Inspection on 30/01/07 for Egerton Lodge Care Home

This inspection was carried out on 30th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Egerton Lodge Care Home 02/11/05

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 Mick Walklin Key Unannounced Inspection 30th January 2007 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.V324042.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. Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 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.V324042.R01.S.doc Version 5.2 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 2nd November 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, and alongside Egerton Park. This affords some rooms views across the river. Residents rooms are located on three floors, including the ground floor and are accessible by 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 very high standard. Edgerton Lodge aims to provide a homely environment where residents can exercise choice, enjoy companionship, and feel secure. Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was undertaken using a review of all the information available to the inspector regarding the service history of Egerton Lodge, and through undertaking a visit to the home. The fieldwork visit took place over 8 hours. The registered manager was not present during the inspection. The main method of inspection used was called case tracking which involved selecting three residents and tracking the support they receive through the checking of their records, discussion with the care staff and observation of care practices. A tour of the building was undertaken, and documents connected with the running of the care home were also inspected. A pre-inspection questionnaire had been completed in October 2006. The range of fees charged is between £385 and £550 per week. What the service does well: What has improved since the last inspection? Apart from the issues raised below, the home provides a very high standard of care and support. Since the last inspection, the form used to get staff references has been changed, so that the referee’s contact details are available. Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 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.V324042.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good pre-admission procedures, ensuring that prospective service users needs are fully assessed prior to admission. EVIDENCE: Three new admissions to the home all had comprehensive pre-admission assessments, outlining their support needs and individual preferences. Senior staff carry out the assessment to ensure that the prospective residents needs can be met. Two of the residents had attended the home for day care previously, so had a good knowledge of the home when they came to make a decision about where to live. Residents admitted directly from hospital, had accompanying discharge information, together with information from Social Services. One new resident said that staff had helped him to settle in, and said, “So far, the care has been first class”. A relative said, “Mum visited a Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 9 couple of care homes, but after visiting Egerton Lodge, she only wanted to come here”. The home accepts emergency admissions, but these would usually be for initially for one week of respite care, as a trial period. The home does not provide intermediate care. Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 10 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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans provide good information to ensure that residents needs, and there are good arrangements with local healthcare providers. Residents are treated with respect. Medication administration record are not fully completed, which could potentially lead to a medication error. EVIDENCE: On admission, a further assessment is carried out by staff, to identify support needs to be covered in the care plan. Care Plans contain detailed information, and are written in a way that is clear, concise and easy to read. Care plans had been signed by residents, and reviewed on a monthly basis. A new resident said, “Staff have talked to me about my care plan, and listened to my views”. There are good daily records, and fluid balance and repositioning recording charts inspected were thoroughly completed. Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 11 Staff said that there is an excellent working relationship with the local GP surgery. Care plans outline residents health needs, and required interventions. Services such as chiropody, and opticians visit on a regular basis. A dental surgery is situated close to the home, and dentists will visit the home if required. Staff said that the correct equipment is obtained for residents with particular health needs from district nursing services. Medication is stored in a locked room. The home uses a pre-dispensed system, and medication is administered by senior staff, who have received ‘Safe Handling of Medication’ training from the pharmacist. Staff are clear on the policy for administering homely remedies. Medication storage and stocktaking arrangements are satisfactory. However there was an issue with one of the administration records, where a member of staff had signed in the wrong place, indicating that the medication had been given in the afternoon, rather that the morning. This was confusing for other staff, and could have potentially led to a medication error. This led to administration dates being out of synchronisation, but no steps had been taken to rectify this during subsequent days. Residents said that staff respect their privacy, and were respectful towards them when talking to them. A resident said, “The carers are very polite – they always knock on my door before they come in – they never just come barging in”. The residents handbook tells residents, “Members of staff will address you either by using your first or full name, whichever you prefer”. Staff gave good examples of how they maintain residents privacy when carrying out personal care. Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 12 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 excellent. This judgement has been made using available evidence including a visit to this service. There are an excellent range of activities to ensure that residents are stimulated. Residents maintain good contact with their families, and are consulted about how they live their lives. Catering arrangements provide residents with good quality food. EVIDENCE: There are a team of five activity co-ordinators. Residents praised their enthusiasm and commitment, and said that there are an excellent range of activities. There is a choice of planned activities every morning and afternoon, which are displayed on a blackboard in one of the seating areas. On the day of the inspection, residents were enjoying carpet bowls, dominos, music, and 1-1 activities. There is a monthly residents meeting to consult residents about the forthcoming months activities. The co-ordinators take every opportunity to celebrate any special occasions. Residents had recently attended a Burns Night dinner, and forthcoming events include Pancake Day, when residents Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 13 participate in a pancake tossing competition, and Valentines Day, when the Mayor has been invited to present red roses. The cook prepares special menus for these events. There are many competitions, including a monthly word search and crossword competition, and skittles and bowls competitions. A quarterly newsletter is produced for residents and their families, which contains many photographs of recent events. Comments from residents included: • • • • • “We have a lot of fun”. “There is plenty to do here – we have a laugh”. “We are always very busy”. “I choose not to get involved in the activities, as I like my own company”. “We are right next to the town centre, so it is easy to get into town”. Relatives said, “We are really impressed with the activities here – there is something happening every day”. The residents handbook says, “Visitors are always welcome. Meals can be provided by prior arrangement with the chef, at a small charge”. Relatives said that they are always well received, and one commented, “The staff are like family – we visit most days, and they are great”. A resident said, “The staff always ask my family if they want a drink”. Residents preferences are outlined in their care plans, and they confirmed that staff offer them choices, and consult them about their daily routines. Details of advocacy services are displayed on a residents notice board. Residents praised the standards of catering. There is a choice of two main meals, and other choices can be accommodated. The chef described his role enthusiastically. Care plans clearly outline dietary requirements, with information about appetite, any special equipment needed, allergies, and likes and dislikes. One resident said, “The food is very varied, and well cooked. Tea is a snack, like sandwiches, but there is always plenty”. Relatives commented, “The lunch is smashing, but the tea is not always as good”. Sherry is served with the main meal, and wine is served with Sunday lunch. A resident said, “I enjoy the sherry – they look after us very well here. They come round every day and ask us what meal we want”. Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 14 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. This judgement has been made using available evidence including a visit to this service. Residents know that their complaints will be treated seriously, and feel safe living at the home. EVIDENCE: The complaints procedure is explained in the residents handbook, and their terms and conditions, which also give the contact details of the commission. Residents said that they would see a member of staff if they had a complaint, and one said, “I would trust them to take it seriously, and do something about it”. There have been no complaints since the last inspection. Staff demonstrated an excellent knowledge of their reporting responsibilities, and what to do if they suspected abuse was occurring. They confirmed that they receive regular training updates. However, the homes own policy gave staff incorrect advice about investigating suspicions of abuse, and it did not reflect the Leicestershire Safeguarding Adults Procedure. It was agreed that only the Leicestershire procedure would be used for guidance, and the home’s procedure would be removed. Residents said that they felt safe living at the home. Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 15 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 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home provides a very high standard of accommodation for residents to enjoy, and standards of cleanliness are excellent. EVIDENCE: The home is very well maintained and decorated. There are a variety of comfortable communal areas for residents to enjoy. All areas are well furnished, and although televisions, including a large flat-screen TV, are situated in living rooms, they were only turned on when residents requested this. One resident said, “This is very grand”. Another said, “We couldn’t really wish for better – this is a good place to live when you get old – it’s really nice here”. Bedrooms are all en-suite, and personalised to taste. There is a large Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 16 garden situated next to Egerton Park, and there is also an enclosed courtyard, with garden furniture. There are usually three cleaners on duty during the day. All residents and relatives interviewed, said that standards of cleanliness are excellent, and this was confirmed during a tour of the building. Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents receive good support from well-trained staff. Training opportunities for staff are excellent. Recruitment and selection procedures are not robust enough to protect residents. EVIDENCE: There are usually eight care staff on duty, supported by three domestics and two activity co-ordinators. Residents said that they receive a good level support, and staff said that there are enough staff to meet residents support needs. Comments from staff included: • • • “We provide a good level of care – we don’t use agency staff, so there are not lots of new faces”. “We have enough staff – the mornings are busy, but we are OK. There has been some turnover of staff, which has affected staffing levels in the past”. “We look after the residents very well – there is a commitment to good care from the top to the bottom (of the organisation)”. Relatives described the staff as “very nice”. Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 18 The files of three new staff were inspected. Although there was evidence of a formal recruitment and selection process, all three had been employed before the home had received satisfactory references or Protection of Vulnerable Adults (POVA) checks. This potentially puts residents at risk, and an immediate requirement was made. Training opportunities for staff in the home are excellent. The home employs a dedicated full time training manager, who is responsible for co-ordination training. Staff described the training as “excellent”. One said, “The training is really good – we get all the training we want”. Another said, “The training is very good – we’ve been offered a lot”. The training manager outlined the wide range of courses available, a large number of which, staff are required to attend. The training plan for the next six months was inspected, which also described a range of optional courses covering specific conditions that staff can nominate themselves for. Training will be arranged for any residents who are admitted with specific medical conditions. All new staff complete a comprehensive ‘First Steps’ induction and foundation course. There are a high level of staff who have completed, or are undertaking National Vocational Training (NVQ), with 63 of staff having gained a qualification, and 26 of staff studying towards it. Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. The home is very well managed and organised, and residents are consulted about the quality of care that they receive. Some health and safety issues were identified, which could potentially put residents at risk. EVIDENCE: Residents said that he home is well organised. Staff said that they are well supported, feel valued, and some said that they are proud of the home and what it achieves. Comments from staff included: - Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 20 • • • • “The home runs very smoothly – teamwork and morale is good, and we help each other”. “The home is well managed –communication is very good, and we have regular staff meetings, when we are asked for suggestions and improvements”. “We are well looked after”. “We have regular supervision, and we are asked for ideas about any ways to improve the service”. Residents views are obtained by periodic questionnaires, which cover the environment, choices and lifestyle. It is aimed to sample the views of residents four times per year. Generally, health and safety and maintenance records are up to date. Regular fire checks are conducted, and equipment such as hoists and the lift had recently been serviced. However, the following health and safety concerns were identified: • • • • A residents bedroom contained two cylinders of oxygen, but there were no warning signs, in case of an emergency, that oxygen was stored in this room. A large amount of hazardous cleaning materials are stored in the laundry area. Although this is not an area that residents would access, these materials should be locked. The fixed electrical wiring certificate could not be located. The legionella risk assessment could not be located. Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 21 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 1 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 x X 2 Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 22 Yes 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 OP9 Regulation 13(2) Requirement The registered person must ensure that medication administration records are accurately completed. The registered person must ensure that the documents outlined in schedule two of the Care Homes Regulations be obtained before staff are employed at the home. This requirement is outstanding from the inspection on 2nd November 2005. 3. OP38 13(4) The registered person must attend to the health and safety issues identified. 28/02/07 Timescale for action 28/02/07 2. OP29 19 30/01/07 Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Egerton Lodge Care Home DS0000001779.V324042.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!