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Inspection on 23/11/05 for Etherley Lodge

Also see our care home review for Etherley Lodge for more information

This inspection was carried out on 23rd November 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Etherley Lodge is a well-established home that offers a lifestyle that according to the people who lived there they liked. Those staff spoken with were able to show that they respected the rights and confidentiality of the residents. The Inspector observed during the inspection process how the residents and staff were working together in a friendly and relaxed manner. Residents were being given the opportunity to take part in different activities and attend various places of interest and socialise with the local community.

What has improved since the last inspection?

The home has increased the number of ensuite rooms available to the residents as well as updating the electrical systems within the home and refurbishing some of the rooms that residents use.

What the care home could do better:

Although Etherley Lodge has in place good systems of recording, for the planning of care some improvements could be made in how they record the detail of how they tried to address those residents who have tried to quit smoking.

CARE HOME ADULTS 18-65 Etherley Lodge Etherley Lodge Low Etherley Bishop Auckland Durham DL14 0HD Lead Inspector Mr Leonard Hird Unannounced Inspection 23rd November 2005 09:30 Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 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.V257137.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V257137.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Etherley Lodge Address Etherley Lodge Low Etherley Bishop Auckland Durham DL14 0HD 01388 832879 01388 833647 tirving159@aol.com 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 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.V257137.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st February 2005 Brief Description of the Service: Etherley Lodge provides residential care services for up to 1 person in the category of dementia over the age of 65, 20 persons in 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). The home is situated within its own large and pleasant grounds in the village of Low Etherley and is close to the the town of Bishop Auckland and its amenities. Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Friday November 23rd and lasted for 4 1/2 hours. This inspection looked at a number of important areas, such as how people were admitted to the home, how personal needs were met, what meals were provided and how residents could influence decisions in the home. During this inspection ten residents were spoken with as well as four members of staff, the registered manager and the registered provider. A tour of the of the home was made and observations were made throughout the day. 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. Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 Page 6 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.V257137.R01.S.doc Version 5.0 Page 7 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, NMS 3, NMS 4 The systems found to be operating in the home regarding the admission of prospective residents enabled prospective residents as well as their relatives to make an informed choice as to whether the home was suitable for them to live there. EVIDENCE: Looking at the records of recent admissions to the home it was seen that assessments of need had been undertaken prior to admission. These records had been signed either by the resident themselves or their representatives to indicate that they had been involved in the assessment process. From looking at residents files it was seen that trial visits had occurred. Residents spoken with confirmed that they had been offered the opportunity to visit the home before moving into it. Specialist services required by individual residents were been accessed by the homes staff on behalf of the service user. Records had been maintained of these interventions eg the involvement of CPN’S. The home made available information in regard to the accessing of independent advocacy schemes for residents. Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 Page 8 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): NMS 6 , NMS7, NMS 8,NMS 9 and NMS 10 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. EVIDENCE: Residents spoken with during the inspection process confirmed that they could make decisions for themselves and this was being recorded on their care plans. Where decisions had been made by others on behalf of the resident a record was being maintained of who had been involved in this decision-making process and the reasons why these decisions had been reached. Residents records were being well maintained and managed by the home and all of the information was being kept on a computer database that was the accessible only to authorised persons. Residents who wanted to manage their own finances were being encouraged to do so by staff and records of this were being maintained. Residents said that they had enjoyed going out and spending their money on things that they wanted e.g. new clothes or a pint at the local pub. Residents meetings had been held and records of these meetings were being kept at the home. Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 Page 9 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): NMS 12, NMS15, NMS 16 and NMS 17 There were good links with the local community and these were helping to support and enrich residents social and educational opportunities. The meals in the home are of a good standard and residents are offered both choice and variety of food from the Menus EVIDENCE: Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 Page 10 Residents were encouraged to maintain links with both family and friends by the home. Residents confirmed that they had visits from their family and that they could invite their family members into their rooms if they wished. Observations made during the inspection process confirmed that visitors were coming into the home to see individual residents and that they were being made welcome. From records reviewed as well as from conversations with residents during the inspection process it was confirmed that the home assisted residents in dealing with their personal finances. Staff were also trying where ever possible to develop residents interests in vocational and further educational skills. Residents plans confirmed that the individual residents were being given the opportunity to be alone in their own room if they did not wish to partake in any of the homes activities. From discussions with residents, management and staff it was confirmed that residents requiring specialist diets were being catered for, it was also confirmed by residents that there were alternative choices available. Residents were able to access a small separate kitchen facility in the home enabling them to prepare their own snacks and drinks as and when required. A record was being maintained of food served to individual service users. Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 Page 11 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): NMS 18 NMS 19 The health needs of residents were being well met with evidence of good multidisciplinary working taking place and on a regular basis. EVIDENCE: A review of residents plans confirmed that service users were receiving support and advice from the appropriate health professionals as and when required. Staff were observed during the inspection process to be providing sensitive, dignified and flexible support to the individual resident. Residents were seen to have chosen clothes in their own style and their overall appearance reflected their personality. Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 Page 12 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): NMS 22 NMS 23 The home is currently providing an environment where residents could feel safe as well as being able to speak up for themselves. EVIDENCE: There was a complaints procedure displayed in the home and those residents spoken with indicated that they knew howand who to complain too.The information provided by the home to its residents on how to make a complaint was contained in a user-friendly document and this was being made available to all of the residents. The policies and procedures relating to this standard were subject to an annual review by an external company and this review also took account of changes in guidance where applicable. In discussions with staff they confirmed that in their training courses the Protection of the Vulnerable Adult was covered. They also indicated they were aware of the homes policies and procedures on how to deal with any allegations that might occur. Staff confirmed that they were fully aware of the importance of this standard and also the need for confidentiality when dealing with any allegations that might occur. Records of training undertaken by staff were being maintained on their respective files. Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 Page 13 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): NMS 29 NMS 30 Residents were being provided with equipment to help them remain independent. The home was generally clean and hygienic and free from unpleasant odours. EVIDENCE: Residents were being provided with the specialist equipment they required to maximise their independence. When equipment and aids had been provided to residents records were being kept to show that this had happened. Individual assessments for specialist equipment were being maintained by the home on the residents plan of care. During the inspection it was observed that the home was generally clean, hygienic and on the whole free from offensive odours. However the majority of the residents living at the home were smokers and consequently there was a very strong odour of cigarette smoke throughout the home. The home were taking measures to to deal with this problem by collecting ash and used cigarettes in the home as well as undertaking risk assessments to deal with both the physical and health dangers of smoking. There was a designated non-smoking room for the residents who did not smoke. Residents spoken with said that they enjoyed having their cigarettes and pipes to smoke and that smoking helped them get through their the daily life. Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 Page 14 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): None of the standards were assessed. EVIDENCE: Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 Page 15 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): None of the standards were assessed. EVIDENCE: Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 x 14 x 15 3 16 3 17 Standard No 31 Score x x x x x x X X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Etherley Lodge Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x X x x x x x DS0000007470.V257137.R01.S.doc Version 5.0 Page 17 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. Refer to Standard Good Practice Recommendations Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Etherley Lodge DS0000007470.V257137.R01.S.doc Version 5.0 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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!