Inspection on 27/02/06 for Etherley Lodge

This inspection was carried out on 27th February 2006.

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 10/01/07

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 27th February 2006 09:30a Etherley Lodge DS0000007470.V275577.R01.S.doc Version 5.1 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.V275577.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 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.V275577.R01.S.doc Version 5.1 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.V275577.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd November 2005 Brief Description of the Service: Etherley Lodge provides residential care service 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). The home is situated within its own large pleasant grounds in the village of Low Etherley and is close to the town of Bishop Auckland. Etherley Lodge DS0000007470.V275577.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Monday, February 27 and lasted for 4 hours.The inspection looked at those key standards not inspected at the last inspection these included, the involvement of residents within local community, medication, the environment, staffing and the conduct and management of the home. During this inspection 12 residents were spoken with as well as 4 staff and the registered provider. A tour 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.V275577.R01.S.doc Version 5.1 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.V275577.R01.S.doc Version 5.1 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): None of these standards were assessed at this inspection. EVIDENCE: Etherley Lodge DS0000007470.V275577.R01.S.doc Version 5.1 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): None of these standards were assessed at in this inspection. EVIDENCE: Etherley Lodge DS0000007470.V275577.R01.S.doc Version 5.1 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 13 There were links that had been developed by the home that enabled residents to develop and enrich their opportunities either individually or as a group to live and interact in the local community. EVIDENCE: Evidence was available to show that service users took part in a range of leisure, social and cultural activities supported by staff at the home. The home employed an activities organiser who regularly took residents out either individually or in small groups to different locations within the local community. Residents were being encouraged wherever possible to make use of public transport and taxis to go into Bishop Auckland and the surrounding district. Records were being maintained of activities undertaken by individual residents as well as records showing the options that were available to the individual resident. Several residents spoken with said that they enjoyed going out to different places with the support of staff from the home but they indicated that they also enjoyed doing their own thing within the community e.g. visiting the local cricket club on a night or going out with their partners. Etherley Lodge DS0000007470.V275577.R01.S.doc Version 5.1 Page 10 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 20 There was no residents self- medicating at the time of the inspection. There were appropriate policies, procedures and guidance in place for both staff and residents to ensure that if any resident wished to self medicate then they could. EVIDENCE: There were appropriate policies, procedures and guidance available for both residents and staff on how to manage the area of self-medication for residents. All residents had signed a document to indicate that they were happy for the home to manage and administrate their medication and this record of agreement was being kept on the individual residents file. Etherley Lodge DS0000007470.V275577.R01.S.doc Version 5.1 Page 11 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): Neither of these standards was assessed at this inspection. EVIDENCE: Etherley Lodge DS0000007470.V275577.R01.S.doc Version 5.1 Page 12 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 24 Etherley Lodge provides a safe, comfortable and homely environment for it’s residents. EVIDENCE: A new resident who had lived at the home for approximately three months commented that they were very happy with the home because it was “what they wanted, it was the best home they had been in and they were very happy with their room ”. Refurbishment and redecoration had been undertaken in both the communal and individual residents living spaces over the past months. Individual residents had helped choose the decorations and fittings in their rooms prior to them being redecorated. Residents spoken with said that they were happy with their rooms and where ensuite facilities had been added they said they felt it was a great improvement. Records were being maintained of work both undertaken and completed. There were risk assessments in place for the health and safety of the individual resident and staff who lived and worked at the home. These risk assessments were being regularly reviewed and updated where necessary by an external company. Etherley Lodge DS0000007470.V275577.R01.S.doc Version 5.1 Page 13 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 had NMS 35. Staff had received appropriate levels of training, support and supervision to ensure that residents were been looked after by competent staff. EVIDENCE: Records were being maintained of all training undertaken by the staff and these indicated that 22 staff had undertaken and successfully completed a NVQ level 2 in care, 4 staff had successfully completed NVQ level 3 in care and 2 staff had successfully completed NVQ level 4 in care. Staff had also received training in the following; first aid, dementia awareness, and were about to undertake a course in managing conflict. Senior staff had also undertaken a safe handling and administration of medication course. The members of staff who were spoken with confirmed that they had received supervision and training whilst at the home. All staff employed at the home had undergone prior to their employment an appropriate reference check, an enhanced criminal records bureau check and an interview. Personnel records were being maintained in an orderly an up-to-date manner. Etherley Lodge DS0000007470.V275577.R01.S.doc Version 5.1 Page 14 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): NMS 37, NMS 39 and NMS 42. Etherley Lodge is being properly managed for the benefit of the residents and staff who live and work there. The home carries out regular health and safety checks throughout the home so that the residents and staff living there are protected. EVIDENCE: The registered manager had the appropriate management qualification and was in the process of completing the NVQ level 4 in care. It is clear that the records, the policies and procedures and other documents looked at during the inspection were being properly managed and used by staff in the day to day running of the home. The refurbishment and redecoration programme was being well received by residents and had improved facilities for the residents. Residents confirmed that they had been involved in choosing furnishings and decorations for their rooms. Policies and procedures were being reviewed regularly both by the home and an external company. There had been recorded residents meetings arranged by the home and suggestions made by the residents had been acted upon. Etherley Lodge DS0000007470.V275577.R01.S.doc Version 5.1 Page 15 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 X 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 X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 3 X 3 X X 3 X Etherley Lodge DS0000007470.V275577.R01.S.doc Version 5.1 Page 16 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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