Inspection on 06/09/06 for Down Lodge

This inspection was carried out on 6th September 2006.

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 15/12/05

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 Tracy McGuire Brown Unannounced Inspection 6th September 2006 09:45 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 DS0000011397.V306075.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. DS0000011397.V306075.R01.S.doc Version 5.2 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 Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places DS0000011397.V306075.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 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. DS0000011397.V306075.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The service was inspected over a period of 4 days between 21st August and 7th September with a visit to the establishment taking place on 6th September between 9.45am and 4.45 pm. The Inspector spent some time talking to 5 service users; staff and management.3 Resident files and care plans were seen. Information from providers, other professionals, visitors and inspection records were used. A pre- inspection questionnaire was completed and surveys were received from 9 residents. The Inspector toured the building and observed practice throughout the visit. What the service does well: What has improved since the last inspection? Since the previous inspection there has been considerable work undertaken to improve the decor of the building, visiting relatives commented “they are very impressed with the work undertaken to improve the home” and a visiting professional said, “The fabric of the building is greatly improved”. Residents are also very happy with the changes and told the Inspector “ home is very comfortable” Staff have been given more responsibility and the visiting professional who knows the home well commented that “the team spirit is now better Staff communicate well with residents and personal care is very good, any problems passed on by the chiropodist are quickly passed on and dealt with, feels the home is well run and has no worries about the care provided in the home”. DS0000011397.V306075.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. DS0000011397.V306075.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 DS0000011397.V306075.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 (6 not applicable to this service) The outcome is good. Assessments are undertsaken prior to admission and service users are continually monitored and assessed. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Files examined at the previous inspection and the case tracking of 3 service users on the site visit confirm that home completes detailed assessment information for each service users prior to admission to the home. The Manager informed the Inspector that the home has also recently started to admit service users via local authority referrals and a care management assessment is provided prior to admission assessment. All relevant areas are covered in the assessment process currently in place. DS0000011397.V306075.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 The outcome in this area is good, there are detailed care plans and healthcare needs are attended to. Medication procedures and training are good, practice is generally robust. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The records of 3 service users were examined and case tracked.MW, HH and EG. The care plans and healthcare records of the service users were examined , these were up to date and reflected the care practice observed in the home.A visiitng health proffessional commented on the good standard of personal care in the home.2 service users spoken to commented that the personal “care and support is good”,another stated that there is “no faults” in the home. Care plans detail the requirements of care and how these are to be carried out in practice. There are some basic risk assessments are in place.Care plans are reviewed on a monthly basis. Health care is detailed on the Standex system in the initial assesment, depency score and physical and care plan.Service users weights are monitored and recorded. On the day of the site visit the District nurse was visiting and attending to service users and so was the Chiropodist.The Inspector noted that DS0000011397.V306075.R01.S.doc Version 5.2 Page 10 the service user records are updated with any healthcare changes.All appointments are recorded on each individual service user file, in addition the home is working hard with local G.P.s to request they add comments to records when they visit. The home has a detailed policy in place in respect of medication, all staff trained prior to administering medication. Samples of trainng records were seen and 8 staff were due to attent a mediacation course on the 7th September. The homes stores all medication in locked metal cabinets and uses a blister pack system. The Inspector sampled stock and mar sheets during the site visit and found 1 error, the Manager in the home will be invetistigating the error, all other records and stock sampled were correct. The Inspector observed practice in the home to promote the privacy and dignity of service users. Some Service users have their own telephones. The only shared room in the home has screening for privacy. Staff were observed addressing service users in a proffessional and courteous manner. Staff always knock on service users doors and assisit with personal care in an appropriate manner (as detailed in care plans also). 2 relatives spoken to were very happy with the home and commneted on the proffesional manner of the staff in the home. DS0000011397.V306075.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): 12,13, 14 and 15 The quality outcome in this area is good. Service users are offered activities and maintain contact with family and friends. Service users are supported to make choices in their lives. Service users benefit from the provision of a healthy and nutritious diet. This judgement has been made using available evidence including a visit to the service. EVIDENCE: 6 of the 9 Surveys received from service users indicate that they are happy with the activities provided by the home. The other 3 were usually happy with the activities on offer. On the site visit the Inspector observed some service users going out with family, friends or for one service user who is able going out alone. Staff in the home worked with some service users who chose to join in with a sing along session. The Inspector spoke with 5 service users who were all completely satisfied with the activities on offer, others choose not to join in activities but staff were observed working hard to encourage and support. Some service users were happy to read or chat to each other and some choose to spend time in their rooms. Social activities for each individual are recorded on the cardex care plan system and records sampled demonstrate a range of activities including, board games, outings, story reading, T, V reminisance and exercises. One service user also attends a day centre. Staff spoken to try to arrange activities dependent on choice. Service DS0000011397.V306075.R01.S.doc Version 5.2 Page 12 users spoken to comment, “ I like reading and doing puzzles,” “ I am never bored and can join in the activities offered in the lounge”. The home is located close to the town centre and on the site visit the Inspector observed a number of visitors coming to the home, the visitors book was examined and indicates that the home has frequent visitors on a daily basis. The Inspector spoke with 5 Service users who were positive about visitors to the home. Service users also informed the Inspector that they utilise the local community where possible, recently a trip to the pub was enjoyed by those who chose to participate. Service users are encouraged and supported where appropriate to manage their own finances. The home encourages service users to bring their own possessions in to the home and evidence was seen of this on a tour of the premises. Service users spoken to were also complimentary of their own rooms and that they are able to make them homely. The Inspector spent some time with the catering Manager who has recently completed the “Better Food” course, following this course she has reviewed the catering practice and set up a variety of new forms. The forms are clear and concise and ensure good practice. The Catering Manager has also undertaking in house training with all staff to introduce the new forms and good practice changes made in the kitchen. The Inspector observed lunchtime; the menu was displayed on a small board in the dinning room. Surveys completed and discussions held with a number of service users confirm that service users are generally happy with the menu and that there are alternative choices available. All foods consumed and any change is choice is recorded by the catering staff. The food is freshly prepared and there are homemade cakes available. Tea, coffee and other drinks are available throughout the day. The home is able to cater for different diets and evidence was seen of menus for the current diabetic service users. Staff offer support with lunch if required and this was seen to be offered in a sensitive and professional manner, staff join the service users for lunch. DS0000011397.V306075.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 The outcome in this area is good service users; relatives and friend feel confident that they can complain if necessary. The home works hard to protect service users from abuse. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Surveys received indicate that 7 service users are clear about how and who to complain to and 2 are sometimes. 5 service users spoken to during the inspection stated that they had no complaints about the home and that they felt they could approach staff if they had any worries or concerns. There is a complaints policy on the wall in the hallway and relatives spoken to on the day of the visit stated that they felt they could approach staff in the home if they had any complaints and are confident they will be resolved. Detailed complaint policies and procedures are in the office and staff are familiar with these. The complaint log was seen and there were no recorded complaints. The home has protection of vulnerable adults policies in place and training is ongoing, records were seen for planned training on 3rd April 2007. DS0000011397.V306075.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 and 26 The outcome in this area is good. The home has been greatly improved, is well maintained throughout and clean and tidy. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Staff, service users relatives and a visiting professional all commented that the fabric of the building has been greatly improved in the past 6 months. Service users spoken to comment that the “home is very comfortable.” A tour of the premises revealed extensive decorative work has been undertaken, the hall way is lighter and the flooring replaced, fire doors have been refitted throughout the home and replaced with white doors and some with windows to increase the light. One room has had an ensuite toilet and washbasin added. A new call bell system has been installed throughout the home, this system can also be linked to pressure mats to aid early assistance to service users if required. The Inspector discussed the ongoing improvement plans with the Manager. DS0000011397.V306075.R01.S.doc Version 5.2 Page 15 The home has separate laundry facilities located in a first floor dedicated area. The home was very clean and tidy throughout. DS0000011397.V306075.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): 27,28,29 and 30 The outcome in this area is good, service users benefit from a qualified and experienced staff team who receive ongoing training. Recruitment processes need some further improvement. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home currently employs 14 staff there are always a minimum of 2 staff on duty apart from nights when there is 1 waking night staff but there is an on call system to back up staff if required. The home benefits from a low turnover of staff there have been some new staff recently recruited. After lengthy discussion with the Manager it was concluded that the recruitment records still have some room for improvement to ensure all relevant documentation is in place. Samples of staff records examined demonstrate that staff have receive varied and ongoing training, 7 staff have completed NVQ level 2, 2 have completed NVQ 3 and 2 staff are currently undertaking NVQ 4 and the Registered Managers award. Staff have a variety of skills and equipment relevant to their roles. DS0000011397.V306075.R01.S.doc Version 5.2 Page 17 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. The quality outcome in this area is good. The home is well run, service users views are sought about the running of the home, their finances are safeguarded and health and safety is promoted. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Since the previous inspection there has been a change in Manager, the sole proprietor has now also undertaken the Manager role. The Manager has worked in the home for a number of years and is currently undertaking NVQ 4 and the Registered Manager award. In addition the Manager is completing ongoing training. The Manager needs to be Registered to comply with regulations. The staff and residents spoken to in the home were all complimentary about the current Manager. The home continues to undertake questionnaires and the Manager completes an assessment of these questionnaires. The latest Questionnaires were dated DS0000011397.V306075.R01.S.doc Version 5.2 Page 18 August 2006.The Inspector discussed the need to create a more detailed development plan. The home has a detailed policy in place in respect\of service users money. The home hold some monies in a secure place for some service users, one service user manages his own money. All monies held are accounted for and receipts are issued or maintained for all transactions. Health and safety records were supplied and examined. Safety checks are undertaken on a regular basis and records seen were all up to date. DS0000011397.V306075.R01.S.doc Version 5.2 Page 19 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 DS0000011397.V306075.R01.S.doc Version 5.2 Page 20 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. Standard OP29 Regulation 19 Requirement To ensure the welfare of service users, the registered manager must continue to improve the recruitment process to include copies of all relevant employment checks including CRB’S Ensure that medication practice is robust to ensure no errors. The Manager in the home must be registered. Timescale for action 31/10/06 2. 3. OP9 13 (4) 9 31/10/06 31/01/07 OP31 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 OP33 Good Practice Recommendations 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 DS0000011397.V306075.R01.S.doc Version 5.2 Page 21 DS0000011397.V306075.R01.S.doc Version 5.2 Page 22 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 DS0000011397.V306075.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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