Inspection on 18/05/05 for Egerton Lodge Care Home

This inspection was carried out on 18th May 2005.

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

Egerton Lodge Care Home 30/01/07

Egerton Lodge Care Home 02/11/05

Egerton Lodge Care Home 21/12/04

Egerton Lodge Care Home 20/07/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Egerton Lodge Wilton Road Melton Mowbray Leicestershire LE13 0UJ Lead Inspector Ruth Wood Unannounced 18 May 2005 09:30 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 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. Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Egerton Lodge Address Wilton Road Melton Mowbray Leicestershire LE13 0UJ 01664 410202 01664 482124 egertonlodge@hotmail.com Egerton Lodge Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Joyce Wells Care Home 46 Category(ies) of DE (E) Dementia - over 65 (12) registration, with number MD(E) Mental Disorder - over 65 (3) of places OP Old Age (46) PD (E) Physical disability - over 65 (10) Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Named resident No-one falling within category PD(E) may be admitted into the home when there are 5 service users of category PD(E) already accommodated within the home. No-one falling within category DE(E) may be admitted into the home when there are 10 service users of category DE(E) already accommodated within the home. No-one falling within category MD(E) may be admitted into the home when there are 3 service users of category MD(E) already accommodated within the home. Date of last inspection 21/12/2004 Brief Description of the Service: Egerton Lodge provides a service for forty-six older people including those with dementia, mental disorder and physical disability. The home is located in the centre of Melton Mowbray and its facilities alongside Egerton Park. This affords some rooms views across the river. Residents rooms are located over three floors, including the ground floor and are accessible by shaft lift and stairs. All of the rooms have en-suite facilities. There are two lounges and a dining room on the ground floor and a large hallway which also has comfortable seating. On the first floor there is a further lounge/dining room. The home is well furnished and decorated to a high standard. Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection took place on a weekday between 10.30am and 5pm. Planning for the inspection took approximately one hour and included reviewing previous reports, letters and notifications of significant events. The inspection included direct and indirect observation of care practice, examination of records and discussion with managers. Discussion was also held with one relative, six residents, four staff members and a volunteer visitor. What the service does well: What has improved since the last inspection? What they could do better: The home should inform the Commission when work required by the fire officer has been completed. Materials were in place for this on the day of the Inspection. The home should ensure that it has proof of each staff member’s identity by keeping a copy of their birth certificate or passport on file. The home must also remember to inform the Commission of all events that adversely affect the well-being of residents. Finally staff members should be reminded to fully date all entries in daily records to include the year as well as the day and month. Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 Page 6 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. Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 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 standard(s) 3,4,5 Residents’ needs are effectively assessed and well met. Arrangements for trial visits are very flexible and allow residents and their families to get to know the home. EVIDENCE: Full assessments of need were on file for all residents whose files were examined (5). Social workers’ assessments of need were also in place for those residents placed by the local authority. Observation of care practices such as moving and handling and communication with residents with a hearing loss indicated that staff were meeting assessed needs effectively. Staff also displayed a good understanding of residents’ needs during discussion. Residents and/ or their families had made visits, sometimes several, prior to moving in to the home. This was confirmed through discussion with residents and staff and reading residents’ care files. Some residents have previously attended the home for day care. Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 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 standard(s) 7,8,9,10 Care plans are comprehensive and effectively managed. Residents’ health care needs are well met and medication is well managed within the home. Residents are consistently treated with respect and their right to privacy is upheld. EVIDENCE: The five care plans examined covered a wide range of need in detail and there was evidence of monthly review. Staff must remember to fully date (including year) all daily records. Staff demonstrated a good understanding of the information in care plans and plans reflected observed care needs. There was documentary evidence that residents received regular optical, chiropody and dental services and this was confirmed through discussion with staff and residents. District nurses visited some residents during the inspection in the privacy of their own rooms and residents said that if they needed a doctor, staff arranged this quickly. The lunchtime drug round was observed; a senior carer with accredited training conducted this. All medication was stored and administered appropriately. Staff were observed to treat residents with respect, to speak to them appropriately and to knock and wait for a response before entering bedrooms. Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 Page 10 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 standard(s) 12,13,15 The home offers an excellent activities programme which very effectively meets residents’ social, cultural and recreational interests. The home maintains very good links with residents’ relatives and the wider local community. Residents are served good, nutritious food in pleasant surroundings. EVIDENCE: Four dedicated activities workers were on site during the inspection including the Activities organiser. Documentary evidence was seen of the regular meetings of this team together with consultation with residents as to their particular interests. Residents are kept regularly informed as to what is taking place. One relative commented, “There are always activities going on, they don’t just sit here doing nothing – they’re really stimulated.” Activities directly observed were flower arranging, craftwork and scrabble. Other activities include carpet bowls (this is competitive and prizes are awarded), bingo and quizzes (again competitive). There are sufficient staff available to allow one to one work with residents with dementia, and staff demonstrated a good understanding of different residents’ needs. A tea dance was held at the home the weekend prior to the inspection and many residents told the inspector how much they had enjoyed this. Relatives were also free to join this event; one relative said they could pop in at any time and were always made welcome. Staff support residents to access local services such as Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 Page 11 the local pub and shops. Several residents regularly visit the local library for book and poetry readings, again with staff support. Outings are also arranged for example to Skegness. A beauty therapist visits the home twice per week to offer such services as manicures. Most treatments are included in the home’s fees but residents can pay for additional more specialist treatments if they wish. Residents praised the food describing it as “excellent” and “very good”. The meal served during the inspection was roast lamb with a selection of fresh vegetables, the latter being placed in tureens on the table to enable residents to help themselves. Staff offered assistance to those residents who required it. A choice is offered at each meal and residents can choose to eat in their room or the dining room. Relatives can and do join residents for meals and an appropriate charge is made. Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 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 standard(s) These standards will be fully assessed at the next inspection EVIDENCE: Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 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 standard(s) 19,23,24,26 Individual and communal areas are safe, well maintained and comfortable. All areas are decorated to a high standard and bedrooms are well equipped and personalised. There is a very high standard of cleanliness in the home. EVIDENCE: The home has a maintenance worker who deals with any repairs promptly and there is a planned programme of decoration in the home. Requirements made by the fire inspector relating to the basement area have been partly met. Evidence was seen, (materials and work in progress) that the requirements should soon be fully met. Residents’ rooms are light, airy, well equipped and furnished. Many residents have also brought their own furniture into the home and other personal possessions. There are three domestic staff on duty each day and cleaning was taking place during the inspection. Residents said the home was always clean and tidy. Each Wednesday extra staff hours are allowed for a more thorough ‘spring clean’ of all areas. Staff demonstrated a good understanding of infection control procedures and have received formal training in this area. Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) The home has a high ratio of well trained and competent staff who effectively meet residents’ needs. Good recruitment procedures are in place. EVIDENCE: Rotas showed at least six care staff on duty during daytime shifts and three waking night staff. Daytime staffing was confirmed by observation. Two additional staff were on duty during the lunch and tea time periods. There were also dedicated activity, laundry, domestic and kitchen staff on duty. Residents’ requests for assistance were dealt with promptly during the inspection. One resident commented, “The girls are lovely here!” The home has a dedicated training officer and training room and staff receive core training in health and safety, moving and handling, dementia care and fire safety. Training is updated regularly and all staff have training records which contain documentary evidence of training received. Staff also attend external training events and there is a comprehensive NVQ training programme. The majority of care staff have achieved or are working towards level 2 and 3 awards and several senior care staff are working towards level 4. Application forms, two written references and evidence of Criminal Records Bureau checks were evident on staff files. The home should ensure evidence of each staff member’s identity by keeping copies of birth certificates or passports. Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,35,36,38 There are good management systems in place which enable residents and staff to have input in to the running of the home. Staff also benefit from good supervision practices. Effective policies and procedures ensure residents’ financial interests are safeguarded and the health and safety of residents and staff is also well met. EVIDENCE: Minutes of resident and staff meetings were available, together with minutes for individual groupings of staff. These showed that consultation was carried out with residents and staff and their ideas put into practice. Staff receive regular one to one supervision from managers which is documented. There is also a formal appraisal system in place again which is fully documented. Residents deal with their own financial affairs or are supported by their relatives. The home manages a small amount of ‘petty cash’ for each resident and records and receipts are kept. A random sample of these showed that records and actual amounts of money tallied. Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 Page 16 Fire Records showed regular testing and servicing of equipment and systems. Formal fire safety training had taken place the week prior to the inspection. Risk assessments are in place for all working practices including risk assessments relating to residents going out for various outings and activities. The home must ensure that it informs the Commission of all incidents that adversely affect the safety of any resident. Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 x 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 x 15 4 COMPLAINTS AND PROTECTION 2 x x x 3 3 x 4 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x 4 x x 3 3 x 3 Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 Page 18 No Are there any outstanding requirements from the last inspection? 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 19 Regulation 23 Requirement Evidence that the work required by the fire officer has been fully completed must be forwarded to the Commission. Evidence of all staff members identity must be kept on file. The Registered Person must ensure the Commission is notified of all incidents as detailed in Regualation 37. Timescale for action By 10 June 2005 By 10 June 2005 With immediate effect. 2. 3. 29 38 17 37 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 7 Good Practice Recommendations Staff should fully date all daily records, remembering to include the year of entry. Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 Page 19 Commission for Social Care Inspection The Pavilions, 5 Smith Way Grove Park, Enderby Leicestershire LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Egerton Lodge c51 S1779 Egerton Lodge Care Home V221585 180505.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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