by the fire service, on December 9 2005, has revealed some deficiencies in fire safety procedures. This standard cannot be met until the requirements made by the fire service officer have been satisfactorily met. Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 Page 18 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X 3 X 2 3 STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 2 Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 Page 19 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 OP29 Regulation 19 Requirement To ensure the welfare of service users, the registered manager must improve the recruitment process to include the authentication of references and the obtaining of a full employment history. To ensure the safety of service users, the responsible individual and the registered manager are required to ensure that all the requirements made by the fire service officer in their inspection of 9 December 2005 are met; including the provision for emergency lighting referred to under standard 25 above. Timescale for action 12/02/06 2 OP38 23 (4) 12/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations It is recommended that consideration be given to including DS0000011397.V272117.R01.S.doc Version 5.0 Page 20 Down Lodge 2 3 OP29 OP33 service users’ views in the Service User’s Guide It is recommended that the application form for prospective employees be revised to ensure the applicant signs a declaration of health. It is recommended that the findings of the quality assurance survey be used to analyse the home’s performance in relation to the aims and objectives contained in its Statement of Purpose. Down Lodge DS0000011397.V272117.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 Down Lodge DS0000011397.V272117.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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