Inspection on 08/03/06 for Downham Lodge

This inspection was carried out on 8th March 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

Downham Lodge 12/03/07

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 Wendy Mills Unannounced Inspection 8th March 2006 09:00 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 Downham Lodge DS0000011735.V254195.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. 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.V254195.R01.S.doc Version 5.1 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.V254195.R01.S.doc Version 5.1 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 9th August 2005 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. Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection consisted of in depth discussion with the registered persons, conversation with several of the residents and a tour of the home. Documentation was examined and both indirect and direct observation was used throughout. The residents, staff and registered persons are thanked for the welcome they gave and their assistance throughout this inspection. What the service does well: What has improved since the last inspection? 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. Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 Page 6 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.V254195.R01.S.doc Version 5.1 Page 7 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 The home assesses the needs of prospective residents and ensures that adequate plans are in place prior to admission. This ensures that the needs of the residents are met. EVIDENCE: Since the last inspection one new resident has been admitted. The care plan of this resident and two others, selected at random, were examined. The home has its own pre-admission pro forma. Pre-admission assessments were in place and risk assessments had been made. The care plans were up-to-date and in good order. Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 Page 8 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, 9 & 10 The home promotes the health and well-being of the residents well. This means that they can enjoy their lives in the home as much as possible. EVIDENCE: Residents are free to come and go as they wish and are able. Risks are discussed with the residents and appropriate health care professionals. Care plans show that GPs are called in appropriately and the advice of other health care professionals is sought. All the residents were in good health and spirits on the day of inspection. Many were having their hair done. Conversation with the hairdresser confirmed that the residents are treated with kindness and respect by all the staff and the registered persons. The residents to whom, the inspector spoke all said that they are well cared for that that the staff are all “very kind”. Since the last inspection, care plans have been revised to give more details about the likes and dislikes of the residents. Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 Page 9 Medication is stored safely in a locked cupboard in a locked room. The registered manager said that there have been some recent difficulties with the pharmacy and she is in discussion with a new provider for pharmacy requirements. Policies and procedures for the administration of medicines are sound and the MAR sheets were in order. Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 Page 10 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 &15 The residents are satisfied with the lifestyle they experience in the home. The are able to make choices about how they spend their time and what they eat. Links with families and friends are encouraged. The home manages nutrition well and provides a healthy and nourishing diet for the residents. EVIDENCE: On the day of inspection the hairdresser was working in the home. Several residents were having their hair done. Another resident was on his way out. Discussion with the residents and the registered manager, and inspection of care plans, showed that the residents are consulted on their activities and choices. One resident who wished to undertake an activity that carried significant risk has been helped to discuss the issues and risks with the relevant healthcare professionals. Records show that contact is maintained with friends and families. In some cases, friends come to take residents to church and other activities. Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 Page 11 Inspection of the menus, kitchen, fridges and food store confirmed that there was a wide range of good quality food in the home. The residents said that they have plenty to eat and that they enjoy their meals. The kitchen and fridges were found to be very clean and hygienic on the day of inspection. The registered manager is a trainer in food hygiene and maintains her continuous professional development. Conversation with her showed that she has a very good understanding of the importance of good nutrition and is clear about the way this is provided in the home. Food is purchased locally and a number of good quality suppliers are used. Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 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): 16 & 18 There is a good understanding of complaints and adult protection issues. This protects the residents from harm and enables them to express their concerns freely. The whistle-blowing procedure could be improved by making it clearer. EVIDENCE: Written complaints and adult protection policies and procedures are in place. Staff understand their responsibility to report and concerns through the proper channels. However, the written procedure for reporting concerns lacks clarity. The home should produce a flow chart to show the correct whistle-blowing procedure. This should indicate named persons and their responsibilities. Ultimately it should refer to the CSCI. A simple flow chart will provide more clarity for staff, residents and their supporters should they ever have to report concerns. 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. There have been no formal complaints since the last inspection. Although some residents were unable to say whether they had complaints, those that were able said that they had no complaints and that they could talk to staff of the manager if they were worried. Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 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): 19, 20, 22, 23, 24, 25 & 26 The home is well maintained and environment of the home is safe, pleasant and clean. Continued investment in the environment provides the residents with a safe, comfortable and homely place in which to live. EVIDENCE: A tour of the home was undertaken. There have been a number of environmental improvements since the last inspection. A stair lift has been fitted between the two levels of the lounge and dining room. A bathroom has been renovated. The rooms are well furnished and airy and there is a high standard of cleaning. All areas of the home were free from offensive odours. At the time of inspection the kitchen was being cleaned. Observation showed that this was carried out to a very high standard. Staff said that they clean the kitchen to this standard every day. No health and safety hazards were noted. 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.V254195.R01.S.doc Version 5.1 Page 14 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 The home makes all appropriate checks before allowing new staff to work in the home. This protects the residents from harm from unsuitable staff. EVIDENCE: Inspection of the staff file of the most recently recruited staff member showed that all appropriate checks had been carried our prior to the individual being offered work in the home. A CRB check was in place and references had been taken up. Two other staff files were selected at random. These were also found to be in order and to contain current CRB checks. Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 Page 15 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, 32, 36, 37 & 38 The home is well managed. This ensures that the best interests of the residents are promoted. EVIDENCE: Conversation with both the registered persons showed that they have a clear understanding of the needs of the residents, their supporters and the staff. Where possible, the views of the residents are sought. If this is not possible, relatives and supporters are asked for their views. Evidence of this was seen on the care plans. 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. Both the registered persons demonstrate a great deal of pride in their home and said that they feel it is, “part of their family”. Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 Page 16 The registered providers said that the home is financially viable but that they need to continue work to ensure that funding levels meet the needs of the residents. The home is well maintained and the providers make the necessary investments in the home to ensure it is safe and comfortable. One-to-one staff supervision is established and conversation with Mrs Lingaloo showed that appropriate topics are discussed during these sessions. Records are well maintained and stored appropriately. Policies and procedures are in place to cover all aspects of running the home. A small sample of these was examined and found to be in order. All areas were noted to be safe on the day of inspection. Radiator guards are fitted, carpets are in good condition and do not present a trip hazard. The electrical plans have been improved and additional fire lighting has been fitted externally. No health and safety hazards were noted on the day of inspection. Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 Page 17 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 X 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 3 X 3 3 X 3 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 3 3 Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 Page 18 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. 1 Refer to Standard 18 Good Practice Recommendations The home show produce a simple flow chart to guide residents, their supporters and staff through the whistleblowing procedure. This should name the people to whom concerns should be reported and the hierarchy for the reporting process. The address and the telephone number of the local CSCI office should be included in this document. Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Downham Lodge DS0000011735.V254195.R01.S.doc Version 5.1 Page 20 - 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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