Inspection on 03/10/07 for Eclipse Lodge

This inspection was carried out on 3rd October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eclipse Lodge 20/11/08

Eclipse Lodge 24/01/07

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 07:30 3 October 2007 rd 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.V346036.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. Eclipse Lodge DS0000018350.V346036.R01.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 Vacant 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.V346036.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th and 25th January 2007 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, and a new stair lift has been fitted to the top floor . There are a few steps down into the lower floor communal areas. There is a pleasant secluded garden and a sizeable car parking area, and residents are able to access outside areas fairly securely. Fees range between £350 to £400 per week dependant on needs. Information on the homes previous inspection reports is available on request within the home. Eclipse Lodge DS0000018350.V346036.R01.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 an application was awaited from the care manager, who has now had to leave for personal reasons. A new manager is being sought. 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; A site visits of 9.5 hours was 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. 13 relatives and 5 members of staff completed and returned questionnaires. This approach hopes to gather as much information about what the experience of living at the home is really like, and make sure that people’s experience of the home form the basis of this report. This is especially important when, as at Eclipse Lodge, most people living at the home suffer from moderate to severe memory loss. The site visit was timed to start at 7:30 am to see the night staff handing over to the day staff and look at how staff organise their work for the day. What the service does well: Eclipse lodge offers a good standard of care for people 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 Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 6 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 has an excellent 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. Residents are able to bring their pets into the home with them, following negotiation and agreement with the management. 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. There is an active relative support group and “Friends of Eclipse lodge”. This will help relatives feel better involved in the operation of the home. The home has had an exhibition of local history and photographs and has objects from past times on display. This helps to provide stimulation and interest for residents and can be used to start conversations and activities. A collection of dolls has also been built up, which has involved the local community and press in making donations. People living at the home have found comfort and interest from these dolls and will continue to do so when the collection has been housed in a new display. A counsellor is available to help staff caring for people with dementia or for relatives who are having difficulties in accepting their relatives condition. This is available to people at no cost to them and is an excellent support service which is commendable. The home produces a newsletter telling relatives what is going on at the home and of any developments. This helps people feel in touch even if they are not living near to the home. Comments from people who completed questionnaires included “The staff are very good at their job and are very attentive to my mothers needs and help her in any way”. What has improved since the last inspection? A new wet room has been provided, which means that people living at the home can be showered more easily. The owner has confirmed that adequate heating is provided to the toilets. This helps residents to live in attractive and comfortable surroundings. Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 7 The window on the entrance floor corridor has had a restrictor fitted. This is so that people could not accidentally fall from it. Safe, lockable storage has been obtained for medication that requires refrigeration. This is so that peoples medication can be kept safely. Two new medication trolleys have been provided which helps staff to administer medication to people more easily. The manager has commenced gathering information about people’s histories and the lives they have lived before coming into the home. This is so that staff have information that helps them care for the person better. Staff have been reminded about maintaining residents confidentiality in discussions, and no areas of concern were seen on this visit. This helps to maintain peoples privacy. Adult protection training should is being made available to all staff. This is so that all staff know what to do if they suspect abuse. Some new beds have been obtained. An administrator and new handyman have been employed which helps to ensure that routine tasks are kept up with and some of the responsibility for paperwork is taken from the manager. What they could do better: The responsible individual must register a manager. This is so that there is a person who is legally responsible for the day to day running of the home. The owner and manager must ensure that all parts of the home are kept clean and reasonably decorated. This applies in particular to areas where there is poor odour control, so that people can live in comfortable and attractive surroundings. The position regarding day-care must be discussed with CSCI and appropriate staffing provided to ensure that people living at the home are not disadvantaged by day care clients coming into the home. Staff applying prescribed creams to residents should ensure this is recorded on the medication administration sheets. This is so that everyone is clear that the cream has been used as prescribed. Adult protection training should be made available to all staff. This is so that all staff are clear about what to do if they suspect abuse. Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 8 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.V346036.R01.S.doc Version 5.2 Page 9 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.V346036.R01.S.doc Version 5.2 Page 10 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. People thinking about moving into the home receive a full assessment, 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 containing information about services available at the home, as well as a copy of the standard contract or terms and conditions of residency. This helps people to make a decision about whether the home is the right place for them. The contract details the fees to be paid, and what people can expect to receive in return. It also contains information about the homes complaints procedure. Relatives who completed questionnaires indicated that they always or usually received enough information about the home to help them make decisions about the home and it’s suitability to meet their relatives needs. Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 11 Four files for people living at the home were selected at random on the site visit. These files were inspected, and discussions were held with the manager about how people had come to live at the home, where known to her. Discussion was also held on the last two people admitted to the home and how the home had been able to make sure they could meet that persons needs. Full pre-admission assessments help to ensure that the home knows they are able to meet the persons 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 person 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. One person had been very recently admitted to the home and the night staff seen confirmed in the handover how they had helped that person to settle. For one person 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. Assessments are carried out by the manager or another senior staff member, and would usually involve visiting the person, and discussing their care with current carers, relatives, and the person themselves wherever possible. In another recent admission which had been completed in a hurry the home had to rely on an assessment carried out by professionals involved with the persons care and an assessment from Social services. Once the person had moved to the home the manager had completed a full assessment to make sure that staff had information available to explain the persons needs and how they were to be met. People and their families are also encouraged to visit the home before any decision is made about admission. This allows them to look at the accommodation available, meet staff and other people living there. 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.V346036.R01.S.doc Version 5.2 Page 12 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. People’s healthcare needs were being met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Files for four people living at the home were selected to reflect a range of need. Discussions were then held with the manager and staff on duty concerning the actual care delivered to each individual. Files were also crossreferenced to other documentation within the home such as the accident book, to verify these documents were being used appropriately. Discussions with three staff members showed they had a clear understanding of the care needs of the people they were looking after, and the way they explained their work showed they were consistent in the way they were looking after them. The morning handover showed staff were organised to work with specific people each day and that these were also rotated regularly. Staff explained that this allocation meant that people were clear about who they Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 13 were caring for on that day and so they could plan how to get them up in a way that met their preferences. For example some might like to get up early, while others might like to lie in for a while and so be seen to later. One person was allocated to bathe those people who were due a bath that day. Each person living at the home 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. Care plans ensure that people’s needs are regularly reassessed and updated, and that all staff are aware of these changes so they can work consistently in supporting them. Plans also contained risk assessments, which are a way of managing and reducing foreseeable risks, for example people falling. Evidence was seen in people’s 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 people had a need for specialist moving and handling equipment, adjustable beds and pressure relieving mattresses. Discussions with the manager and staff indicated that peoples health needs are being met well. The manager has started working on increasing the amount of personal information about people living at the home in their files. This includes information on how they have spent their lives, information about their hobbies and interests, pets they have owned and their families. This helps staff to better understand people living at the home, particularly where people are no longer able to communicate that information themselves. The medication systems in use at the home were seen and discussed with the manager. 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 has two new medication trolleys, which will make it much easier to take medication throughout the home to residents. Staff sign a record for each medication administered, and discussion with the manager 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. Some entries were not signed. One relative who completed a questionnaire felt their relative would benefit from more baths being given to their relative as they felt that sometimes she did not look clean. Another said “Considering mums needs they look after her in every area very well.” Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 14 Since the last inspection the homes management have re-organised the home so that the more able people are catered for on the middle and upper floor of the home with people with severe disabilities on the lower ground floor. This means that they have better been able to target activities and care to those who need differing types of support. A counsellor has been provided by the home to support staff or relatives who have found difficulties in caring for the client group or accepting their relative has a deteriorating disease. This has been an excellent development. Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 15 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. This goes on until just before tea time, as the home has found people with Dementia often get anxious or wander around 4pm. People engaged in the activities which included games in one lounge, cards in another and singing in a third area, were seen to be enjoying themselves and actively engaged with the staff. The home also has had an exhibition on local history and has period items of everyday use on display that could promote interest and conversation. The home also has a collection of period dolls, donated by the public, that are used for people with Dementia for reminiscence, to provide an interest or comfort. Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 16 Eclipse Lodge has locked external doors, 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. The home manager should examine this policy in the light of recent changes to legislation. Other choices are encouraged in day to day life to the extent of the resident capabilities. The home has also tried to make activities available that meet the needs of people of both genders. Visitors are encouraged to the home and discussions were held concerning the role they can play in supporting care for their relatives. People were seen coming and going throughout the day of the inspection site visit, and some spoke to all the people in the rooms they passed through not just the people they had come to see. A relative who completed a questionnaire said the home updated them weekly on their relatives wellbeing, while another said that the home did not keep them in touch with their relatives condition as regularly as they would like. People have access to religious services and there is a monthly in house church service. The meals served to residents were of a good quality, including home made cakes and fresh fruit and vegetables. Several residents had their meal liquidised or softened as they had swallowing difficulties, which was documented in their care files. Discussion was held on several people who have lost weight through the last year and on steps the home can take to minimise this A relative who completed a questionnaire said that “Eclipse lodge really does try to involve residents in all activities ……. and as we visit different times and days something always seems to be going on for them there”. Another expressed concerns that on a day they had visited there was an inappropriate programme on the television. Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 17 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. Good systems are in place for the management of complaints and protection of adults 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. Most peoples 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. One said “I have no need to complain, but if I had I should go to the manager of the home and try to solve any problems”. One other said they did not know how to complain and another said that they had tried to make contact with the owner or manager for several days and had left messages but had not been contacted back. The manager usually sets aside Wednesday mornings to make herself available to anyone wishing to see or call her, but this may have been disrupted recently. Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 18 Most of the people living at the home 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.V346036.R01.S.doc Version 5.2 Page 19 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 adequate. There are odour control problems at the home, and some areas require deep cleaning to ensure people are not subject to cross infection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour was made of all areas of the home during the site visit. In the last year efforts have been made to improve the furnishings and décor at the home which improves the environment for people to live in. Further work is continuing and the manager and owner have a plan of work to be implemented in the coming year. However some of the accommodation does not reflect the very good care that is actually being delivered to people. The home is situated in a residential area of Torquay, close to shops and local facilities. There are gardens to the side of the home which are enclosed and Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 20 there are seating areas where people can spend time outside in safety. There is some parking, and good on street parking close by. Eclipse lodge is an old period villa, which offers high ceilings and period features to some of the rooms. Rooms vary considerably in size from those that are spacious with en-suite facilities to those much smaller, some of which are purpose built. A new chairlift has been fitted since the last inspection to enable better access to the top floor. This meant that a staircase had to be widened to accommodate this development. There are few specific environmental adaptations to suit people with Dementia and some of these were discussed with the manager on the site visit. These might for example include certain colours for particular areas. Discussions were also held about the re-siting of the lower ground floor seating area to an area with more natural light. Peoples bedrooms showed evidence of personal belongings and interests including photographs of family and friends. Some had evidence of specialist beds to support people with moving and handling needs. Hoists are available to help ensure people are transferred safely and the home has some adapted bathing facilities. Discussion was held on an in bath hoist which needed immediate cleaning to ensure that people were not being left open to cross infection. Safe storage is available for used continence aids and clinical waste until it is collected by a specialist disposal company. Many people who completed questionnaires commented upon an odour at the home. Some commented they felt this was a urine odour. During the site visit a tour was made of all areas of the home with the manager and particular problem areas were identified. There have been cleaning staff difficulties at the home for the last few months which clearly have not helped the situation, however new staff have now been recruited. No cleaning staff are employed on a Sunday and discussion was also held with the manager on this. During the course of the day staff were seen responding appropriately to an incident of incontinence and the people living at the home are supplied with continence aids appropriate to their needs. The home has air freshening devices and has a carpet cleaner, urine neutralising sprays and specialist carpet shampoo. The handyman deep cleans a room every week, including washing the walls and all paintwork and cleaning the carpets. Advice is taken from the nurse continence advisor. The homes laundry is situated at the rear of the home and discussion was held with the manager on making sure there is a clear separation of clean and dirty laundry. Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 21 Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 22 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. Staffing arrangements are generally satisfactory, however some attention is required to staffing levels to make sure people receive the care they need and the building can be kept clean. Staff recruitment procedures must protect people robustly. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion was held with 3 members of staff, five staff members completed questionnaires and discussions were held with the manager about the staffing arrangements at the home. In addition three staff files were looked at, including details of their recruitment, training and supervision and staff rotas were seen. Examination of the homes rota and discussions with management indicated a staffing level for the home which seemed at a low level for the number and current dependency level of the people living at the home. In addition to the people living at the home, the home takes in people for day care, sometimes up to 9 a day and no additional staffing appears to be provided for this group, which leaves the home short of staff. People who completed questionnaires, both staff and relatives felt the home was short of staff at times. One wrote “Staffing levels on occasions are very low” Another said “I feel that the service Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 23 cares for the residents well, that they make sure that they are all looked after and get the care they need and deserve, even when they are short staffed”. Staff seen during the site visit were well organised and clear about the duties they were to do and the people they were caring for on that day. The home has been short of cleaning staff but this is due to be remedied shortly and the manager confirmed that hours have been covered wherever possible by care staff cleaning. Three staff files were selected for inspection on the site visit. The files contained information on the way in which staff were recruited. Not all files seen contained two written references, although the manager said that she always obtains a verbal reference as well as applying for those in writing, and was sure these had been obtained. People have access to the general social care council code of conduct which sets standards of professional conduct and behaviour for care staff. Criminal records bureau checks are carried out, which should help to protect people living at the home from being cared for by staff who are unsuitable to work with vulnerable people. Staff files contained information on qualifications and the training staff have received, including induction and foundation training. The home has a plan for future training to be delivered, including further training for all staff on Dementia. Staff spoken to were knowledgeable about the people they were caring for, and were praised by relatives for their caring skills. Supervision is provided for staff on a regular basis and those having particular difficulties have access to the homes counsellor for private support outside of the homes management structure. Supervision is a system that combines performance management and personal development for staff and should ensure that they are working to their full potential in caring for the people at the home. A relative wrote “XX has been at Eclipse Lodge for nearly six years and they have always cared for her very well. The staff are excellent.” Another wrote in their questionnaire it was good to take the chance “To thank the staff who are involved – I know they work very hard all the time.” Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 24 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: The manager in post has not been registered and is now sadly having to leave due to personal reasons. She has instituted a significant number of improvements and initiatives since being at the home. One relative wrote the home has “improved a great deal since Jan Jenkins took over as manager.” A replacement is being sought. Eclipse lodge has a quality assurance system with a series of questionnaires having been sent out to relatives and visiting professionals. Results from these Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 25 are being collated and action taken as a result of comments. The manager could outlines changes that have been made as a consequence of the feedback received. The manager and owner have many plans for the development of the home. One of these detailed in the homes Annual quality assurance assessment was for restaurant evenings, where families can come and enjoy a “meal out” with their family within the home. The home would be adapted to a restaurant setting with menus and staff as waitresses. The homes administrator manages a system for personal allowances and small amounts of peoples money handed over for safe keeping. This series of floats for people means that they can pay for small items such as hairdressing and chiropody bills. The system was checked for two people at random and found to balance with the running accounts and receipts held. Health and safety issues were also looked at during the sit visit. The homes handyman deals with the fire tests, which were all being completed appropriately. Maintenance contracts were seen for servicing of lifts and hoists and for the removal of clinical waste. All taps were said to have automatic regulators fitted, which helps to ensure that people cannot be scalded by coming into contact with very hot water. The water system is regularly tested for bacteria that may cause diseases. Portable appliances are tested for electrical safety and the environmental health officer visited in January 2007, making some requirements which the manager said have been actioned. Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 26 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 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 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 Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 27 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 OP31 OP19 Regulation 8 23 (2) (c) (d) (f)(p) Requirement The responsible individual must employ and register a manager. Timescale for action 31/01/08 The registered person shall, 30/11/07 having regard to the number and needs of the service users ensure thatAll parts of the home are kept clean and reasonably decorated. This applies in particular to areas where there is poor odour control. The position regarding day-care 30/11/07 must be discussed with CSCI and appropriate staffing provided to ensure that people living at the home are not disadvantaged by day care clients coming into the home. 3. OP27 18, 12 Eclipse Lodge DS0000018350.V346036.R01.S.doc Version 5.2 Page 28 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 OP9 Good Practice Recommendations Staff applying prescribed creams to residents should ensure this is recorded on the medication administration sheets. Adult protection training should be made available to all staff. 2 OP18 Eclipse Lodge DS0000018350.V346036.R01.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. 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