Inspection on 23/11/06 for Dr Anderson Lodge

This inspection was carried out on 23rd November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Dr Anderson Lodge 19/11/09

Dr Anderson Lodge 08/11/07

Dr Anderson Lodge 08/05/06

Dr Anderson Lodge 19/01/06

Dr Anderson Lodge 29/06/05

Dr Anderson Lodge 04/11/04

Dr Anderson Lodge 05/05/04

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Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

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 Sarah Powell Key Unannounced Inspection 23rd November 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 Dr Anderson Lodge DS0000049440.V312596.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. Dr Anderson Lodge DS0000049440.V312596.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Dr Anderson Lodge Address East Lane Stainforth Doncaster South Yorkshire DN7 5DY 01302 350003 NONE NONE 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 54 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (40) of places Dr Anderson Lodge DS0000049440.V312596.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. All service users requiring nursing care and OP care can be admitted to the Dr Anderson Lodge only. 14 service users in the category of Dementia can be admitted to the annex only. The service may admit persons between the age of 60 to 65 years only within their registration category of (OP) 8th May 2006 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. Fees are nursing £420 plus free nursing care, residential £375 and residential for service users with dementia placed in the annex £410. Dr Anderson Lodge DS0000049440.V312596.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second key inspection in the year 2006/07 it was unannounced and took place over one day on 23rd November 2006 it commenced at 09.00 and finished at 17.10. As part of the inspection process the inspector spoke to 8 Service users, 2 visitors, 5 staff and the Manager. A full tour of the building took place, observing environmental standards, staff and practices. A number of records were examined these included medication, three service users care plans, menus, staff rotas, training records, recruitment, service users finances and quality assurance systems. Feedback was given to the Manager when the visit was completed. What the service does well: What has improved since the last inspection? What they could do better: The bedding including pillows, quilts, sheets and pillow cases were in a poor state this has since been addressed and all new bedding has been delivered to the home. Dr Anderson Lodge DS0000049440.V312596.R01.S.doc Version 5.2 Page 6 Some furniture was old and in need of repair the manager is to carry out an audit to identify what needs replacing or repairing. Some baskets of communal toiletries were found again in two bathrooms this poses a risk of cross contamination service users own toiletries must always be used and then returned to their room. This is an ongoing problem the manager needs to address. Air freshener was found throughout the home and some were unlabeled these need to be locked away to safeguard service users. 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.V312596.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 Dr Anderson Lodge DS0000049440.V312596.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. Standard 6 does not apply at Dr Anderson lodge. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. All service users needs had been assessed. EVIDENCE: Two service users were case tracked as part of the inspection process and the assessments seen in these care plans were fully completed, comprehensive and identified all the service users needs. Service user who had been referred through the care management arrangements had copies of social services assessments in the plans of care. Dr Anderson Lodge DS0000049440.V312596.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 & 10. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. All health and personal care needs of service users were met. EVIDENCE: Two plans of care were looked at during the inspection. The plans set out in detail the action, which needed to be taken by care staff to ensure all aspects of the health, personal and social care needs of the service users were met. The manager and staff promoted service users health and ensured access to all health care services to ensure their needs were met. Details of the services accessed were clearly recorded in the plans of care. Staff spoken to talked about service users in a sensitive and respectful way and understood the need to promote their dignity. Staff observed during the day treated service users and visitors with respect. Some service users clothes were stained with food and drink this was observed in the morning after breakfast and later in the afternoon the service users had not been changed but still had on the same clothes, Not maintaining service users dignity. Dr Anderson Lodge DS0000049440.V312596.R01.S.doc Version 5.2 Page 10 Medication policies and procedures are good safeguarding service users. All medication is checked and signed for on arrival, administration and disposal. Dr Anderson Lodge DS0000049440.V312596.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 & 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users social, recreational and dietary needs were met. EVIDENCE: The home has employed an activities co-ordinator since the last inspection. She works 16 hours a week organising group and 1 to 1 activities depending on what the needs of the service users are, the activities were varied. Organised activities are clearly displayed in the entrance hall. The home has also organised many trips and entertainment which were well liked by the service users, many told the inspector that the entertainment was very good and they were able to go on trips if they wished. The service users and relatives spoken to all said that contact with family, friends and the local community were encouraged by the staff and relatives were always made welcome. The home now has regular contact with the Church of England, Methodist and Catholic churches in the area. A varied, balanced and wholesome diet is provided for the service users with good choices available. The home has continued with the two sittings at meal Dr Anderson Lodge DS0000049440.V312596.R01.S.doc Version 5.2 Page 12 times to enable the needs of the service users who require assistance to be met. The manager is currently reviewing the meals with input from the service users to ensure their needs are met. Dr Anderson Lodge DS0000049440.V312596.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 & 18. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The policies and procedures to protect service users were good however the home had a number of adult protection referrals. EVIDENCE: The home had a comprehensive complaints procedure, which set out clear guidelines and timescales. The service users and relatives who were spoken to were all aware of the procedure and how to raise a concern or complaint should one arise. The manager had greatly improved the adult protection policy and procedure following a number of referrals. The manager had followed the correct procedure at the last referral and protected service users. All staff had received protection of vulnerable adults training. When the inspector spoke to staff during the inspection they were aware of adult protection and the importance of notification/whistle blowing. The manager had also arranged for the Doncaster Council adult protection officer to deliver training to staff in 2007. The home had had a number of adult protection referrals which once notified had been dealt with appropriately by the manager who followed the policies and procedures. However some staff had not followed correct procedures, which had resulted in one referral to adult protection. The manager had following this incident tightened up the policies and procedures and had dealt with the staff to ensure this does not happen again. Dr Anderson Lodge DS0000049440.V312596.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 & 26. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home was maintained to a high standard of cleanliness and issues identified by inspector were dealt with by the manager immediately to ensure service users safety. Some furniture in the lodge needs replacing to improve the overall standards of provision. EVIDENCE: A full tour of the building was carried out with the manager. The annex was decorated to a high standard this was clean and fresh smelling. Good quality furniture was provided for service users and rooms were personalised. The lodge was maintained to a high standard of cleanliness, however the quality of bedding, pillows, quilts and some furniture was poor. Bedding was addressed on the day of the inspection and the manager ordered sheets, pillow cases, quilt covers, quilts and pillows for all forty rooms. Since the inspection Dr Anderson Lodge DS0000049440.V312596.R01.S.doc Version 5.2 Page 15 the manager has sent the inspector confirmation that these had been received and provided for each room. The manager also agreed to carry out a full audit on furniture to identify what required replacing or repairing. This was to be included in the homes maintenance and renewal plan which has yet to be implemented to ensure a good quality environment. Many areas of the home had been improved since the last inspection; the lounge had been decorated and new carpet and curtains provided. Quality of laundry had improved and the home had received no further complaints regarding stained clothes. During the tour a strong odour of fumes was smelt in a number of toilets and bathrooms from the use of bleach. This was discussed with the manager and for safety of staff she has agreed to cease using bleach and find an alternative cleaning fluid. Everfresh spray was found throughout the home left unattended and unlabelled, placing service users at unnecessary risk. Toiletries and ointment were found in bathrooms. Dr Anderson Lodge DS0000049440.V312596.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 & 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing levels are maintained to a good level, recruitment procedures protect service users. The training continues on a rolling programme to ensure all staff recieve mandatory training. EVIDENCE: The home provided adequate numbers of staff on duty to meet the needs of service users. Both units were staffed separately the rota was seen and numbers were maintained. The home has a rolling programme for training staff to NVQ level 2 and seven staff were just completing level 2 and when these have completed the home would have in excess of 50 of staff trained making sure service users are in safe hands at all times. The home operated a thorough recruitment procedure protecting service users. Three staff files were seen on the day of the inspection and contained all the required information. Good progress had been made on the mandatory training and approximately 80 of staff had completed the training this was a good achievement as it had been a requirement at the last inspection. The manager had drawn up a training programme for next year, which will ensure all staff are kept up to date and competent to carry out their jobs. Dr Anderson Lodge DS0000049440.V312596.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 & 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The management and administration of the home is in the best interest of service users. Most health and safety procedures were good however some needed improving. EVIDENCE: The manager is qualified and experienced to run the home, she has achieved the registered managers award and in the last year has worked very hard to meet the homes stated purpose, aims and objectives. Quality monitoring was carried out, the manager did regular audits and the provider carried out regulation 26 visits and sends the reports to CSCI these audit tools identify problems or faults and rectify them. The manager had drawn up some quality questionnaires and was in the process of giving out to Dr Anderson Lodge DS0000049440.V312596.R01.S.doc Version 5.2 Page 18 all service users or relatives to ensure the home is run in the best interests of service users. Most service users maintain their own money or asked their family to, however the home maintained some money for 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 were safeguarded. The maintenance records for gas safety, electrical safety certificates, portable appliance testing, legionella and safe environment including equipment and machinery were available at the time of the inspection and were maintained up to date. However the water temperatures had not been recorded for some time. The home had problems with the boiler and an engineer was at the home at the time of the inspection to identify the problem. The use of cleaning fluids and air fresheners are to be reviewed by the manager Everfresh was found throughout the home in bathrooms and corridors and some were unlabelled, which potentially poses a risk to service users. The manager had again improved the accident reporting and auditing as a result of an adult protection referral. The procedure was much improved and the audit tool was excellent and meant that all accidents had to be followed up to protect service users Dr Anderson Lodge DS0000049440.V312596.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Dr Anderson Lodge DS0000049440.V312596.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? Yes 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. 2. Standard OP26 OP30 Regulation 13 12 Requirement Ensure communal toiletries are not used. Ensure all mandatory training is given to all staff and then updated yearly. (old timescale 01/08/06) Implement a maintenance and renewal programme for the home as part of the annual development plan. Carry out an audit on all bedroom furniture to identify what needs repairing or replacing and implement a programme for replacement. Ensure that any cleaning fluid or air freshener is clearly labelled and is kept in a locked cupboard or room. It is necessary to change service users clothes after meals or drinks if they have spilt any on themselves in order to maintain service users dignity. Timescale for action 01/01/07 01/03/07 3. OP19 23 01/02/07 4. OP19 23 01/02/07 5. OP38 12 01/01/07 6 OP10 12 01/01/07 Dr Anderson Lodge DS0000049440.V312596.R01.S.doc Version 5.2 Page 21 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 Dr Anderson Lodge DS0000049440.V312596.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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.V312596.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. 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!