Inspection on 24/01/07 for Eclipse Lodge

This inspection was carried out on 24th January 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

Eclipse Lodge 20/11/08

Eclipse Lodge 03/10/07

Eclipse Lodge 27/01/06

Eclipse Lodge 30/08/05

Eclipse Lodge 27/01/05

Eclipse Lodge 10/08/04

Eclipse Lodge 18/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Eclipse Lodge Rawlyn Road Torquay Devon TQ2 6PQ Lead Inspector Michelle Finniear Unannounced Inspection 08:45 24 and 25th January 2007 th 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 Eclipse Lodge DS0000018350.V319666.R02.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. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eclipse Lodge Address Rawlyn Road Torquay Devon TQ2 6PQ 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) 01803 607604 01803 607604 clare@crocuscare.co.uk Crocus Care Limited Application pending Care Home 27 Category(ies) of Dementia - over 65 years of age (27), Old age, registration, with number not falling within any other category (27) of places Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27/1/06 Brief Description of the Service: Eclipse Lodge is a detached building in a residential part of Chelston, fairly close to local shops and Torquay sea front. It is registered to accommodate people aged 65 and over and principally cares for people with dementia. All but two of the bedrooms are single rooms and some have en suite facilities. There are several spacious communal areas, including three lounge areas and a dining room. Disability equipment includes stair lifts, assisted baths, mobile hoists, raised toilet seats, toilet frames and grab rails. There is a sophisticated call system. Residents are accommodated on three floors, but the top floor is not accessed by a stair lift and there are a few steps down into the dining area. There is a pleasant secluded garden and a sizeable car parking area, and residents are able to access outside areas fairly securely. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report reflects a summary of a cycle of Inspection activity at Eclipse Lodge since the last inspection visit to the home in January 2006. Since the last inspection the previous manager of the home has left, and an application is awaited for the current care manager to be registered. To help CSCI make decisions about the home the owner gave us information in writing about how the home is run; documents submitted since the last inspection were examined along with the records of what was found at the last inspection; two site visits totalling 11 hours were carried out with no prior notice being given to the home as to the specific date and timing of the first visit; discussions were held with the responsible individual from Crocus Care Ltd, the home manager and staff on duty; various records were sampled, such as care plans and risk assessments; questionnaires were sent to the people who live at the home (some of which were completed by relatives) and staff who work at the home; a tour was made of the home and garden; time was spent with the people who live at the home both individually and in groups observing interactions; and discussions were held with visitors met on the site visit. In addition a sample group of residents were selected and their experience of care was ‘tracked’ and followed through records and discussions with staff and management from the early days of their admission to the current date – looking at how well the home understands and meets their needs, and the opportunities and lifestyle they experience. Questionnaires were then sent to their relatives, general practitioners and care managers where appropriate. This approach hopes to gather as much information about what the experience of living at the home is really like, and make sure that residents experience of the home form the basis of this report. This is especially important when, as at Eclipse Lodge, residents suffer from moderate to severe memory loss. What the service does well: Eclipse lodge offers a good standard of care for residents who are mentally frail. Care staff are very dedicated towards the people they are looking after and work well as a team. Staff interactions seen were supportive and the recorded information in care plans gave a clear indication of residents current needs and the support they require. The environment offers several areas for residents to sit, and wander if they choose, and there are attractive gardens and seating areas for use in warmer weather. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 6 Eclipse Lodge has a good programme of activities available for residents. Work is beginning on developing person centred plans and life histories which helps to give staff a better understanding of the ‘whole person’ they are caring for. Two residents have been able to bring their pets into the home with them. This allows people to continue to care for their pets with support, and helps them to feel at home with animals they have cared for over many years. The manager has ideas for several developments for the home, and is planning to set up a relative support group. This will help relatives feel better involved in the operation of the home. The home has objects and an exhibition of local history and photographs. This helps to provide stimulation and interest for residents and can be used to start conversations and activities. What has improved since the last inspection? What they could do better: The responsible individual must ensure an application is made for a person to be the registered manager. This is so that they are legally responsible for the day to day control of the home. The toilets and bathrooms identified on this inspection would benefit from redecoration and ensuring that toilets are available that are accessible for the needs of service users with disabilities. This includes the repair of the broken bath panel and replacement of the clinical waste bin in one bathroom as identified. Two toilets are heated by hot water pipes running through them. The home should monitor that the heating provided by these pipes is satisfactory, as indicated by the heating professionals they consulted. This helps residents to live in attractive and accessible surroundings. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 7 Ensure the window opening on the entrance floor level has a restricted opening. This is so that residents could not accidentally fall from it. Safe, lockable storage must be obtained for medication that requires refrigeration, preferably a dedicated, lockable medication refrigerator. This is so that residents medication can be kept safely. The registered person is recommended to increase the amount of person centred planning on residents. This is so that staff have information that helps them care for the resident better. Staff applying prescribed creams to residents should ensure this is recorded on the medication administration sheets. This is so that a record is kept of when it has been applied and who by. The registered person is recommended to ensure that staff are reminded about maintaining residents confidentiality in discussions. This is to maintain residents privacy. Adult protection training should be made available to all staff. This is so that all staff know what to do if they suspect abuse. The registered person is recommended to consider a cyclical programme for the replacement of beds. This is so that older beds are replaced in rotation. The registered person is recommended to provide a first aid risk assessment. This is so that a decision can be made on the level of first aid cover needed. 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. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 8 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 Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 9 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): 1, 2, 3, 5, 6 Quality in this outcome area is good. Potential residents receive a full assessment from the home and sufficient information about the home to enable them to decide if it is the right place for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Eclipse Lodge has a statement of purpose and service user guide available to current or potential residents. The guide contains information about services available at the home, as well as a copy of the standard contract for residency. The contract details the fees to be paid, and what the residents can expect to receive in return. It also contains information about the homes complaints procedure. Signed contracts were also available in resident files. Relatives who Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 10 completed questionnaires indicated that they received enough information about the home before making a decision about the suitability of the home. Five files for people living at the home were selected at random on the site visit. These files were inspected to see the process that had been followed before the person had moved into the home. Discussion was also held with the manager, and with a relative concerning how that process had been managed. For each resident who had been recently admitted a full assessment was documented on their file. The assessment covers areas such as physical and mental health, and current needs for example any special equipment required. The assessment would be carried out by the manager or another senior staff member, and usually involves visiting the resident, and discussing their care with current carers, relatives, the resident themselves if they are able to comment, and taking notes of any professional assessments or reports that have been made regarding the persons needs. In some files copies of assessments made by community mental health team members could be seen. Full pre-admission assessments help to ensure that the home knows they are able to meet the potential residents needs before they make a commitment to live there, and also that they are likely to mix well with other residents currently living at Eclipse Lodge. For the resident or their family this helps to ensure that they can be confident the home is aware of all of their needs and can meet them, avoiding another move. Potential residents or their families are also encouraged to visit the home before any decision is made. This allows them to look at the accommodation available, meet staff and current residents. Eclipse lodge does not provide for intermediate care. Intermediate care is a specialised programme of intensive rehabilitation, aimed at returning the resident to their own home. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 11 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, 10 Quality in this outcome area is good. Residents health care needs are being met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five resident files were selected at random, and discussion was held with the manager and staff on duty concerning the actual care delivered to each individual. Files were also cross-referenced to other documentation within the home such as the accident book, to verify these documents were being used appropriately. Each resident has a full care plan, based on an assessment and detailing the support that they need to live their life and how this is to be given. The care plans ensure that the residents needs are regularly reassessed and updated, and that all staff are aware of these changes so they can work consistently in Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 12 supporting the resident. The care plan for one resident who had been admitted to the day before the inspection site visit was only partially completed, as the home wished to get to know them before finalising their plan, but initial assessments completed gave good basic information on their care. Plans also contained risk assessments, which are a way of managing and reducing foreseeable risks. Evidence was seen in the resident files about their healthcare needs, and how these were being met. This included information about the visits of doctors and district nurses, regular blood tests and reviews. Some residents had a need for specialist moving and handling equipment, adjustable beds and pressure relieving mattresses. Discussions with the manager, with staff and a visiting relative indicated that residents health needs are being met very well. During the course of the site visit staff could be seen responding to alterations in residents physical condition rapidly and with consideration. The manager has plans to update all of the resident care plans to better reflect a person centred philosophy, which means plans will be better focused on the needs of the individual resident. This is particularly important where residents are unable to communicate verbally with staff about their wishes. One residents file contained old terminology which the manager immediately agreed to alter. The medication systems in use at the home were seen and discussed with a member of staff who was responsible for administering medication. The home uses a blister pack system which is prepared by the pharmacist. This system makes it easier to check that medication has been given and makes it less likely for mistakes to happen. The home is awaiting the delivery of two new medication trolleys, which will make it much easier to take medication throughout the home to residents. Some staff are waiting to do a medication refresher course. Medication requiring refrigeration is at present stored in a box in the homes general refrigerator. At the time of the inspection site visit this was only eye drops, however recently liquid antibiotics had also been stored there. Staff sign a record for each medication administered, and discussion with the member of staff showed that the administration was done in a safe fashion. Regular blood tests are required for residents who take particular medication, which then leads to a variable prescription dependant on the results. Discussion was held on the signing for creams, which may be kept in the residents room and therefore not administered by the person giving out and signing for the rest of the medication. The supplying pharmacist completed an inspection of the medication storage and administration systems in September 2006. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 13 In the interactions witnessed staff were careful to respect residents privacy and dignity, however some verbal discussions between staff could have been overheard by other residents. Residents themselves would not have been able to make statements on their privy or dignity being maintained which makes it significantly more important that staff take responsibility for this happening. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 14 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, 15 Quality in this outcome area is good. Eclipse Lodge has a full activities programme for residents. Meals served are of a high quality. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Eclipse Lodge has a member of staff dedicated to providing activities during both the morning and the afternoon. During one of the site visits, time was spent sitting in one of these activities which demonstrated the high level of commitment required to keep people motivated and maintaining an interest. The process of gathering life history information on service users has already begun at the home and the manager could outline several instances where particular items or activities had been arranged for individual residents to meet their pre-existing hobbies and interests. The home also has a current exhibition on local history in the dining room and period items of everyday use Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 15 on display that could promote interest and conversation. Discussion was also held on the development of activities for those residents who are very frail, which is supported by the homes activities provider. During the second site visit it was a member of staffs birthday and all of the residents participated in a party. This shows the sense of community within the home. During the site visit a period of two hours was spent sitting in the lounge/dining room area observing interactions and the behaviours of residents. This period of observation demonstrated that residents were aware of their environment, and showed signs of well-being. Staff interactions seen were overwhelmingly positive and enhancing for residents. Eclipse Lodge has a locked door policy, which is detailed in the resident guide and statement of purpose. This reduces choices from residents and restricts their lives. It is understood that this is to preserve the safety of the resident group, all of whom suffer from some degree of memory loss from moderate to very severe. Other choices are encouraged in day to day life to the extent of the resident capabilities. This may mean small choices, such as where they sit, what they choose to eat etc. Visitors are encouraged to the home and discussions were held concerning the role they can play in supporting on going care for residents. The manager is hoping to start a relative support group in the near future and one family had prepared a book of photographs of residents family with relationships identified to support the resident in maintaining their memory as well as retaining contacts. The meals served to residents were of a good quality, including home made cakes and fresh fruit and vegetables. The meal being served on the day of the first site visit was Roast beef and fresh vegetables with sponge and custard or semolina for dessert. Some residents were still eating their breakfast late in the morning as they had risen later. Two resident were given an alternative meal choice as they did not want the main meal on offer, and several residents had their meal liquidised or softened as they had swallowing difficulties. This demonstrates that residents meal choices and needs were being respected. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 16 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, 18 Quality in this outcome area is good. The home has a complaints procedure and adult protection policies help to protect residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Eclipse Lodge has a clear complaints procedure that is available in the resident guide and in the hallway of the home. The procedure spells out how to make a complaint and that the home will investigate all concerns raised. The name of the manager will need amending when a new manager is registered, as the procedure on display still has the old managers name as a point of contact. Residents relatives who completed questionnaires indicated that they were clear about who they would go to if they were concerned about something at the home or wished to make a complaint, and this was backed up in discussions. Most of the residents would find it difficult to make a formal complaint, which makes it very important that staff are aware of clues other than verbal that indicate that a resident may be unhappy about something. The staff at Eclipse Lodge have received training in the protection of vulnerable adults, and questionnaires completed by staff indicated that they were aware of an Adult protection policy and would know what to do if they saw something happening that they knew was wrong or abusive. This training will need to be refreshed for new staff. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 17 Discussion was held with the manager on the complaint that was received by the home during last year. This complaint was managed successfully within the home, and in accordance with the homes complaints procedure. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 18 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, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is good. Eclipse Lodge provides a comfortable environment for residents to live in. Minor attention was required to some bathrooms and maintenance issues. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Eclipse Lodge offers a variety of accommodation for residents over three floors with several spacious communal areas, including three lounge areas and a large dining room. Rooms vary in size and shape, including some suitable for shared accommodation. Rooms in the newer accommodation are larger, with en suite facilities. In the older part of the building some rooms are smaller but may Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 19 have high ceilings and period features. Adapted bathing facilities are provided, including the use of bath hoists where needed. There is no shaft lift. All areas of the home seen on this inspection were clean and free from serious odour. The home has air freshening devices, carpet cleaning equipment and rooms are naturally ventilated whenever possible. Staff practices and continence aids minimise any odour problems so that residents can live in a pleasant and hygienic environment as far as possible. Some of the older areas of the home would benefit from décor and furnishings being refreshed, and discussion was held with the manager on a programme of refurbishment, including the ongoing replacement of older style beds. All service areas seen were clean and tidy, with attention paid to hygiene and safety. Windows above the lower ground floor have restricted openings to protect residents from accidentally falling from them however one in the entrance hallway needed to be adjusted. Water temperature to baths and wash hand basins is restricted so that residents cannot be scalded and radiators are protected so that they cannot accidentally come into prolonged contact with a hot surface. Water tested in one room took a very long time to become warm and the manager agreed to examine this. Discussion was also held on the cleaning of commode pans and the replacement of a clinical waste bin, which had no lid and was presenting an infection risk. A bath panel also needed replacement or repair. The home has a hairdressing room, and at present has a limited number of residents who attend for day care. Some bathrooms require renovation, some toilets are heated by water pipes running through which act as heating, and few toilets are accessible for people with a severe disability, for example wheelchair users. One resident has been able to bring their dog into the home with them and another has a cat. This has obviously been a comfort to them and is good practice wherever possible. Staff receive training in Infection control, and information is available for reference. Equipment such as aprons and gloves is available and antibacterial soap sprays are available in toilet areas. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 20 Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 21 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, 30 Quality in this outcome area is good. The staffing arrangements are satisfactory. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the site visit six staff files were selected at random to be inspected. The files contained evidence of the recruitment process followed when new staff are being appointed. Files seen showed that a full recruitment process is followed, with staff completing application forms, providing references and undertaking a criminal records bureau check. This should help to protect residents from being cared for by people who are unsuitable to work with vulnerable adults. Discussion was held on the induction process followed for new staff. This was available in some files, however not detailed in all. The owner later stated that Induction booklets are available for all staff. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 22 The staff seen on the inspection were very caring and committed to the residents they were looking after. They had a good understanding of the needs of older people with dementia and have received training to support them in doing their job. Recent training at the home has included training in dementia and a person centred approach to care, falls prevention, understanding loss and bereavement, food hygiene, first aid, fire training medication training, and continence training. Further training is planned in moving and handling, eye care, caring for confusion and activities and reminiscence. Discussion was held with two members of staff about National vocational qualifications that they are currently taking and may wish to take in the future. National vocational qualifications are a nationally recognised award recognising the level of skill and competency of a member of staff in their work role. Discussion was held with the manager on the number of staff on duty. The manager has recently increased the staffing in the early evening as a result of discussions with staff and a review of the tasks needing to be done at that time. The manager has the authority to bring in additional staff at times of extra pressure, and has managed to not have to employee agency staff to cover shifts, as staff are willing to work additional hours if needed. Some staff have flexible job roles which means that they are able to support care staff from time to time if there is a need. Other dedicated domestic staff are also employed, including cleaning and catering staff. Throughout the day staff were clearly busy, however no residents were rushed whilst carrying out tasks. Risk assessments are available for working practices including a pregnancy risk assessment, to ensure that staff can safely carry out their work. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 23 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, 38 Quality in this outcome area is good. The home is being well-managed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the registered manager has left, and a new manager is in post. An application will need to be made for her to be registered. Being registered means she takes on legal responsibility for the day-to-day running of the home. She is an experienced and qualified nurse, with many positive ideas for future developments of the home. The home has a quality assurance system in place involving a series of questionnaires which are sent out to residents relatives, visiting professionals Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 24 and other interested stakeholders. The results of the questionnaires are then collated to form a report and inform an action plan. At the time of the inspection site visit the home was midway through a quality assurance cycle, having circulated questionnaires but not completed the final analysis of the responses. Responses seen so far were positive and gave useful feedback on the operation of the home. The manager is implementing a system for staff supervision. Supervision is a process whereby an individual member of staff has a regular meeting with their manager to review the performance, any training needs and any additional support they need for carrying out their work. It should help ensure that staff are working to their maximum potential and in a consistent fashion to support residents. An examination was made of the systems for the management of small amounts of resident money. This money would be held for example when a decision has been made that the service user is not able to manage their own money in safety. Amounts for other than day to day expenditure are managed outside of the home by relatives or through formal proceedings such as the Court of protection. A small float is held individually for a number of residents at the home, and this is used for individual day-to-day expenditure on behalf of residents for example for hairdressing or chiropody. Receipts and small amounts of cash are kept in individual containers. Three of these were selected at random and found to balance with the recorded balance held. This indicates residents money handed over in trust is being well-managed. Discussion was held with the manager on health and safety issues for the home. There is a range of risk assessments for the environment and working practices, and the manager completes a regular environmental audit and spot check for such areas as medication management. A legionella test report was completed in November 2006 and the home completes regular tests of the fire alarm system, which were recorded in the fire log book. Information sheets were available to detail precautions to be taken for chemicals and cleaning materials in use, and there is regular servicing of boilers, and hoisting equipment. Staff receive training in basic first aid precautions. There was however no first-aid risk assessment. Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 25 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 3 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 4 3 3 3 3 3 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 2 x 3 x 3 x x 3 Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 26 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 OP31 Regulation 8 Requirement Timescale for action 28/02/07 2. OP19 23 (2) (c) (d) (f) (p) The responsible individual must ensure an application is made for a person to be the registered manager. The registered person shall, 28/04/07 having regard to the number and needs of the service users ensure thatAll parts of the home are kept clean and reasonably decorated. The size and layout of rooms occupied or used by service users are suitable for their needs; Ventilation, heating and lighting suitable for service users is provided in all parts of the care home which are used by service users. (Redecorate/refresh the toilets and bathrooms identified, monitor heating to these areas and ensure that toilets are accessible for the needs of service users with disabilities. This includes the repair of the broken bath panel and replacement of the clinical waste bin on one bathroom as identified.) DS0000018350.V319666.R02.S.doc Version 5.2 Eclipse Lodge Page 27 3. OP19 13 (4) (a) 4. OP9 13 The registered person shall 28/04/07 ensure that – all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. (Ensure the window opening on the entrance floor level has a restricted opening.) The registered person shall make 28/02/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. (Safe, lockable storage must be obtained for medication that requires refrigeration, preferably a dedicated, lockable medication refrigerator.) 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 3 4. 5 6 Refer to Standard OP7 OP11 OP9 OP10 OP18 OP19 OP38 Good Practice Recommendations The registered person is recommended to Increase the amount of person centred planning Staff applying prescribed creams to residents should ensure this is recorded on the medication administration sheets. The registered person is recommended to ensure that staff are reminded about maintaining service user confidentiality in discussions. Adult protection training should be made available to all staff. The registered person is recommended to consider a cyclical programme for the replacement of beds. The registered person is recommended to provide a first aid risk assessment. DS0000018350.V319666.R02.S.doc Version 5.2 Page 28 Eclipse Lodge Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Eclipse Lodge DS0000018350.V319666.R02.S.doc Version 5.2 Page 30 - 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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