Inspection on 12/03/07 for Downham Lodge

This inspection was carried out on 12th March 2007.

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

Downham Lodge 08/03/06

Downham Lodge 09/08/05

Downham Lodge 14/02/05

Downham Lodge 20/12/04

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 Downham Lodge 29 St Edward`s Road Southsea Hampshire PO5 3DH Lead Inspector Ms J Hartley Unannounced Inspection 12th March 2007 11:30 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 Downham Lodge DS0000011735.V329241.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. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Downham Lodge Address 29 St Edward`s Road Southsea Hampshire PO5 3DH 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) 023 9283 9816 Mr Narain Lingaloo Mrs Balamanee Lingaloo Mrs Balamanee Lingaloo Care Home 12 Category(ies) of Dementia - over 65 years of age (5), Mental registration, with number disorder, excluding learning disability or of places dementia (5), Mental Disorder, excluding learning disability or dementia - over 65 years of age (5), Old age, not falling within any other category (12) Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users in the MD category must be over 55 years of age Date of last inspection 8th March 2006 Brief Description of the Service: Downham Lodge is a detached building, situated in a residential area of Southsea, close to Southsea Common, the promenade and a shopping centre. The home provides accommodation to service users aged over 65 years who have dementia or a mental disorder. There are 4 double bedrooms and 4 single bedrooms, all of which have an en-suite toilet except one. Staffing is provided on a 24 hour basis. The two registered persons work in the home on a full time basis. Fees range from £332.83 to £429.45 per week. Fees do not include hairdressing, chiropody, toiletries, newspapers, entrance costs to entertainment such as cinemas. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit for this key unannounced inspection took place over four and a half hours. The registered manager Mrs Lingaloo was present throughout the inspection and provided the information required. The inspector examined information held on the CSCI service file since the last inspection in March 2006, and read the previous two inspection reports, the Service User Guide and the Statement of Purpose. Evidence was also gathered from the pre-inspection questionnaire completed by Mrs Lingaloo and the results of surveys, completed prior to the inspection by residents, relatives, visitors and staff. During the visit the inspector spoke with the residents, undertook a tour of the premises and looked at three care plans and three staff files. Various record books, policies and procedures were also examined. What the service does well: What has improved since the last inspection? What they could do better: At present none of the support staff have an NVQ. Mrs Lingaloo said she is planning to register some of her staff on NVQ courses in the near future. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Downham Lodge DS0000011735.V329241.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 Downham Lodge DS0000011735.V329241.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed prior to admission to ensure that the home can meet their needs. Prospective residents are able to visit the home. EVIDENCE: Three residents’ files were case tracked during the visit to Downham Lodge. They all held pre-admission assessments that were thorough and detailed. Each resident file contains a background history that has been complied with the residents and their relatives. Residents’ social interests are also recorded. The manager said that prior to a resident moving in they try to arrange for two visits to the home. The first one just to look round and the second one prospective residents are able to stay for a meal. This enables the prospective resident and current residents to meet and for the manager to assess whether or not the home is suitable for them. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 9 Downham Lodge does not provide Intermediate Care, therefore Standard Six does not apply to this home. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Plans of care are in place that reflect the individual needs of the residents. They are reviewed monthly. The health of residents is promoted and maintained by the registered person. Residents have access to health services to meet their assessed needs. Medication policies are in place regarding the receipt, recording, storage, handling, administrations and disposal of medicines. These policies and procedures are adhered to by staff. Residents are able to take responsibility for their own medication if they wish, within a risk management framework. Residents feel that they are treated with resprect and their right to privacy is upheld. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 11 EVIDENCE: All the residents’ files seen during the visit contained detailed care plans that had been generated from the assessment. Care plans are drawn up with the residents where cognitive abilities allow. If residents are unable to take part in the process then the home involves relatives and carers. Care plans are detailed but concise and easy to understand. They all include the likes and dislikes of the residents. Clear goals and objectives and how they can be met are set out. Care plans are reviewed monthly and changed if required. Daily records are kept and details about concerns, health problems, visits and participation in activities are recorded. Care plans show that GPs are called in appropriately and the advice of other health care professionals is sought. All the respondents to the Service User Survey said that they receive the medical support that they need. All the relatives that responded to the survey said that the home meets the needs of their relative. One resident attends a memory clinic every six months. Risk assessments for falls and pressure sores are up to date. Weight is monitored every two months. Medication is stored safely in a locked cupboard in a locked room. Policies and procedures for the administration of medicines are sound and the MAR sheets were in order. The home keeps accurate records on the receipt, administration and disposal of medication. Clear guidance is readily available for staff on the side effects of medication. At present none of the residents self-medicate, but a risk assessment is in place if any future residents wish to do so. Residents said that they are treated with dignity and respect by the staff and manager. One resident said that he is able to talk to his friends and relatives on the telephone. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents find that the lifestyle they experience in the home matches their expectations and meets their needs. They are supported in maintaining contacts with family, friends and the local community and are able to exercise choice and control over their lives. residents enjoy the food provided at the home. Special diets, likes and dislikes are catered for. EVIDENCE: Results from the Service User Survey reflect that the residents are happy with the routines in the home and the service they receive. One resident has Holy Communion in the home. Residents’ interests are recorded in their care plans. One resident said, “I am free to come and go as I want. My family can come almost any time, there are no visiting hours, they are made very welcome”. The home has an activities coordinator who plans the sessions with the residents. Activities include crafts, games bingo and trips out. One resident said that there is a good choice of activities. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 13 The home holds residents meetings every two months to enable residents to have a say about the running of the home. Residents’ relatives come into the home to take the minutes. Residents are able to help with tasks in the home such as laying the tables ready for dinner, watering plants and setting up the orientation board. The home provides a varied and wholesome diet for the residents. Seven respondents to the survey said they always like the meals and two said they usually do. One resident described the food as “excellent”. The home is able to provide for specialised diets. One resident has diet controlled diabetes. The manager said liquidised meals can be provided if needed. An anonymous caller to the Commission raised a concern that residents do not have anything to eat after their meal at teatime. The manager said that residents are able to have food at suppertime if they wish. Two of the residents spoken confirmed this to the inspector. A member of staff said that meals are cooked daily using fresh ingredients. The registered manager is a trainer in food hygiene and maintains her continuous professional development. Food is purchased locally and a number of good quality suppliers are used. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 14 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. 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. The home has a simple, clear accessible complaints procedure. Residents are confident that their complaints will be listened to and taken seriously. The policies, procedures and staff training protect reisdents, as far as possible, from abuse. EVIDENCE: The homes complaints procedure was seen and found to be clear and accessible. The home keeps a record of any complaints received. There have not been any since the last inspection. Residents said that they would discuss any problems with the manager. All staff have received adult protection training and this is also included during the induction process. One-to-one supervision is established and the registered manager said that she takes this opportunity to raise awareness about adult protection issues. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The location and layout of the home is suitable for its stated purpose. The home provides a safe, comfortable, well maintained environment for residents. It is clean pleasant and hygienic. EVIDENCE: The inspector undertook a tour of the home during the visit. Downham Lodge is a detached property located in a residential area of Southsea close to shops and other amenities. There are 4 double bedrooms and 4 single bedrooms, all of which have an en-suite toilet except one. All shared rooms have screens to protect the privacy of the residents. Comments from residents about the cleanliness of the home include, “Never less than spotless” and “Perfect, top marks”. A new bath has been fitted in the bathroom. The rooms are well furnished and airy and there is a high standard of cleaning. All areas of the Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 16 home were free from offensive odours. No health and safety hazards were noted. Windows have restricted openings and all radiators and pipework are covered. The communal areas are well maintained and comfortable. There is a large main lounge that opens onto a pleasant courtyard garden. There is a further quiet lounge where the residents can receive visitors if they wish. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel their needs are met by the numbers and skill mix of staff, who are well trained and competent to do their jobs. Residents are protected as far as possible by the home’s recruitment policy and practices. EVIDENCE: The staff rota was sent in with the Pre-inspection Questionnaire prior to the site visit. It indicated that the home provides enough staff to meet the needs of the residents. There are three staff on shift in the morning, 2/3 in the afternoon and evening and two night staff. All the respondents to the Service Users Survey said that staff are available when needed. Comments from residents and relatives include, “The staff are caring people”; “Very good staff”; and “The staff and manager are very good”. At present there are two Registered Nurses at the home. None of the support staff have an NVQ. Mrs Lingaloo said she is planning to register some of her staff on NVQ courses in the near future. The home has a thorough recruitment procedure in place. Three staff files were examined and found to include all the required documentation, including an Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 18 application form, two written references, and a Criminal Records Bureau Check. The home’s training plan was sent in with the Pre-inspection Questionnaire. Training available includes Health and Safety courses and courses relevant to the needs of the residents including Adult Protection, Infection Control and Dementia. A member of staff spoken with during the visit said she is given opportunities to attend many training courses. All new staff complete Induction Training within six weeks of their employment starting. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 19 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. 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. The registered manager has the qualifications and experience needed to run the home and meet it’s stated objectives. The home has a quality assurance and monitoring system in place. Residents’ financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: Mrs Lingaloo, the registered manager is a registered mental health nurse. She has maintained her continuous professional development and contributes to the training of others both within the home and locally. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 20 The home has a quality assurance and quality monitoring systems in place that includes residents meetings and audited quality assurance questionnaires. Residents are encouraged to control their own money for as long as they are able and willing to do so. At present two residents are doing so. The manager is not responsible for handling the financial affairs of any of the residents. Documentary evidence was seen that regular safety checks and services are made on the equipment and appliances at the home. Staff training records show was also seen that staff receive training in safe working practices such as Fire Safety, Infection Control, First Aid and Moving and Handling. Staff confirmed that they have attended Health and Safety training. Accident records were seen during the inspection and found to be clearly recorded. Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 21 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 22 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. 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 Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Downham Lodge DS0000011735.V329241.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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