CARE HOMES FOR OLDER PEOPLE
Eclipse Lodge Rawlyn Road Torquay Devon TQ2 6PQ Lead Inspector
Mark Sharman Unannounced Inspection 27th January 2006 12:00 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 Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 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 SUEW21@HOTMAIL.COM Crocus Care Limited Mrs Susan Mary Wright 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.V262955.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30/08/05 Brief Description of the Service: Eclipse Lodge is a detached building in a residential area, 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. There is a sophisticated call system and a range of other disability equipment. This includes stair lifts, assisted baths, mobile hoists, raised toilet seats, toilet frames and grab handles. The building was not purpose-built as a care home, and the residents’ bedrooms are located over three floors. The top floor is not provided with a stair lift, and there are a few steps down into the dining area. There is a pleasant secluded garden which residents can access fairly safely, and there is a sizeable car parking area. Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection and a little over five hours were spent at the home. Time was spent with the registered manager and with one of the company’s directors. Several of the residents were spoken with (although all are quite confused) as well as five of the staff, and a sample of the care records was examined. All of the communal parts of the home were seen plus many of the bedrooms. What the service does well: What has improved since the last inspection?
At the last inspection an unpleasant odour was detectable in two of the bedrooms, but this was not noticeable on this occasion. Some of the bedrooms on the top floor are being redecorated at present, which will create a fresher environment for any resident accommodated there. A recommendation was made at the last inspection that staffing levels should be reviewed for the tea-time period and early evening because of the pressure
Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 Page 6 on staff at that time. This was done and an extra staff member is now on duty between 4.00 pm and 6.00 pm. 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. Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 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 Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 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): None of these Standards was considered on this occasion. EVIDENCE: Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 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, 9 and 10. The residents’ health care and social care needs are set out in individual care plans, and residents are treated with respect. There is a satisfactory system for handling their medication. EVIDENCE: A small sample of the residents’ individual care plans was inspected. These described actions to be taken by staff to ensure that their health care and social care needs are met. There were written assessments of need, which included a mobility assessment. The care plans examined had been reviewed recently, although not every month since the last inspection (which is recommended). Residents are not capable of self-medicating safely, and their medication is kept in secure storage. A sample of the medication administration recording sheets was examined. The supplying pharmacist’s last report (18/7/05) was satisfactory. Most of the residents were unable to express an opinion as to the standard of their care, but they appeared contented and they looked well presented and cared for. Certainly they were treated in a respectful and caring way by the
Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 Page 10 staff on duty. Apart from a married couple, only two residents share a bedroom and screening is used in that room for their privacy. There are two telephones in communal areas for residents’ use, and a cordless telephone is also available if greater privacy is needed. Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 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 and 15. Residents receive some appropriate stimulation and entertainment, although this has been reduced lately. The catering arrangements are satisfactory. EVIDENCE: All of the residents are confused and many are unable to initiate activities for themselves, and so it is important that they are given stimulation. Two ladies are employed part-time to provide suitable activities. One of them principally does this for individual residents on a paying basis, and the other runs activities on weekday afternoons. However her duties have been altered and she now runs activities for only an hour each afternoon. Accordingly the stimulation provided for residents in a planned way has been reduced, although all of the staff do try to spend some time with individual residents (which was apparent during the inspection). A professionally run weekly exercise session no longer takes place. Music is played frequently and musical films are shown, and a professional musician is employed to entertain residents each month (very popular). The lunch on the day of the inspection looked appetising and the residents enjoyed it. The staff helped those who could not feed themselves, in a patient and dignified way. The kitchen was clean and orderly. Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. Complaints will be listened to and taken seriously. EVIDENCE: The home has an appropriate complaint policy, a copy of which was on display. In addition there is a feedback form available to complainants to comment on how well their complaint was handled. In practice it is more likely that a relative rather than a resident would make any formal complaint, in view of the residents’ degree of confusion. No complaint has been made to the Commission for Social Care Inspection since the last inspection. Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 and 26. Residents are provided with comfortable accommodation, including substantial communal spaces. The home was clean and warm. EVIDENCE: There are several spacious communal areas, including three lounge areas and a large dining room. The amount of space is well in excess of that required by the Standard, and the variety of areas available would allow for different activities to take place at the same time. All parts of the home which were seen at this inspection were very clean, including bathrooms and toilets. The kitchen was also left very clean when the cook went off duty. There are liquid (spray) soap dispensers and paper towels in the bedrooms and toilets, thus helping to control cross infection. The laundry is well equipped with commercial washing machines and dryers, and both washing machines have a sluicing function. It was pointed out to the responsible individual (company director) that the main lounge and adjoining hallway are now looking a little shabby and in need of redecoration.
Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 Page 14 Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 29. The staffing arrangements are adequate for the current residents. The staff are competent and caring, and recruitment practice in respect of new staff is generally satisfactory. EVIDENCE: This was an unannounced inspection and the number of staff on duty was sufficient to meet the needs of current residents. The staff spoken with felt that the staffing levels maintained are sufficient. At lunch time the more dependent residents received the help they needed with their meal, and following the last inspection one extra staff member is available to help at tea time. The staff on duty took care to speak to residents and interact with them as part of their normal duties. The staff group is stable and there has been little staff turnover recently, which has contributed to continuity of care for the residents. The manager said that at present the 50 NVQ level 2 training target is met, but the staff’s certificates were not checked on this occasion. Generally the recruitment practice for new staff was found to be satisfactory, and a sample of Criminal Records Bureau disclosures and written references was inspected. However Criminal Records Bureau disclosures must also be applied for in respect of foreign nationals working in a care home, which had not been done in the case of two staff employed here. (The manager had not been aware of this requirement.) Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31. The manager is well experienced with this client group and has a responsible, caring attitude. EVIDENCE: The registered manager is a qualified nurse (RGN currently registered) with substantial care home management experience, and is working towards the registered manager award at present. When she has completed this award this Standard should be fully met. Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x x 4 x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x x x x x Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 Page 18 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 OP38 OP29 Regulation 13 19 Requirement The window openings in bedrooms 22, 23 and 24 must be restricted to about six inches. A Criminal Records Bureau disclosure must be obtained in respect of any foreign national employed to work in the home. A report must be sent to the Commission for Social Care Inspection following a monthly (at least) visit to the home by a representative of the company, who is not directly concerned with the conduct of the home. The vanity unit in room 8 must be replaced. Timescale for action 28/02/06 31/01/06 3. OP33 26 28/02/06 4. OP19 23 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 23 Good Practice Recommendations The main lounge and adjoining hallway should be redecorated.
DS0000018350.V262955.R01.S.doc Version 5.1 Page 19 Eclipse Lodge Eclipse Lodge DS0000018350.V262955.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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