Inspection on 08/11/07 for Dr Anderson Lodge

This inspection was carried out on 8th November 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

Dr Anderson Lodge 19/11/09

Dr Anderson Lodge 23/11/06

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 8th November 2007 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.V350516.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.V350516.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 01302 351985 platinumcarehome@nascr.net 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.V350516.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP and Dementia - Code DE The maximum number of service users who can be accommodated is: 61 23rd November 2006 2. Date of last inspection Brief Description of the Service: Dr Anderson Lodge comprises of two separate buildings one can accommodate 40 people with Nursing, the other unit can accommodate service users within the category of old age with dementia which has recently increased to 21. Both units have safe accessible outdoor space. The home is situated in Stainforth close to local amenities. The fees at Dr Anderson Lodge at the time of the inspection ranged from £380.15 - £426.30 plus free nursing care. For further clarification please contact the home. Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit, which occurred on the 11th November 2007 and took place over 7 hours commencing at 09:30 and ending at 16:30 hours. The visit included talking with people living at the home, a number of relatives, the manager and seven staff. A walk round the building to gain an overview of the facilities also some records were checked. Some surveys forms were sent to people who live at the home and their relatives. At the time of this visit eight were completed and returned to the Commission. The comments received were very positive. The manager completed an annual quality assurance assessment (AQAA) and returned this prior to the visit this focuses on how well outcomes are being met for the people using the service. It also gives us some numerical information about the service. What the service does well: What has improved since the last inspection? The quality of the bedding and pillows has improved since the last visit. Many rooms on the unit for people with dementia had been re-decorated to a high standard. The activities provided were appropriate and met the peoples needs. The activity co-ordinator had a good understanding of the peoples needs including people with dementia. Activities to suit the people and their choices were arranged, one lady said, “the activities are excellent we get to do what we choose and the activities lady is lovely”. Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 6 Staff training was up to date; staff we spoke to were very knowledgeable and understood how to meet peoples needs. The manager had provided new contracts and terms and conditions to all the people in the home. These were excellent they gave clear information on what was included in the charges and what care would be provided. This ensured the people clearly understood what to expect when they moved into the home. 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. The summary of this inspection report can be made available in other formats on request. Dr Anderson Lodge DS0000049440.V350516.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.V350516.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): 2, 3 and 6. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in the home had their needs assessed prior to moving into the home and each was provided with a written contract and statement of terms and conditions to ensure these could be met. EVIDENCE: Suitably qualified staff carried out the pre admission assessments on people who wanted to move into the home. The assessments were very detailed with all peoples needs identified, ensuring that the home could meet their needs before a place was offered to them, Every person in the home had a contract, and terms and conditions issued at the time of moving in. These had been drawn up by the manager since the last Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 9 inspection, they were very detailed and explained what would be provided while the person lived at the home. The home does not offer intermediate care so standard 6 does not apply. Dr Anderson Lodge DS0000049440.V350516.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. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person in the home had a plan of care with clearly identified needs, these were met, and people were treated with respect. Medication procedures did not always protect the people living in the home. Although medication procedures did not fully protect people the manager has put measures in place to prevent the poor practice occurring again. This has been confirmed in writing to us, ensuring people are protected. EVIDENCE: Three people in the home were case tracked and their plans were looked at in detail. The plans had identified the needs of the people with good recordings of the measures to take to meet their needs. The plans were regularly reviewed; people and their relatives were involved in this process. This ensured their Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 11 views were listened to and their needs met. People spoken to were aware of the plans and said “I have input into them if I wish”. Relatives said, “I am aware of the plans and have been involved in changes and reviews”. This ensured their relatives’ needs were being met. All health care needs were met and regular input from health care professionals was obtained. Their advice was followed and well documented in the plans ensuring the wellbeing of the people who lived in the home. We spoke to a district nurse who said, “The staff are always very helpful, advice we give is followed and people seem well cared for”. Aids for moving and handling people and adaptations to enable people using wheelchairs to have access to all parts of the home were provided to meet peoples needs. People were treated with respect and privacy and dignity upheld. During the visit we observed staff interacting well with people and their relatives. One lady said “The staff are lovely they look after you very well, I am very happy it is home from home”. We observed a medication round during the visit and a number of issues were identified which did not protect the people. Medication was put in pots and left in front of two residents, this was still there when the nurse left the room, a carer eventually put them in the mouth of one person so she would take them. The medication trolley was left open and unattended in the dining room. One persons medication was signed for on Sunday 4th November, yet was still in the blister pack, therefore they did not get any medication at 8am on that day. This was not picked up and addressed by the nurse who did the next shift. The home had a detailed medication policy, which was available in the office. Medication was documented on receipt and disposal with good records seen. The manager did audit medications in the monthly audit tool for the home and previously no errors had been noted. The manager agreed to address these points and would increase the audits to weekly to ensure procedures are followed to protect the people in the home. The manager has told us since the visit that she has addressed the above shortcomings. The member of staff has been appropriately supervised and retrained where necessary to protect people. Policies and procedures have been given again to all staff through supervision to ensure the issues identified do not happen again. Dr Anderson Lodge DS0000049440.V350516.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. People who use the service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People exercised choice and control over their daily lives and activities ensuring their needs were met. EVIDENCE: An activities co-ordinator is employed 16 hours a week, group activities and 1 to 1 sessions were organised depending on the people’s needs and choices. Activities were varied and changed depending on the choices of the people who attended on the day. Activities were taking place on the day of the visit, some people had requested a pamper session, this included nails cleaned and nail polish applied, food spas and massages. The people spoken to told us they liked the pamper sessions. “We sit together in a group have a good laugh and a joke”. This gave people a good state of wellbeing. Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 13 For the afternoon activity session people requested a film, which was shown in the activities room with food and drinks of their choice. This was enjoyed by all who attended. One lady said, “The activities are excellent we get to do what we choose and the activities lady is lovely”. The people and their relatives we spoke 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 had regular contact with the Church of England, Methodist and Catholic churches in the area that visited the home. People can also attend services at the church of their choice to meet their religious and spiritual needs. A varied, balanced and wholesome diet was provided for the people with good choices available. We observed the meal, which was well presented, there was good communication to the people from staff when it was served, seconds were offered and a choice of drinks were also offered ensuring peoples needs and choices were met. The home had not continued with the two sittings at meal times due to the number of people in the home this was discussed with the manager who agreed it would be better for the people if this could recommence ensuring their needs could be met fully. One lady told us “The meals are good here”. Dr Anderson Lodge DS0000049440.V350516.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. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who lived in the home were listed to and protected. EVIDENCE: There was a comprehensive complaints procedure, which was clearly displayed, in the entrance hall. All people we spoke to were aware of the procedure and told us they would either speak directly with staff or complete one of the forms that were available in the entrance hall and give to the manager. The manager had received a number of concerns which had all been resolved, good records were kept of outcomes. This showed they had been fully investigated, acted on and taken seriously. All staff had received training in adult protection; all staff we spoke to had a good knowledge of the procedures and what to do should an incident occur. Staff were also aware of the whistle blowing policy, which safeguards people in the home. Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 15 Two senior care staff were also to attend a further training course run by Doncaster council on adult safeguarding. Ensuring they are fully up to date on new policies and procedures to protect people. There had been two adult protection referrals since the last visit. These however were regarding people’s family and not affecting the home directly, the manager was working with the investigating officer to resolve these referrals ensuring the people were protected. Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 16 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 and 26. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was well maintained clean, pleasant and comfortable ensuring people lived in a safe environment. EVIDENCE: The unit for people with dementia has recently increased the number of bedrooms to 21; the rooms had all been re-decorated and furnished to a high standard. Providing a well-maintained environment for the people who lived there. The nursing unit had also much improved since the last visit, the manager regularly carries out environmental audits to identify areas that require improvement. The dining room had been identified as requiring re-decorating Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 17 and this was due to be carried out. A large number of bedrooms were scheduled to have new carpets fitted in November 2007. Ensuring the people lived in a well maintained safe environment. The newly opened bedrooms on the unit for people with dementia had a passenger lift installed, there is also stairs to access the upper floor. However there were gates top and bottom to prevent the people using them without assistance for their safety. When we accessed this it proved very difficult to open the top gate once on the stairs. The manager agreed to look into this seeking advice from the fire officer to provide an alternative, which still safeguarded the people when they move into this unit. The standard of cleanliness observed during the visit was very good and no odours were noted anywhere in the building providing a pleasant and hygienic home for the people who lived there. One relative told us “the home is always very clean whenever I visit”. Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 18 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. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were appropriately trained, the recruitment procedures were robust ensuring people were in safe hands at all times, had their needs met and were protected. EVIDENCE: There was a qualified nurse on the nursing unit, 24 hours a day to meet people’s needs. The residential unit had a unit manager and senior carers to ensure peoples needs were met. Care staff numbers were determined by the number and needs of the people on each unit and appropriate levels were maintained on the day we visited ensuring peoples needs were met. The manager had made good progress with NVQ training for care staff, nearly all care staff had either completed NVQ level 2 or were enrolled on the course. This ensured the staff could meet the needs of the people in the home. The unit manager on the residential unit had also enrolled on NVQ level 3. This commenced in January 2008, this will ensure she continues to keep up to date and meet peoples needs. Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 19 All mandatory training was up to date, the manager had put robust systems in place to ensure this remained up to date for all staff ensuring people were in safe hands at all times. Staff told us, “Training is very good and we are encouraged to do NVQ’s”. The manager also said, “Any additional training I feel would be beneficial to staff will be obtained”. This ensured staff were competent to meet the needs of the people in the home. A thorough recruitment procedure was in place, two staff files were seen on the day of the visit and contained all the required information. Protecting people who lived there. Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 20 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. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management and administration safeguards people, good health and safety policies and procedures were in place ensuring the safety of people in the home. EVIDENCE: The manager was qualified and experienced to run the home. She had achieved the registered managers award and continually kept herself updated to ensure the homes stated purpose, aims and objectives were met. Quality monitoring was carried out, the manager did regular audits and the provider carried out regulation 26 visits, these are visits to gain feedback from Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 21 staff, people living at the home and relatives. The provider would also look at the environment and care plans and other documentation, which may be relevant. A report would then be written and a copy sent to Commission for Social Care Inspection. The manager had regularly sent quality-monitoring questionnaires to people in the home and their relatives. This ensured the home was run in the best interests of the people who lived there. The home managed some people’s finances and personal money and we checked some records. These were well recorded and signed for by two people and all receipts were kept, ensuring peoples financial interests were safeguarded. The home had a comprehensive health and safety policy. We were able to evidence that regular maintenance of equipment and systems was carried out. Risk assessments were carried out on all safe-working practices, regular audits were carried out on the building and all accidents were properly recorded and reported ensuring people in the home were safeguarded. During the visit staff were observed giving support to people, moving and handling techniques were used these were safe and appropriate. However belts were available which could have helped the staff but were not used. This was discussed with the manager who assured us that staff will be told to use the belts when appropriate to help with the moving and handling and further safeguard people. Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 22 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 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 Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement All medication must be administered as prescribed and recorded and signed for on the medication administration charts. This will make sure that people receive their medications as prescribed. Medication must be administered safely ensuring the correct person is given the medication and observed taking it. The medication trolley must not be left open and unattended to ensure people are safeguarded. Timescale for action 10/12/08 2. OP9 13 10/12/08 3. OP9 13 10/12/08 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 2 Refer to Standard OP38 OP19 Good Practice Recommendations It is recommended that the staff use the belts provided when moving and handling people to minimise the risk for people and staff. It is recommended that the identified areas requiring DS0000049440.V350516.R01.S.doc Version 5.2 Page 24 Dr Anderson Lodge 3 OP19 improvement are included in the improvement plan and addressed. It is recommended that the gates on the stairs can be opened easily to gain access to the upstairs by staff ensuring it is accessible and safe. Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Dr Anderson Lodge DS0000049440.V350516.R01.S.doc Version 5.2 Page 26 - 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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