Inspection on 02/11/05 for Egerton Lodge Care Home

This inspection was carried out on 2nd November 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 18/05/05

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 Care Home Wilton Road Melton Mowbray Leicestershire LE13 0UJ Lead Inspector Ruth Wood Unannounced Inspection 2nd November 2005 10:00 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 Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 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. Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Egerton Lodge Care Home Address Wilton Road Melton Mowbray Leicestershire LE13 0UJ 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) 01664 410202 01664 482124 egertonlodge@hotmail.com Egerton Lodge Limited Ms Joyce Wells Care Home 46 Category(ies) of Dementia - over 65 years of age (12), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (46), Physical disability over 65 years of age (10) Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers (PD(E)) No-one falling within category PD(E) may be admitted into the home when there are 10 service users of category PD(E) already accommodated within the home. Service User Numbers (DE(E)) No-one falling within category DE(E) may be admitted into the home when there are 12 service users of category DE(E) already accommodated within the home. Service User Numbers (MD(E)) 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. Service User Numbers (Total) The total number of service users does not exceed forty six (46). Admission of KP: The home is able to admit the person of category LD/DE as named specifically in variation application number V16081 18 May 2005 2. 3. 4. 5. Date of last inspection 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 Care Home DS0000001779.V262595.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on a weekday between 10:30am and 2:30pm. Planning for the Inspection took approximately two hours and included a review of the Pre-inspection information returned by the Registered Provider and the 19 Relative and 27 Resident Comment Cards. Discussion was held with Elaine Hinds (who has managerial responsibility for the home during Joyce Wells’ absence) 4 members of staff, 6 residents and 1 relative. Residents’ assessments and care plans and staff records were examined as well as fire safety and other records. Staff interaction and practice with residents was directly and indirectly observed. What the service does well: What has improved since the last inspection? 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 Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 Page 6 contacting your local CSCI office. Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 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 Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 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): 3,4 Residents’ needs are effectively assessed and well met. EVIDENCE: Three care files were examined; each contained a copy of the home’s assessment, which was undertaken prior to the resident moving to Egerton Lodge. The assessment covered all aspects of personal care including social and emotional needs. Social workers’ assessments were also on file for those residents placed by the local authority. Observation of care practice and discussion with residents, staff and the manager indicated that residents’ needs were being effectively met. Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 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): 7,8,10 Residents are treated with respect, their health needs are well met and care plans accurately reflect assessed needs. EVIDENCE: Three care plans were examined in detail and contained accurate and full details of the respective residents’ care needs. These were verified through observation and discussion with staff and residents. Plans also contained evidence of regular review. The full date (including year) was recorded in daily care notes as recommended at the previous inspection. There was documentary evidence in residents’ files of regular access to dentists, chiropodists, opticians, hearing aid services and district nurses. All residents are assessed for pressure area care and appropriate equipment is sourced from the district nursing service. Staff interaction with residents was directly and indirectly observed. At all times residents were treated with respect and spoken to in an appropriate manner. Of the 27 residents who submitted Comment Cards all felt that their privacy was respected and that staff treated them well. Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 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 the following standard(s): 12,14 Residents are able to exercise choice and their social, cultural and religious needs are exceptionally well met. EVIDENCE: Dedicated activities staff offer a full recreational programme, which includes craft sessions, games and social events. On the day of inspection several residents were involved in a craft activity making decorations for the forthcoming bonfire night party. Residents had also made a ‘Guy’ and were involved in a competition to name him. Of the 27 residents who returned Comment Cards 24 said that the home provided suitable activities with the remaining 3 stating that they ‘sometimes’ did. Residents’ religious affiliation was noted in their care plans and there was further documentary evidence that provision was made for residents to pursue their faith. Residents are able to bring personal possessions into the home and the majority of their individual rooms reflect this. There is a clear statement within the Residents’ Handbook informing people that records will be kept as part of their care and that they have the right to access these records at any time. Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 Page 11 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): 16,18 Residents and relatives have confidence in the complaints procedure. Improvements are needed in the implementation of some aspects of the Guidance for the protection of vulnerable adults. EVIDENCE: The complaints procedure is clearly outlined in the Residents’ Guide; the manager stated that they had never received a formal complaint as they try to encourage both residents and relatives to voice any concerns to prevent any escalation of the problem. A complaints and compliments book is also available. Of the 19 relatives who returned Comment Cards 16 stated that they were aware of the Complaints Procedure. Of the 27 residents who returned Comment Cards 20 said that they would know who to complain to. All staff (including domestic staff) receive training in the recognition of abuse as part of their induction. Staff demonstrated a good understanding of the concept of whistle blowing and were aware of the role of the Commission for Social Care Inspection if they had ongoing concerns. Discussion was held with the Manager about the Guidance concerning Protection of Vulnerable Adults. A staff member was recently employed without a check being made as to whether they were on the Vulnerable Adults Register. This is against current Guidance and the manager agreed that she would rectify this. Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 Page 12 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): 19,26 Residents live in a safe, comfortable and clean environment. EVIDENCE: The home has a maintenance worker who deals with any repairs promptly and there is a planned programme of decoration in the home. A report from the fire officer dated 31.05.05 confirmed that fire prevention work in the basement had been completed satisfactorily. The communal areas of the home were clean, tidy, well decorated and furnished. 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 have received formal training in infection control procedures. Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 Page 13 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): 27,28,29,30 There is a high ratio of well-trained and competent staff who effectively meet residents’ needs. Some improvements are needed in recruitment practices. EVIDENCE: Rotas showed at least six care staff on duty during daytime shifts and three waking night staff. Daytime staffing was confirmed by observation. Additional staff are on duty during the lunch and tea time periods and there are dedicated activity, laundry, domestic and kitchen staff. Residents’ requests for assistance were dealt with promptly during the inspection. Fifteen of the nineteen relatives who submitted Comment cards felt that there were always sufficient numbers of staff on duty. One relative commented, “Outstanding care is provided. Staffing levels are high and staff are consistently well trained and patient.” A comprehensive staff training programme is in place and staff spoke positively about the training opportunities offered to them. All senior care staff are currently undertaking National Vocational Qualifications at level 4 and over 70 of care staff have NVQ at level 2 or above. Domestic staff are also offered the opportunity to undertake vocational qualifications in their area of work and all staff, whatever their role undertake annual training in dementia, the recognition of abuse, first aid, infection control and food hygiene. Recruitment practices are generally good with formal application forms being completed and two references being sought before employment is confirmed. Evidence of identity is retained on all staff files as required at the previous Inspection. The Reference pro-forma used did not contain the contact details of the person supplying the reference; it is recommended that provision be made Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 Page 14 for these. The procedure regarding the checking of prospective staff against the Protection of Vulnerable Adults register was discussed and the Provider’s responsibility in this area clarified i.e. that all new staff should be check against this list prior to their employment in the home. Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 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 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): 33,37,38 Effective quality assurance and good health and safety practice ensure that the home is run in the best interests of residents and that their safety and welfare is promoted. EVIDENCE: An annual questionnaire is supplied to all residents, which seeks their views on all aspects of the service offered by the home. Residents who need help completing the questionnaire are given this by the Activities staff or by their relatives. The manager stated that the results are to be included in the Residents’ Guide. There was documentary evidence that policies and procedures in the home are regularly reviewed; staff undertaking National Vocational training are involved in this process. All staff receive annual training in moving and handling, first aid, food hygiene and health and safety. Documentary evidence of regular fire and emergency light testing was available together with evidence that hoists are serviced on a 6 monthly basis. Staff use of the hoist was observed to be competent and appropriate. Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 Page 16 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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 4 STAFFING Standard No Score 27 4 28 4 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X 3 3 Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 Page 17 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 OP18 Regulation 13 Requirement The Registered Person must review their knowledge of the Department of Health Guidance concerning the Protection of Vulnerable Adults and ensure that it is followed. The Registered Person must ensure that all staff are checked against the vulnerable adults register and obtain an enhanced criminal records bureau check before they are employed by the home. Timescale for action 02/11/05 2 OP29 19 02/11/05 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 OP29 Good Practice Recommendations Contact details of referees should be included on the staff reference pro-forma. Egerton Lodge Care Home DS0000001779.V262595.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester 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 Care Home DS0000001779.V262595.R01.S.doc Version 5.0 Page 19 - 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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