Inspection on 19/01/06 for Dr Anderson Lodge

This inspection was carried out on 19th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Dr Anderson Lodge 19/11/09

Dr Anderson Lodge 08/11/07

Dr Anderson Lodge 23/11/06

Dr Anderson Lodge 08/05/06

Dr Anderson Lodge 29/06/05

Dr Anderson Lodge 04/11/04

Dr Anderson Lodge 05/05/04

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Dr Anderson Lodge East Lane Stainforth Doncaster South Yorkshire DN7 5DY Lead Inspector Mrs Sarah Powell Unannounced Inspection 19th January 2006 09:40 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 Dr Anderson Lodge DS0000049440.V267591.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. Dr Anderson Lodge DS0000049440.V267591.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Dr Anderson Lodge Address East Lane Stainforth Doncaster South Yorkshire DN7 5DY 01302 350003 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) Platinum Care Homes Limited t/a Dr. Anderson Lodge Sara Louise Wilson Care Home 65 Category(ies) of Old age, not falling within any other category registration, with number (65) of places Dr Anderson Lodge DS0000049440.V267591.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. All service users requiring nursing care only be admitted to the Dr. Anderson Lodge building, and not the building formerly known as Rannoch House The service may admit persons between the age of 60 to 65 years only within their registration category of (OP). 29th July 2005 Date of last inspection Brief Description of the Service: Dr Anderson Lodge comprises of two separate buildings one can accommodate 40 service users with Nursing, the other has recently changed category of registration to accommodate service users over the age of 65 with dementia currently 14 beds are registered and phase two will increase this to 23 when completed. Both units have safe accessible outdoor space. The home is situated in Stainforth close to local amenities. Dr Anderson Lodge DS0000049440.V267591.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection in the year 2005/06 and took place over two days the inspection commenced on 19th January 2006 at 09.40 and finished at 15.30 the second day was on 1st February 2006 at 10.45 and finished at 15.00 Mrs Lancaster accompanied the inspector on the second day A Social Worker from the Thorne Office was also present on the second day to investigate an adult protection issue that is ongoing at the home. 8 Service users, 6 visitors, 4 staff and the Manager were spoken to. A partial tour of the building took place, observing staff and practices. What the service does well: What has improved since the last inspection? What they could do better: The care plans did not reflect the needs of the service users and these need reviewing and updating to ensure all service users needs are identified and met. Risk assessments were also very poor with many risks unidentified this needs to be addressed in order that service users are safe. Staff training needs to be improved to ensure staff are able to care for service users changing needs. Dr Anderson Lodge DS0000049440.V267591.R01.S.doc Version 5.0 Page 6 The manager was not aware of some essential procedures and legislation that affect the running of the home she needs to ensure she is constantly updating her knowledge to ensure service users are protected. 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. Dr Anderson Lodge DS0000049440.V267591.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 Dr Anderson Lodge DS0000049440.V267591.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): 3 Service users needs are assessed prior to admission, however it is not clear if these are met. EVIDENCE: Service users referred through care management arrangements had a care management assessment in their plans of care, however the care plans did not always include all the needs identified on these assessments. Some clear instructions seen in the assessment had been ignored regarding a mental health review. For self-funding service users an assessment was completed, but it lacked detail and did not show that the home was able to meet the needs of the perspective service user. Dr Anderson Lodge DS0000049440.V267591.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 & 9. Each service user had a plan of care however they did not demonstrate that health care needs were fully met. Medication policies and procedures safeguarded service users. EVIDENCE: All service users had a plan of care. Looking at the plans and case tracking a number of service users, it was evident that the plans did not reflect their needs. Many problems and risks had not been identified or lacked appropriate action or identified inappropriate action. This clearly demonstrated a lack of understanding from the manager and staff and did not safeguard the service users. In the care plans looked at all lacked the basic risk assessments for the service users for example risk of falling. Risk assessments completed were poor and required more information to ensure service users are protected. Dr Anderson Lodge DS0000049440.V267591.R01.S.doc Version 5.0 Page 10 There was evidence in the plans that they were reviewed. However looking at medical information it was noted that some care needs had changed yet this was not reflected in the review of the plans and put some service users at risk. Some health care needs of service users were met with input from GP’s, District nurses, Dentists, Opticians and chiropodists. However service users with mental health care and dementia needs were not met. There was no input from a Community Psychiatric Nurse and from looking at the care plans it was evident staff did not have any knowledge of mental health or dementia. There were good policies and procedures in place for medication, good records were seen for receipt, administration and disposal. Regular audits were carried out by the pharmacist and the manager to protect service users. Dr Anderson Lodge DS0000049440.V267591.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): 14 Service users are given choices. EVIDENCE: Service users spoken to by the inspector all said staff gave them choices and respected their decisions. The home has an increasing number of service users with dementia and it was not clear, due to lack of understanding by staff, if these service users were given choices; this needs to be addressed. Dr Anderson Lodge DS0000049440.V267591.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): 16 & 18 Complaints are taken seriously and acted upon. Service users are not protected from abuse. EVIDENCE: The home has a complaints procedure which is accessible to service users and relatives. A record is kept of all complaints; the Manager told the inspector that the home had not received any complaints since the last inspection. The manager also said that regular residents meeting are held and concerns are raised at these, are taken seriously and dealt with to ensure they are resolved. The home had an adult protection investigation ongoing at the time of the inspection this was looked at by the inspector. The incident had occurred early morning on a Monday and had not been notified to the manager until the Wednesday afternoon by a relative of the service user. There was no documentation of the incident in the care plan or on an accident form, however qualified staff were aware as injuries were evident on the service users. Yet no staff member had thought to notify the Manager or document the injuries or account of the incident. The manager instigated an investigation, however did not follow the correct procedure. When asked about the adult protection procedure the manager did not have a copy of this in the home and had never had one. This is available Dr Anderson Lodge DS0000049440.V267591.R01.S.doc Version 5.0 Page 13 on the Internet. Access to the Internet in the home would be a great benefit. The actions following this incident show that the manager and staff failed to protect service users. The manager has now obtained a copy of the policy and is to arrange urgent training for herself and staff on protection of vulnerable adults. Dr Anderson Lodge DS0000049440.V267591.R01.S.doc Version 5.0 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 The environment is safe and well maintained. EVIDENCE: The home was well maintained; there is a programme of routine maintenance and renewal. Major work has just been completed in the annex and is finished to a high standard giving service users a good environment to live in. Service users spoken to told the inspector that staff keep the home very clean and it is always kept nicely decorated. Dr Anderson Lodge DS0000049440.V267591.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): 27, 29 & 30. There is a skill mix of staff on duty. The recruitment policy is robust. Staff training needs to be improved. EVIDENCE: The manager told the inspector that she looks at dependency levels of service users to determine staffing. Care staff numbers did reflect this and the rota showed these numbers on duty. There is always a qualified nurse on each shift and the skill mix of staff on duty could meet the needs of the service users, however the needs need to be clearly identified. A selection of personal files were looked at by the inspector. All the required information was in the files including CRB and POVA checks to protect service users. The staff training records were seen and up to date, however the Manager carries out the training in house and in some training she is not accredited to do this. External trainers who are appropriately qualified must be accessed to deliver training in particular Adult protection, Dementia care and mental health training. To ensure all service users needs are met by appropriately trained staff. Dr Anderson Lodge DS0000049440.V267591.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): 33, 35 & 38. The home has quality monitoring systems in place. Service users financial interests are safeguarded and health and safety is maintained. EVIDENCE: The home has quality assurance and quality monitoring systems in place to seek the view of the service users. Regular meeting are held for residents and relatives to gain feedback and discuss issues. The manager has an annual development plan for the home, which is reviewed to reflect outcomes for service users. Most service users maintain their own money or ask their family to, however the home maintains some money for 5 service users, a selection of these were checked by the inspector, they were well maintained, with good records and were correct ensuring service users financial interests are safeguarded. Dr Anderson Lodge DS0000049440.V267591.R01.S.doc Version 5.0 Page 17 The home has a good health and safety policy, however staff training is not up to date and this needs to be addressed to ensure service users safety. The maintenance records for gas safety, electrical safety certificates, Pat testing, legionella and safe environment including equipment and machinery were not all available at the time of the inspection, as some had just expired. The Manager was to address this and ensure they were carried out. The manager has since contacted the inspector to confirm that dates have been organised for the outstanding checks to be carried out to ensure safety. Not all incidents, accidents or injuries are recorded. This needs to be addressed and staff made aware it is their responsibility to record any incidents they witness or are involved in. The manager also needs to ensure the accident audits are up to date and give enough information to be able to analyse properly. The risk assessments on safe working practices were not available these need to be carried out to ensure the safety of residents and staff. Dr Anderson Lodge DS0000049440.V267591.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 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 2 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Dr Anderson Lodge DS0000049440.V267591.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? N0 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 OP3 Regulation 14 Requirement The registered manager must ensure the assessments are in full and reflect all the needs of the service users. The registered manager must ensure that all service users risk assessments are complete and all risks are identified. The registered manager must ensure the care plans identify all the needs of the service users and give clear instructions how to met these needs. The registered manager must ensure that all health care needs of service users are identified and met. The registered manager must ensure that all service users are given choices. The registered manager must ensure she is familiar with adult protection procedures and ensures service users are protected. The staff must attend appropriate training by suitably qualified personnel to ensure they are qualified to meet DS0000049440.V267591.R01.S.doc Timescale for action 01/04/06 2 OP7 13 01/04/06 3 OP7 15 01/04/06 4 OP8 12 01/04/06 5 6 OP14 OP18 12 13 01/04/06 01/04/06 7 OP30 18 01/04/06 Dr Anderson Lodge Version 5.0 Page 20 8 OP38 13 9 OP38 13 service users needs. In particular Protection of vulnerable adults, dementia care, mental health care and aggressive behaviour. The registered manager must 01/04/06 ensure all incidents and accidents are reported and properly recorded and accidents audits are carried out. The registered manager must 01/04/06 ensure all risk assessments for safe working practices are carried out. 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 OP30 Good Practice Recommendations To improve knowledge and easy access to updated policies, procedures and legislation it is recommended that the home has internet access. Dr Anderson Lodge DS0000049440.V267591.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Dr Anderson Lodge DS0000049440.V267591.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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!