Inspection on 29/12/05 for Elizabeth Lodge

This inspection was carried out on 29th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Elizabeth Lodge 29/07/08

Elizabeth Lodge 08/08/06

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Elizabeth Lodge 29 Beech Grove Alverstoke Gosport Hampshire PO12 2EJ Lead Inspector Beverley Rand Unannounced Inspection 29th December 2005 09:00 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 Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elizabeth Lodge Address 29 Beech Grove Alverstoke Gosport Hampshire PO12 2EJ 023 9258 0802 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) Mr David Mitchell Mrs Karen Ritchie Care Home 18 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (18) of places Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: Elizabeth Lodge is situated in Alverstoke near Gosport in a quiet residential culde-sac. The building is in keeping with surrounding houses in the vicinity and close to local amenities. The home provides care for up to 18 older persons, some of who may have dementia. There is one lounge/dining room which includes a conservatory, and a smaller lounge/dining room which is used for residents who have a higher level of need. The home is well maintained and tastefully furnished. To the rear of the property, there is a large enclosed garden, which is enjoyed by residents and visitors in the warmer months. The forecourt provides ample parking for visitors to the premises. Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection of the year, and took place over two and three quarter hours. This report looks at nine key standards, and should be read in conjunction with the previous report. The inspector spent time sitting in the conservatory and spoke with three residents about life in the home, as well as speaking with another resident in their bedroom. The inspector also spoke with two staff and the manager of the home, and looked at records such as menus. 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 contacting your local CSCI office. Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 Page 6 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 Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 Page 7 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): These standards were not assessed. Standard 6 does not apply. EVIDENCE: Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 Page 8 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): 9 The home’s medication procedures protect residents but further attention should be given to ensuring insulin is locked away. EVIDENCE: Staff described the procedure they followed when administering medication, which included signing records after medication had been taken, and two staff signing for controlled drugs. Staff ensured that residents prescribed insulin would have this at a specific time, i.e. 20-30 minutes before food. The inspector looked at records which had been completed correctly. Medication was locked away, however, although the insulin was kept in a lockable tin, it was not actually locked on the day of the inspection. Only trained staff give medication: training has involved a distance learning course and an exam. Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 Page 9 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): 14 & 15 The home ensures that residents can exercise control over their lives. Residents enjoy their food, which is varied. EVIDENCE: The inspector saw that residents had brought in their own furniture and possessions. None of the residents currently manage their own money, but the manager explained that residents have done so in the past, when they were able. Residents described the food as, ‘very nice’, ‘excellent’, and that they, ‘liked it very much’. The inspector asked three residents sitting at the dining table if they liked their lunch, and they said they did. Residents confirmed that they had a choice of food, and that if they did not like the two lunch choices, they could have something else. The menu is on a four week rota, and is changed with the seasons. The menu appeared varied and showed evidence of choices at lunch and tea time. The inspector heard the cook serving meals as individuals would wish, e.g. one resident likes a small plate, with a small amount of food and no gravy. Extra help is given to residents if necessary, and the inspector saw one resident who had a special spoon to enable them to eat independently. The cook had decorated a cake because it was a resident’s birthday. Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 Page 10 Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 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): These standards were not assessed. EVIDENCE: Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 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): 26 The manager ensures that the home is clean and hygienic. EVIDENCE: The home was clean and there were no unpleasant odours. The home has a laundry and a washing machine with a sluice wash. Staff described how they used disposable gloves and aprons to reduce any risk of cross-infection. Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 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): 28 The home promotes NVQs as a way of ensuring that residents are in safe hands. EVIDENCE: The home employs seventeen care workers, and promotes study for NVQ awards. Eight staff have already achieved NVQ2 or higher, one person is currently studying, and three are waiting to start. Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 Page 14 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 The manager is fit to run the home, and does so with regard to residents’ views. The manager ensures that residents’ financial interests are safeguarded. The home ensures that the environment is maintained in a safe way, but further attention is needed to ensure that risks are reduced regarding hazardous substances and the use of stair gates. EVIDENCE: The manager has worked in the care sector for 22 years. She has achieved the NVQ4 in care and the Registered Managers Award this year. The manager regularly updates her own training and has updated Dementia Care, Medication, Moving and Handling, Fire Safety Awareness, First Aid and Health and Safety. The manager has a quality assurance programme in place, which includes a six monthly questionnaire sent to families, and reviewing of care plans every six Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 Page 15 months with family, if appropriate. The deputy manager undertakes a survey of residents after a party or other social function. The new provider has been visiting the home on a weekly basis. The home looks after personal allowances on behalf of some residents. The inspector looked at records and money for two residents and found that they matched. Receipts are kept for items which are bought. The inspector saw cleaning fluids which were not stored securely. The laundry had large bottles of anti-bacterial soap, cream cleaner and fabric softener stored where residents could access them. In the kitchen, there were also cleaning fluids which were kept in an unlocked cupboard. A razor and nail polish remover wipes were found in the bathroom. The manager said that she had been advised in the past that kitchen cleaning fluids did not have to be locked away. However, the inspector advised her that all hazardous substances must be stored securely as they are a potential risk to residents who have dementia. The home has two stair gates which are in use on the two staircases. The manager was not sure why they were still there, as they were originally put there in response to a situation which is no longer happening. On further discussion, the manager felt that one of the gates could still be needed. The inspector looked at the risk assessment and found that it did not outline the risks of having the gate versus the risks of not having it, nor did it identify the issue of the gate being used as a restraint technique. The bath hoist is serviced every six months, and other maintenance certificates were available. Fire training records were up to date. Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 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. 2. Standard OP9 OP38 Regulation 13 (2) 13 (4)(a) Requirement Prescribed medication must be kept locked at all times The use of the stair gates must be reviewed under a risk assessment framework which must be expanded to take into account the risks of the gate being there, against the risks of it not being there. Hazardous substances must be locked away Timescale for action 18/01/06 31/01/06 3. OP38 13 (4)(a)(c) 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Elizabeth Lodge DS0000065980.V275202.R01.S.doc Version 5.1 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. 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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