CARE HOMES FOR OLDER PEOPLE
Feltwell Lodge Lodge Road Feltwell Thetford Norfolk IP26 4DR Lead Inspector
Kim Patience Unannounced Inspection 16th February 2006 11:15 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 Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Feltwell Lodge Address Lodge Road Feltwell Thetford Norfolk IP26 4DR 01366 728282 01366 727361 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 Thomas Paul Hanley Mrs Sandra Elizabeth Hanley Mr Thomas Paul Hanley Care Home 23 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (15) of places Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 11.05.05 Brief Description of the Service: Feltwell Lodge is a care home providing personal care and accommodation to twenty-three Older people, eight of whom may have dementia. The Victorian house is set in five acres of landscaped gardens, surrounded by woodlands and provides a peaceful location in which to live. The home is situated on the edge of Thetford forest and is two miles from the village of Feltwell. It consists of a two-storey building, with accommodation on the ground and first floor. There are four shared rooms, fifteen single, seven with en-suite. There is a passenger lift and stairway for access to the first floor. Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took approximately 7 hours to complete. The manager was available throughout the inspection and was helpful in facilitating the process, as were other members of staff on duty that day. During the inspection, a tour of the premises was carried out, staff and service users were spoken with and records relating to service users, staff and the running of the business were inspected. The home was taken over by the new owners, Mr and Mrs Hanley in November 2005. Mr Hanley is the registered manager and has many years of experience in running a care home. What the service does well: What has improved since the last inspection?
As mentioned earlier, the management have completed a quality audit and through this process have identified many areas for improvement, which they have built into a 5-year plan. Improvements have already been made to the environment, such as redecoration and re-carpeting in some areas. New furniture has been purchased for the dining area and essential servicing of equipment has been carried out. A new telephone system has been installed and enables residents to have a phone in their room if they wish to. New care plans have been introduced to improve the quality of information relating to residents in addition to improving the recording systems. Staff are undertaking their NVQ training and a total of eleven have started NVQ in the last 3 months. Staff files have been audited and now contain information in accordance with the Care Homes regulations. Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 6 Work has been carried out to the exterior of the home to maintain the safety and standard of the building. The gardens have been improved to make them more attractive to look out on and trees and shrubs have been cut back to improve light and visibility inside the home. 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. Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 7 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 Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 This home does not provide intermediate care services. However, if vacancies arise they will accommodate people for respite. EVIDENCE: The home does not normally provide intermediate care services and do not have beds specifically for this purpose. However, if the home has a vacant bed and the need arises for respite care they will accommodate the request. Pre-admission assessments will be completed as usual and care plans are formulated on admission. The home will, if necessary, work to a plan of rehabilitation as determined by other professionals. If the resources are not available then the request will be refused. Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 The home has systems in place to demonstrate that people’s health needs are met. EVIDENCE: The new management have introduced a more effective care plan system and transferred key information from old records as well as updating records with additional information. The new care plans include a medical profile that assesses peoples health needs and establishes how these will be met. The profile includes details of medical needs and the GP individuals are registered with. Residents can choose to remain with their own GP if feasible in terms of effectively meeting their needs, or they can transfer to a local practice with a GP of their choice. The home has links with the local practice to ensure good access to other professionals such as district nurses and occupational therapists where needed. Residents receive treatment in the privacy of their own room and the home does not have a treatment room. A district nurse was seen to enter the home during the inspection and provided treatment in the resident’s own room. Residents are provided with access to a chiropodist every 4-6 weeks or sooner if required and Opticians visit the home to complete eye tests.
Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 10 Resident’s records also show evidence of health needs being met and all visits are entered into the daily progress notes relating to each individual. In addition, a diary of daily events is maintained for handover purposes. Service users spoken with reported that their health needs are met and they have access to treatment when needed. Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 Not assessed on this occasion. EVIDENCE: Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 Not assessed on this occasion. EVIDENCE: These standards were not assessed. However, the manager reports that no complaints or adult protection matters have arisen since the last inspection. Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25, 26 Service users are provided with a clean homely environment in which to live. There is access to ample communal space in and out of the home and personal living space is comfortable and personalised. However, some refurbishment is needed throughout the home that would improve the overall standards. EVIDENCE: The home is situated on the outskirts of Feltwell with access via a long drive leading to the home, which is surrounded by woodland. The location is peaceful and ideal for people who enjoy the countryside. The grounds attract a variety of wildlife that can be seen from the many windows looking out over the gardens. The new management have invested time in improving the gardens, which were said to be overgrown, to enhance the view for residents. One visitor to the home commented on the ‘much improved’ gardens. The home has an outside patio area that needs some cleaning and repair to make it safe along with new garden furniture.
Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 14 Inside the home, there is a small conservatory area, a large communal lounge and a separate dining room. All were reasonably furnished and decorated. The residents rooms entered, were pleasant and personalised with their own pictures and items of furniture. One room was in need of some refurbishment, however, this is in the plan of renewal and maintenance. Not all resident’s rooms had locks fitted to the doors and not all contained a lockable facility in which to store valuables and personal items. See recommendations. A copy of the Feltwell decorating and maintenance record was supplied during the inspection and shows that a number of improvements have been made such as the redecoration of the kitchen, three residents rooms, the laundry room and the office. New carpets have been fitted in the dining room and three residents rooms. New furniture has been placed in the lobby, dining room and there is a new w/c. In addition, a rolling programme of carpet replacement has been implemented. A number of other general improvements have been made such as a new phone system has been installed that enables residents to choose to have a phone in their room if they wish. The boiler, lift & hoists and fire alarm have been serviced. At the last inspection a requirement was made that hot water regulators must be fitted to ensure that the water temperature from the hot tap is maintained at a safe level. This requirement has not been met and is carried forward for the third time. See requirements. In addition, a recommendation was made that the fuse board on the first floor be covered as this could pose a risk to residents. This recommendation has not been met. However, during discussions with the manager, he confirmed that plans were in place to address this issue. The recommendation is carried forward. See recommendations. When touring the building all areas were seen to be clean and tidy. The home employs two domestic staff to ensure that good standards of cleanliness are maintained. Residents were satisfied with the standards in this respect. Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29,30 The home has plans in place to ensure that staff are trained and competent to do their job. The home has systems in place to ensure that staff are recruited using a robust procedure that protects vulnerable people. EVIDENCE: At the last inspection a requirement was made in respect of staff completing NVQ training. Staff training records show that the new management have registered staff on NVQ training that commenced in December 2005. Six care assistants are undertaking the NVQ3 and five staff are undertaking NVQ2. Two care assistants have completed level 3 already and two have completed level 2. Staff training records show that all staff have been provided with regular training to ensure competence in their role. The new management have developed a comprehensive training plan for 2006 that shows clearly what objectives are to be met, the training needs in this respect, who requires training, where it will be sourced and how it will be funded. The plan shows a good combination of internal and external training. The management clearly demonstrate a good understanding of the need to have a well-trained competent workforce in order to deliver a quality service.
Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 16 A requirement was made at the last inspection in respect of staff files not containing information in accordance with the regulations. The new management have audited the files and completed the necessary checks on staff. Files are now compliant with the regulations. Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 The home is managed by a person who is fit to do so. The new management have a clear focus on improving the facilities and service provided. The home aims to safeguard service users financial interests, however, are not involved in this aspect of care. EVIDENCE: The new owner/manager is a qualified nurse and has significant experience of managing care services. He has commenced an NVQ 4 and is committed to the continuous improvement of his knowledge and skill. When the new owners took over the management of the home their priority was to complete a quality audit. They implemented a Care Track Quality Audit
Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 18 System that looks at each aspect of the service in detail enabling the identification of deficits and thus areas for improvement. Service users and their relatives were surveyed and the results of the survey have been analysed and published in the newsletter. The manager was committed to addressing those issues identified by service users. A full report is yet to be produced and it is recommended that once completed, service users and the Commission are provided with a copy. See recommendations The home does not handle any money for service users, however, they will give advise and support about managing finances in order to safeguard people from possible abuse in this respect. Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 X X X 2 2 3 STAFFING Standard No Score 27 X 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 X Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP25 Regulation 13(4) Requirement The registered person must ensure that regulators are fitted to hot taps to maintain the water at a safe temperature. This is carried forward for the third time Timescale for action 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP24 OP24 OP20 Good Practice Recommendations It is recommended that residents are offered the option of having a lock fitted to the door of their room. It is recommended that the registered person provide a lockable facility in each resident’s room to provide safe storage of personal items. It is recommended that the fuse box located on the first floor be covered to reduce risk to residents. Feltwell Lodge DS0000065148.V284112.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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