Inspection on 29/07/08 for Elizabeth Lodge

This inspection was carried out on 29th July 2008.

CSCI found this care home to be providing an Good service.

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 08/08/06

Elizabeth Lodge 29/12/05

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 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Elizabeth Lodge 29 Beech Grove Alverstoke Gosport Hampshire PO12 2EJ Lead Inspector Jan Everitt Unannounced Inspection July 09:30 29th 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.V367432.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. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 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.V367432.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2006 Brief Description of the Service: Elizabeth Lodge is situated in Alverstoke, near Gosport, in a quiet residential cul-de-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. Accommodation is provided over three floors, in single, en-suite bedrooms. 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 adequately furnished. To the rear of the property is a large enclosed, secure garden, and ample parking facilities are available at the front of the premises. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The visit to Elizabeth Lodge formed part of the process of the inspection of the service to assess the service against the key national minimum standards. The evidence to support the assessed outcomes for people who use the service was gathered from the Annual Quality Assurance Assessment (AQAA), which the manager returned to the CSCI and information received since the last key inspection of August 2006. We also had information in surveys from relatives; people living in the home, staff and one care manager. We had verbal feedback from some of the people living in the home on the day of the visit. We also observed care practices using our observational tool, Short Observational Framework for Inspection (SOFI). Three care staff; the cook, the manager, the deputy manager and the provider were spoken with during this visit. Records and all areas of the home were viewed. The outcome of the surveys indicated that there was a high level of satisfaction with the service and that generally residents and relatives were pleased with the care the home provides. There were no residents from an ethnic minority group. The current fees are currently £525 - £472:50. The fees exclude hairdressing and chiropody. toiletries, newspapers, external activities and community transport are charged at cost. What the service does well: The inspector spoke to most of the residents, staff and visiting relatives in order to obtain their perceptions of the service the home provides. Those spoken to were very happy and complimentary about the care and services that are provided. The home provides a safe, well-maintained homely environment for the service users. The service users and relatives say: ‘The garden is lovely’. ‘The home is clean’,. ‘Everything is done to make the home as homely as possible’. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 6 ‘The home provides a happy caring environment that give relatives peace of mind’. Elizabeth Lodge is excellent and the staff are very caring’. ‘Staff listen to what I say and staff are always available’. Assessments and care plans are detailed and inform the practices of the home to meet the needs of the service users. Staff say that they could easily care for a service user from the information recorded in care plans. Service users’ healthcare needs are provided for. Service users felt safe and secure and happy that staff could look after them properly and treated them with respect: Relative’s comments: ‘My mother’s needs are always met and the home was excellent at settling my mother in. They are very sensitive to her anxiety about moving away from her home’. ‘The home has been very supportive to my mother’. The home’s routines are flexible and it promotes the right of residents to make choices for themselves and exercise personal autonomy as far as is reasonably possible. A well-balanced and varied diet is offered to service users. This can be adjusted to meet their own needs and requirements. The home provides an appropriate and varied training programme for staff who are supported by the manager and more experienced staff. Comments received from staff spoken to support this. Good relationships and team working was observed amongst staff and with service users. What has improved since the last inspection? Window restrictors have been fitted to all windows on the first floor and above. A new boiler and water tanks have been fitted in the last twelve months. A formal supervision programme now takes place with all staff. All bedrooms have now got running hot water with thermostats fitted to all hot water taps. The manager has development plan for the home and a system of internal audit, to ensure the service continues to improve. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 7 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. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 8 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.V367432.R01.S.doc Version 5.2 Page 9 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. Standard 6 not applicable to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are fully assessed prior to admission so the prospective residents and the home can be sure their needs can be met. An intermediate care service is not offered by the home. EVIDENCE: A sample of pre-admission assessments was viewed. These are undertaken by the manager or the deputy manager. If the person is referred by social services, their care needs assessment will be sent to the home for their information. The assessment tool is comprehensive and covers all aspects of personal care needs. The manager told us that the pre-admission assessment is used for the first week as the foundation for a full assessment and care planning. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 10 The manager said in the AQAA that she is currently reviewing her assessment form to add any further information to comply with the for the mental health capacity act. The manager told us that if the home has an enquiry she would send out a brochure and service user guide. A relative told us that she had visited the home prior to her relative’s admission and they had received the statement of purpose, a copy of the latest report and a brochure of the home. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure that personal care; health and medication are well managed. Residents are treated with respect, and their right to privacy promoted. EVIDENCE: We viewed a sample of three service user’s care plans. These detailed an admission assessment at which time risks and needs of the service users are identified. Care plans are then written with specific guidance of how to meet the resident’s needs and also how to minimise any identified risks, whilst ensuring that independence and choice is promoted. Where possible the care plans demonstrated the involvement of the service user or their representative in this process. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 12 The home maintains a falls register, when recording accidents, and the manager advised that if a resident fall three times, they are referred to a local falls co-ordinator for assessment. The preferences in relation to daily routines were also found to be documented in the care plans. Evidence of monthly reviews were available, as well as day and night evaluations and a three monthly dependency assessment tool, which ensure that care plans are adapted to meet changing needs. The manager said she was in the process of reorganising the care planning system as information was spread over several folders and the new system would be more compact and be more person centred. Observation throughout the day and speaking with the staff demonstrated that staff were very familiar with the service users and their specific needs. Staff spoken with confirmed that the care plans are working documents and they are used as working tools to inform their practices. The care plans have records of health support and identify when a resident has been referred to a health care professional. The manager said that people are able to select their own GP and all people living in the home are supported to access local health services with staff or family members. The manager told us she has good support from most of the GP practices but she would like more frequent reviews from some of them. The community psychiatric nurse attends the home six weekly to review the service users. Service users have access to a dentist, optician yearly and the chiropodist who visits the home six weekly. In surveys returned to us, people living in the home and relatives said that medical needs are either usually or always met and that support for meeting health care needs is obtained by the home. The manager and her deputy have completed an ‘end of life care’ course and have disseminated the information to the staff. A survey returned from a care manager commented that the home does well with’ end of life’ care. The home operates a monitored dosage system for the administration of medication and is supplied by a large local pharmacist. The manager and her deputy coordinate the ordering, checking and returning of medication. The manager showed us the records for the ordering. She told us that she always checks the prescriptions before they are taken to the pharmacy to ensure no unwanted medication is delivered. The records for the return of unwanted medication were also evidenced. The cupboards and medicine trolley were viewed and were found to be tidy with no obvious overstocking of ‘as needed medication’ (PRN) Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 13 The medication administration records (MAR) were seen and there were some gaps in the recording and this was pointed out to the manager, who said she would audit these records. The records identify that there have been some medication errors since the last inspection with reference to records not being completed in the controlled drugs register appropriately. This has been resolved by the two members of staff suspended from administering medication and undertaking further training for medication management and supervision whilst administering medicines. There are no service users choosing to administer their own medication. One service user does administer her own eye drops but she has been risk assessed as able to undertake this for herself and this was evidenced in the care plans. There is one service user who has medication administered covertly. This has been agreed with the GP, and family and there were records to support this. Observation throughout the day suggested that the carers and service users have good relationships. Staff were noted to be polite and respectful to the service users and spoke to them in a warm and caring manner. Service users spoken with said the staff are ‘kind’ and ‘good’. Relatives spoken to said that the residents’ privacy is respect at all times and that their care in given in a respectful manner. Surveys returned from relatives say: ‘My mother’s needs are always met’. ‘My relative always has the care and support they need’. ‘It is apparent that the health and welfare of the residents is very important to the staff and manager’. ‘The staff are kindly and caring’ Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Routines are flexible, allowing residents to exercise control over their lives. Family contact is encouraged, and activities and diet are well managed, offering variety, choice and a nutritional diet. EVIDENCE: The home is in the process of recruiting an activities organiser to prepare and organise appropriate activities for the service users throughout the day. Currently there is an activities programme that is arranged by the manager and staff. The manager told us that the home provides social leisure and activities every week and there is an information folder on what activities go on in the home. We sat and observed in the lounge area the activities and interaction between staff and residents. The staff had put on wartime music and a couple of the Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 15 service users were singing along with this. There was a great deal of interaction going on between staff who were frequently coming to the lounge area to chat to the residents and ask them about their memories of the music being played. It was a resident’s 90th birthday and she was continually receiving flowers and cards and one other service user gave her a card and she expressed such delight at receiving it. The cook had baked a cake for afternoon tea to celebrate the occasion. The home has purchased sensory equipment that the manager said is used in the afternoons and that the residents do enjoy and benefit from. Outside entertainers visit the home and undertaken arts and crafts, music, story telling, exercise and music for health. The person who supplies the music for health sessions sends the home a monthly evaluation of the level of benefit each of the residents have gained through the exercise. The staff do reminiscence therapy, organise bingo and clothes parties and take residents out on regular outings. The staff were observed to reminiscence with the residents when talking about the wartime music that stimulated conversation. Each service user has an individual file documenting their life story and the activities they have participated in. Service users spoken with said they enjoyed the activities and said ‘there was always something going on’. Comments on surveys from relatives and service users did say: ‘They could do with more outings’. ‘More stimulation for those with dementia’. ‘My brother and other residents are taken out on trips and entertainment is also provided. The home is excellent’. ‘I enjoy the dancing’. The home has an open visiting policy and the visitor’s book demonstrated that the home does have regular visitors. Two visitors spoken with said they are always made welcome into the home and offered a cup of tea. Discussions with residents confirmed they are happy in the home and that routines are flexible, and based around their own preferences. Staff were observed to promote independence by encouraging service users to make their own decisions about where they wished to sit and what they would like to eat. Some residents were choosing to stay in bed for the morning and staff were observed to be visiting their rooms frequently to enquire if they needed any assistance and taking them drinks. The manager said there are a few residents that prefer to get up late and go to bed later, and this is respected. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 16 A lady resident described how her particular religious needs were met with church visitors coming to the home fortnightly; another said she attends the local church. When speaking to a service user about his choices being respected and how he spends his day, he told us that the home have risk assessed that he is no longer safe to wander out of the home on his own now, and this causes him great frustration. When speaking to his relatives they confirmed that his memory is not good and he would easily get lost, as he was not familiar with this area having lived in Portsmouth all his life. He had chosen this home because it was near to his family, who visit daily to take him out. Another very elderly resident told us that she insists on cleaning and tidying her room every day and would be very unhappy if her room was not ‘just so’. She invited us to visit her room and indeed it was very clean and neat. We visited the kitchen and spoke with the cook. The kitchen was well organised and clean. The cook has been working at the home for a considerable number of years and is very familiar with the nutritional likes and dislikes of the people who use the service. Menus sampled offer variety and choice; the AQAA states the menus have changed in the last year following consultation with the service users, and on residents’ preferences. Nutritional assessments were observed in the care plans and the manager advised that residents are referred to a dietician or nutritionist if a risk is identified. The lunchtime meal was observed to be well presented and service users were reporting that the food was very good. Service users confirmed that those who could make choices of what to eat could do so, and that service users can eat their meals in whatever location they choose. Some residents were choosing to eat their meals in their rooms and one service user told us that she likes her room and chooses to stay in it all the time as she ‘has everything in the room I need’. We observed that appropriate assistance from staff and the supply of specialist utensils to promote independence. Good practice was demonstrated by staff sitting and eating with less able residents, to encourage healthy eating practice. Residents spoken with confirmed they generally liked the food. One of the residents is a vegetarian, and the manager advised that the resident is taken shopping, to allow them to choose the foods they like to eat, as they cannot communicate their wishes. This is seen as excellent practice to promote diversity, choice and independence. Staff have been trained in nutritional needs of those with different religious and cultural needs. The cook told us she caters for diabetic diets only but is familiar with special diets. One of the residents is a vegetarian, and the manager advised that the resident is taken shopping, to allow them to choose the foods they like to eat, Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 17 as they cannot communicate their wishes. This is seen as excellent practice to promote diversity, choice and independence Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 18 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. A complaints procedure has been developed that residents and relatives are aware of. Staff have an awareness of abuse and the appropriate reporting procedures, which ensures that residents are protected EVIDENCE: The home has a complaints policy and procedure, which following the previous inspection, has been reviewed. The AQAA stated that the manager has recently sent out the complaints procedure to relatives in response to a recent questionnaire that identified they were unaware of the procedure. Surveys returned and relatives spoken with commented said they were aware of the complaints procedure saying: ‘I would speak to the manager if there is problem’ ‘Will complain to the manager’. ‘Speak to the staff or manager who are very approachable’. ‘I would feel confident that something would be done if I did have a concern’. The complaints log was viewed and this was appropriately recorded with the action outcome of the one complaint that has been received since the last Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 19 inspection and was resolved within the 28-day period as stated on the procedure. The home has a Safeguarding policy and procedure and the manager is aware of her role when reporting any incidences of suspected or actual abuse. The home has been involved with one such case since the last inspection, which was reported and investigated appropriately as per Hampshire Safeguarding procedures, and was resolved, proving no foundation to the accusation. All staff have now received the Protection of Vulnerable Adults training on abuse and this training is also an element of the induction programme. Staff spoken with are aware of what they must do if they witness or suspect abuse and described going to the senior member of staff to report this immediately. The home has the availability of an advocacy service for one resident who has no family and whose care is reviewed regularly by the care manager. The home has a Whistle Blowing policy and procedure and the manager said all these policies are discussed at staff meetings. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. The home enables service users to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: We visited all areas of the home. There is one main lounge/dining room, which includes a conservatory, and is used by most service users to sit in. It was observed to be homely and comfortably furnished. A smaller lounge/dining room, at the other side of the house, appeared quite cramped and untidy and was being used mainly as an office area. The service users can sit in this area if they choose but at the time of this visit none were doing so, preferring the other brighter lounge or choosing to stay in their rooms. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 21 The manager told us that her office is being equipped with more storage areas and currently much of the office work is undertaken in this lounge area until this is completed but conceded that there is a shortage of storage space in the home and they are trying to be creative with the space they have. Most of the service users rooms were visited. These were noted to be clean and had been personalised with the people’s own belongings and therefore every room was different. All rooms are single with en-suite facilities. Service users spoken with were very happy with the accommodation. The provider told us that the home has a programme of redecoration and refurbishment and that he and the manager meet monthly to discuss general improvements to the home. A number of windows on the first and second floors have now been fitted with window restrictors. The home took advice from the fire authority about one landing window and this was deemed to be safe and did not present any risk to service users of falling out. The home employs one housekeeper five days a week and carers undertake the laundry duties. All areas of the home were noted to be clean and homely and service users said their clothes were well laundered It was observed that the external grounds of the home were safe, secure and well maintained and at the time of this visit a new gazebo was being erected to give more shade in the warmer weather as many of the residents enjoy sitting in the garden. We observed that one service user had sun burnt her arms the previous day and when this was discussed with the manager she said that cream had been applied and they had tried to dissuade the resident from sitting in direct sunlight but it had been difficult because she had kept moving about and appeared to tolerate sitting in the heat. The AQAA states that in the past year the home has purchased garden furniture, plants pots and generally improved the outdoor environment. It was noted that at the time of this visit the outside temperature was very warm and the lounge/conservatory area has a Perspex roof. This was discussed with the manager as to the level of heat this would generate on such a warm day. A roof fan has been fitted and an air conditioning unit was in place and the temperatures are recorded daily to ensure the room stays within acceptable parameters. Comments from relatives and service users say: ‘Environment very clean, warm and safe’. ‘Provides a good homely environment and meets persons care as an individual’. ‘The home is very clean’. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 22 The home does have a portable hoist and appropriate bathing and showering facilities. The previous inspection identified that one room was not getting a hot water supply and that hot water was being transported in jugs, which presented a risk to service users. This has now been rectified and a new independent hot water tank has been installed in this room. The AQAA states that the home has infection control policies and that staff have received training in the principles of infection control. There was evidence of hand washing facilities and disposable towels in toilets, bathroom and bedrooms and protective aprons and gloves are available to staff to use when appropriate. The housekeeper was aware of the procedures for the safe storage of chemicals under the COSHH guidance. The contract for the disposal of waste was seen. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by well-trained staff, in sufficient numbers to ensure that residents’ needs are met. Residents are protected by the home’s recruitment process. EVIDENCE: The staff rotas and observations of the day confirmed that the three staff on in the morning and three in the afternoon with two waking staff at night were sufficient staff to meet the service users needs and maintain standards within the home. It was clear through observation that people’s needs were well met and choices respected by the good staffing levels. Staff were observed giving appropriate assistance when needed and visiting the lounge areas frequently to ensure residents needs were being met. The cook and housekeeper are supernumerary to these numbers. Feedback from residents and relatives confirmed that they consider service users needs are met said that: ‘Staff are lovely’, ‘Very friendly – they make me feel safe and secure’ ‘Kind and respectful’. ‘Staff are patient and kindly to the residents’. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 24 ‘The home is excellent and the staff are very caring’. The manager told us that nineteen staff have achieved the NVQ level 2 and above. At the time of this visit the NVQ assessor was visiting the home to assess a carer doing her NVQ level 3. The manager does encourage the staff to undertake the NVQ qualification and this is currently being funded by Train for Gain organisation. Two more carers area signed up for the next NVQ level 2 courses. There was evidence in the personnel files that the most recently employed staff have undertaken the induction programme based on the Skills for Care induction standards. This is in the form of a workbook that is completed and signed by the carer and the supervisor once they have achieved the standard. Once the carer has completed this induction they are encouraged to undertake the NVQ level 2. Three staff files were viewed, which confirmed that appropriate checks, including a criminal records bureau and the protection of vulnerable adults (POVA) checks, are undertaken prior to their employment, to ensure they are suitable to work in the home. The training matrix seen confirm that training is provided regularly, and that training in core skills are up to date. The matrix also identifies review dates for mandatory training. The manager appraises her staff annually and it is at this time training needs are identified. Supervision of staff is shared between the manager and the deputy manager on an eight weekly rota. Records were evidenced of this taking place and staff told us they are supervised on a regular basis. The AQAA identified that the manager will arrange for all staff to receive training in managing aggression. There were no details of when this was likely to take place. Discussions with staff confirmed they feel competent in their role that training is plentiful and the development of their skills is encouraged. They all confirmed they are well supported by the manager, that they are given clear guidance and direction, and that they are encouraged to contribute to the running of the home. One said there is, .a good team spirit, they work well together’. Another said ‘we have a close knit happy residential home and I enjoy my work’. Carers spoken to at the time of this visit reported that the training opportunities are good and that they have found the dementia training course very valuable in their everyday work. All confirmed they do not feel overworked, and when needed, additional staff are made available, although one said they would prefer to have more 1:1 time with the residents. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 25 Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 26 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of the service users. Systems are in place to ensure service users financial interests are safeguarded. The environment is maintained in a safe way and the health and safety of the service users and staff is promoted. EVIDENCE: The registered manager has been in post for a number of years and has gained her Registered Managers Award, as too has the deputy manager. There was evidence that the manager updates her skills by attending regular training. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 27 A quality assurance system has been developed. The AQAA stated that the service user’s questionnaires have been updated to meet the needs of the service users and relatives. There was evidence in the QA folder that demonstrated that questionnaires have been distributed this year to service users and a report has been written with the outcomes and any actions taken as a result of any issues or comments made on the questionnaires. Relatives are invited to a meeting at the home yearly, at which they can discuss any issues or make suggestions. The minutes of these meetings are taken and kept in the home. Staff meetings also take place and the minutes of these meetings were seen. A representative of the provider undertakes regulation 26 visits and the reports of the findings are maintained in the home and were seen by us. The QA records demonstrated that the manager had audited all the systems, such as accident monitoring, care plans and monitoring medication administration records (MAR) in May of this year. The AQAA states that the manager would like to improve the quality assurance programme over the next twelve months. Small amounts of service user’s monies are kept in the home. These were seen to be stored in separate containers. Individual records were maintained with the money for all outgoing and incoming monies. We saw these and balances of records matched that of the money stored. Health and safety training for staff is undertaken mandatory annually. The manager is trained to train staff in moving and handling techniques. Infection control and POVA training were also seen to be undertaken mandatory by staff. The fire log was viewed. Records of tests and appropriate servicing of the system were evidenced. Fire training records were also current. The home has a fire risk assessment in place. A sample of servicing certificates was seen for the gas system, hoist, waste contract and water testing and were up to date and current. Window restrictors have now been fitted to all first floor and above windows with the exception of one, which has been risk, assessed by the fire authority and deemed safe. Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 28 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Elizabeth Lodge DS0000065980.V367432.R01.S.doc Version 5.2 Page 29 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. Standard Regulation Requirement Timescale for action 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.V367432.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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