Inspection on 10/01/07 for Etherley Lodge

This inspection was carried out on 10th 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 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

Etherley Lodge 21/01/09

Etherley Lodge 27/02/06

Etherley Lodge 23/11/05

Etherley Lodge 21/02/05

Etherley Lodge 12/11/04

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

CARE HOME ADULTS 18-65 Etherley Lodge Etherley Lodge Low Etherley Bishop Auckland Durham DL14 0HD Lead Inspector Mr Leonard Hird Unannounced Inspection 10th January 2007 09:30 Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 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 Etherley Lodge DS0000007470.V310152.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 Adults 18-65. 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. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Etherley Lodge Address Etherley Lodge Low Etherley Bishop Auckland Durham DL14 0HD 01388 832879 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) tirving159@aol.com Mr Timothy Charles Irving Mrs Julie Thompson Care Home 38 Category(ies) of Dementia - over 65 years of age (1), Mental registration, with number disorder, excluding learning disability or of places dementia (20), Mental Disorder, excluding learning disability or dementia - over 65 years of age (17) Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2006 Brief Description of the Service: Etherley Lodge Residential Care Home is located in the small village of Low Etherley near to Bishop Auckland and is on a regular bus route. Set in its own grounds Etherley Lodge is a large converted two- storied former residential house without the benefit of a passenger lift. There are 2 double bedrooms; 31 single bedrooms of which 21 have en suite facilities. Throughout the building there are a number of different communal lounges, dining areas, a conservatory, communal toilets and bathrooms. The home has a large well-maintained garden along with a patio and other hard surfaced areas for residents use. Car parking spaces are located to the front of the home for use by relatives and visitors. Etherley Lodge is registered to provide residential care for up to 1 person in the category of dementia over the age of 65, 20 persons the category of mental disorder (excluding learning disability or dementia) and 17 persons in the category of mental disorder (excluding learning disability or dementia over 65 years of age). Etherley Lodge does not offer intermediate residential care facilities. Mr Timothy Charles Irving and Mrs Julie Brown are the Registered Provider and Registered Manager respectively. The weekly fee to stay at Etherley Lodge Residential Care Home is currently £364.50. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection of Etherley Lodge Residential Care Home took place on 10th January between 1130 and 1530 hrs and 18th January between 1300 and 1600hrs. The inspection process considered all of the Key standard areas as identified by the Commission for Social Care Inspection within the Care Homes for Adults(18-65) National Minimum Standards. These Key standards are: Choice of Home (NMS2), Individual Needs and Choices (NMS 6,7 and 9), Lifestyle (NMS 12, 13, 15, 16 and 17) Personal and Healthcare Support (NMS 18, 19 and 20), Concerns Complaints and Protection (NMS 22 and 23), Environment (NMS24 and 30) Staffing (NMS 32, 34, 35) Conduct and Management of the Home (NMS 37, 39 and 42). Comments were received from Residents, the Registered Provider, the Registered Manager, activities organiser, and members of the care staff team. What the service does well: What has improved since the last inspection? What they could do better: No requirements or recommendations were made at this inspection. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 2 Quality in this outcome area is good.This judgement has been made from evidence gathered both during and before the visit to this service. The Registered Manager at Etherley Lodge had ensured prior to the admission of a resident both the local authorities social care and health team and the home had carried out a full assessment of needs. EVIDENCE: From a review of individual residents care plans and files it was noted that a full assessment of needs had been carried out prior to admission. The local authorities social care and health team and the home had carried out assessments of need before any admission to the home. Information contained in residents’ files confirmed that trial visits had been arranged to the home prior to admission. Residents and where appropriate their representatives had signed the assessment documentation. From the assessment of needs, the home had with the help of the resident developed a care plan that took account of their needs and aspirations. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 9 Information was available in the home for use by residents on how to access independent advocacy schemes and other support groups. The home’s staff on behalf of the residents had accessed different specialist services as and when required by individual residents. Records were being maintained of the use of these different services, including the involvement of the different health teams. Residents spoken with confirmed that they were aware of these assessments, having been undertaken. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS6 NMS7 NMS9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The system for care planning in the home is adequate and provides staff with the information required to assist them in meeting the needs of the individual resident. Residents were being actively encouraged and supported to participate in the decision-making and risk taking process affecting their lives. Residents were being well supported by the home in their chosen areas of employment and the use of advocates. EVIDENCE: Each resident had a care plan in place containing information about, their physical, specialist needs, personal and social well-being. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 11 Staff from the home’s secure computer recording system could easily access residents’ personal files. Contained in the care plans was information regarding any restrictions on individual residents choice and freedom and how this was, be managed. Residents care plans were being reviewed on a monthly basis at the home by the care staff and records were maintained of these reviews. The local authorities social care and health teams had also reviewed the individuals care plan. Records were being maintained of the daily life of the individual resident within the home and included information on the activities the resident had taken part in. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS12 NMS13 NMS15 NMS16 NMS17 Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. The routines of daily living and activities occurring at Etherley Lodge were varied, flexible and meeting the needs of the residents. The independence and personal choices of residents at Etherley Lodge were being promoted by the home. The dietary needs of residents were catered for with a selection of home cooked food being provided. EVIDENCE: Residents had individually planned programs of weekly activities that had been developed to take account of the residents’ own likes and dislikes. Activities offered ranged from a meal or drink at local public houses, quiz sessions, shopping, gardening, watching TV, and listening to music. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 13 The activities were arranged for either the individual resident or the group as a whole by the home’s activity organiser. Residents could arrange their own activities, if they wanted to and many of them had done so. If residents didnt want to take part any activity they didnt need to and staffing levels could be adjusted to enable this to happen. A resident commented that, they did their own thing, when they wanted to . Another commented that they could visit their family at any time and could go out when they wanted to’ A resident had recently arranged with their family and the support of the home an extended holiday to Australia. Families were encouraged by the home to spend time with their relatives either at the home or by taking them out. Records were being maintained of this family contact. Etherley Lodge had an open visitors policy in place. There were regular residents meetings being held enabling residents to influence decisions being made in the home e.g. choice of menus and choice of activities. Records were kept of these meetings. A resident spoken with commented that, ‘the food was okay, and was what they liked to eat’ another said that, ‘ they liked the food and there was a choice at mealtimes, but if they didnt like something they just had to speak to the cook and something would be rustled up that they liked ’. The homes menus took account of the likes and dislikes of the residents the cook tried to keep to a healthy eating menu, wherever possible. but Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS18 NMS19 NMS20 Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. The health needs of residents were being well met with evidence of good multidisciplinary working regularly taking place. EVIDENCE: A review of residents care plans confirmed that residents were receiving support and advice from the appropriate health professionals when necessary. Individual residents care plans included detailed information about the involvement of doctors, dentists and other healthcare professionals. The home had appropriate policies and procedures on how to safely administer medication to residents for staff to refer to. Staff administering medication had undergone a course in the Safe Handling and Administration of Medication. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 15 Records of this training and first aid training were been maintained on the individual members of staffs personnel file. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS22 NMS23 Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. There was a complaints procedure in place at Etherley Lodge and residents indicated that they felt confident that they could approach staff at any time with any problem they had. Etherley Lodge had an appropriate procedure for handling suspected cases of abuse available in the home and staff had received appropriate training in this area. EVIDENCE: Etherley Lodge is a family owned home and there is a simple complaints policy and procedure in place. A copy of this document was available, at the home for every resident. No recent complaints had been made. Discussions with residents confirmed that if small problems arose then staff dealt these with quite quickly. One resident spoken with commented, they knew who to complain to and how to complain if they needed to. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 17 The home’s procedures for handling adult abuse were available for staff use in the home. Staff had received training on how to deal with the Protection of Vulnerable Adults and records were being maintained of this training. In discussions with staff they confirmed that they were aware of the importance of acting quickly in cases of suspected abuse and that they would follow the homes policy and procedures if necessary. There had been no recent adult protection issues at the home. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS24 NMS30 Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. Etherley Lodge is clean, pleasant, and hygienic and provides a safe, homely and comfortable environment for its residents to live in. EVIDENCE: Etherley Lodge was clean, tidy and generally free from unpleasant odours. Individual residents rooms had been decorated and furnished in a homely manner and to the taste of the resident. Etherley Lodge was generally well decorated, furnished and maintained. Maintenance work undertaken on the homes equipment and facilities had been recorded appropriately. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 19 A full physical audit had been undertaken recently, and a 12 month action plan had been developed to ensure that areas requiring redecoration and refurbishment work would be completed within identified timescales. There were appropriate systems in place for infection control. The homes infection control policies and procedures were written in accordance with relevant legislation and professional guidance. It was confirmed by staff that they had received appropriate training in infection control and a record of this had been kept on their personnel file. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS 32 NMS 34 NM S35 Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. Etherley Lodge through its recruitment, employment, and training procedures were ensuring that only suitably qualified staff were employed the home. Staffing levels at the home were sufficient to meet the current assessed needs of the residents. EVIDENCE: The Registered Manager had the required qualifications and experience to run the home. From a review of the staff rota provided it was noted that staff were being deployed in sufficient numbers as to ensure the needs of the residents were being met. There was a commitment to training for all staff at the home and currently over 50 of the homes care staff were qualified at NVQ level 2 or above with the rest of the staff in the process of completing the qualification. Staff who had recently been employed had received induction training. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 21 There was a rolling training programme operating in the home that provided training for staff in moving and handling, first aid training and the Protection of Vulnerable Adults. Records of training undertaken and completed by staff were being maintained on individual members of staffs personnel file. All staff employed at the home had being recruited in accordance with the homes policies procedures. All of the appropriate employment checks prior to starting to work at the home had been undertaken and recorded accordingly. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NMS37 NMS39 NMS42 Quality in this outcome area is good. This judgment has been made from evidence gathered both during and before the visit to this service. Etherley Lodge had in place, a variety of quality assurance systems, including resident meetings to enable residents to express their views. Etherley Lodge actively promoted the health, safety, protection and welfare of the residents EVIDENCE: Records of individual staff and management supervision sessions were being maintained securely and staff confirmed that they had received copies. There were also regular staff meetings and group supervisions being held to enable the staff group to develop their own individual care roles. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 23 From discussions with staff it was confirmed that they were aware of the management structure within the home. Records were being maintained of the regular health and safety checks when they had been completed. Etherley Lodge undertakes surveys of residents, visitors, or visiting professionals to find out their views of the home and the care provided. Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 x 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X Etherley Lodge DS0000007470.V310152.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. 1. Refer to Standard YA8 Good Practice Recommendations It is recommended that the home further develop systems to involve residents in the decision-making processes at. 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