Inspection on 13/12/05 for Filsham Lodge Residential Care Home

This inspection was carried out on 13th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Filsham Lodge Residential Care... 31/07/07

Filsham Lodge Residential Care... 15/08/06

Filsham Lodge Residential Care... 28/06/05

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

CARE HOMES FOR OLDER PEOPLE Filsham Lodge 135 - 139 South Road Hailsham East Sussex BN27 3NN Lead Inspector Nigel Thompson Announced Inspection 13th December 2005 09:30 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 Filsham Lodge DS0000062001.V250073.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 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. Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Filsham Lodge Address 135 - 139 South Road Hailsham East Sussex BN27 3NN 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) 01323 844008 Mr and Mrs T Ravichandran Mrs Radha Ravichandran, Mr Nallanathan Suganthakumaran, Mrs Suganthini Suganthakumaran Mrs Olive Dunford Care Home 39 Category(ies) of Dementia - over 65 years of age (39) registration, with number of places Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That only service users with a dementia type illness are admitted to the home The number of service users will not exceed thirty nine (39) Service users must be aged sixty five years (65) and over on admission. 28th June 2005 Date of last inspection Brief Description of the Service: Filsham Lodge is registered to provide personal care for a maximum of thirtynine service users with a dementia type illness. The building is on two floors with a passenger lift and one stair lift providing safe and easy access to all parts of the home. Service user accommodation comprises 31 single rooms and 4 shared double rooms. Adequate communal space includes 4 lounges (3 with integrated dining areas), a conservatory and sufficient bathrooms and toilet facilities. For personal care and support purposes the home is divided into three areas, with service users allocated rooms in these areas depending on their individual needs and assessed level of dependency. There is level access to the front of the building with safe and attractive gardens to the rear. Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over five hours in December 2005. It found that all of the National Minimum Standards that were assessed had been met or partially met and the overall quality of care provided was good. Service users spoken to during the inspection expressed satisfaction with the home, the staff and the service provided. On the day of the inspection there were thirty seven service users living at the home. The inspection involved a tour of the premises, examination of the home’s records and discussion with the Registered Manager and Providers. Three members of staff and four service users were also spoken with. The focus of the inspection was on the quality of life for people who live at the home. In order that a balanced and thorough view of the home is obtained, this report should be read in conjunction with previous inspection reports. What the service does well: What has improved since the last inspection? Communication and consultation with service users’ family members has improved. Relatives have the opportunity to partake in individual assessment, care planning and reviewing processes. A motivated and enthusiastic activities coordinator has been appointed and is working hard to develop stimulating activities to meet the individual and collective recreational and social care needs of service users. Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 6 As part of an ongoing maintenance programme of refurbishment and redecoration, new carpets have been fitted in one of the lounges and three service users’ rooms have been redecorated. The passenger lift has recently been serviced and upgraded. Quality assurance checks (audits) have been introduced and will ensure that environmental standards are maintained and all aspects of care, including catering, medication, laundry and activities are regularly reviewed and monitored. 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. Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 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 Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 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): 1&6 Documentation, including a comprehensive ‘Statement of Purpose’ and ‘Service Users’ Guide’ ensures that prospective service users and their relatives have sufficient information about the home and the services provided. EVIDENCE: Information is available to prospective and existing service users in various formats. The Statement of Purpose and the Service User Guide, amended as required since the previous inspection, have been produced to a satisfactory standard and are both comprehensive and informative. The Manager confirmed that intermediate care is not currently provided at Filsham Lodge. Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 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): 7, 8 & 10 Service users’ care plans are developed from a comprehensive assessment of an individual’s needs and enable staff to meet such needs in a structured and consistent manner. However plans need to be regularly reviewed and updated to reflect significant changes in an individual’s condition or care needs. EVIDENCE: Care plans have been developed for each service user and are clearly and directly linked to the individual’s assessed needs. The majority of service users’ individual plans that were inspected were found to be accurate, generally well maintained, and up to date. The Manager confirmed that service users’ relatives are given the opportunity to attend care plan reviews and this was evidenced by copies of ‘invite letters’ in individual service user’s files. It was also noted that in certain cases relatives had signed review records to confirm their involvement. However, in the case of one service user’s plan that was examined, it was noted that although an entry on the communication sheet referred to the Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 10 appearance of a pressure sore, this was not cross referenced or reflected in the section of the care plan which details action to be taken by staff. Although members of staff, spoken with during the inspection, confirmed that they were made aware of the individual’s pressure area, ‘generally during handovers’, there was evidence of inconsistencies regarding the appropriate action to be taken. It was also noted, in this particular case, that the plan had not been reviewed or updated since 31 August 2005. Following discussion with the Registered Manager and to ensure a structured and consistent level of care and support provision, it is required that all service users’ care plans be regularly reviewed and updated to reflect significant changes in the individual’s condition or care needs. All service users continue to be registered with local GPs and have access to other health care professionals, via the surgeries. As part of their induction programme, the Manager confirmed that all staff receive instruction on the principles of dignity and respect. This was evident, through discussions during the inspection, and from direct observation of staff interacting sensitively and professionally with service users. Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 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): 12, 13 & 14 Social and recreational activities are generally well managed, creative and provide daily variety and interest for people living in the home. EVIDENCE: Since the previous inspection, a motivated and very enthusiastic activities coordinator has been appointed. From discussions with service users and their relatives and through direct observation, it is evident that some much needed stimulation is now being provided throughout the home with the introduction of individual and small group activities, including music, crafts, gentle exercise and various games and quizzes. Although service users’ recreational and leisure interests are recorded in their individual care plan, as part of the assessment process, there is no evidence that this information is utilised to form the basis of the activities now being provided. To ensure that service users’ social and recreational needs are met, it is recommended that a structured programme of activities be developed based on their individual assessed needs, interests and preferences. Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 12 Service users’ level of contact with their family and friends is variable, however, the Manager confirmed that visiting to the home is unrestricted and friends and relatives are welcome at anytime, either in the service user’s own room or in one of the communal lounges. Service users’ relatives, spoken with during the inspection, expressed a high level of satisfaction with visiting arrangements and the hospitality of the staff: ‘We come here at different times throughout the day and at weekends and are always made to feel very welcome’. Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 13 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): These standards were not assessed on this occasion. All key standards were assessed during the previous inspection carried out on 28 June 2005. EVIDENCE: Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 14 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, 23, 24, 25 & 26 The service is accessible and safe and remains suitable for its stated purpose. Service users benefit from pleasant accommodation that is comfortable, clean, well maintained and decorated to a satisfactory standard. EVIDENCE: There has been little change in the physical environment of the home since the previous inspection and standards remain high throughout. The well maintained décor and good quality furniture and furnishings provide a comfortable and pleasant environment for service users. Since the last inspection, the Manager has developed and implemented an environmental quality assurance checklist, relating to the cleanliness and general condition of all areas throughout the home. Infection control procedures are in place and clearly adhered to and levels of cleanliness remain high throughout. In the interests of hygiene and to eliminate previous offensive odours, the carpets in two service users’ rooms have recently been replaced with more appropriate floor covering. Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 15 The Manager confirmed that independence and individuality continue to be promoted within the home, as far as is practicable, and this is evident from the personalising of service users’ rooms, which clearly reflects individual tastes, preferences and interests. Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 16 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): These standards were not assessed on this occasion. All key standards were assessed during the previous inspection carried out on 28 June 2005. EVIDENCE: Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 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, 32, 33, 35 & 36 Service users and staff benefit from the manager’s open and approachable style of leadership and clear and positive sense of direction. Quality assurance and self-monitoring systems have improved and help to ensure that the home continues to be run in the best interests of the service users. Despite previous requirements, formal staff supervision is still not currently provided within the home. EVIDENCE: The Registered Manager is competent and experienced and has been in her current post for over five years. Although she is a registered nurse (SRN), she does not currently hold an up to date and relevant management qualification. Therefore, following discussion with her and the Registered Providers and to ensure compliance with Standard Requirements, she is to research the Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 18 necessary ‘management’ units needed to supplement her existing qualifications. Staff, spoken with during the inspection confirmed how approachable and supportive the Manager is: ‘She is firm but fair. You know where you stand with her and what she expects of you’. Comments received from service users’ relatives also supported this view: ‘The home is very well run with very caring staff. Without doubt, the Manager is a tremendous asset. Well done!’. Since the previous inspection, as recommended, the views of service users’ relatives are now sought, by way of satisfaction questionnaires. Responses to a recent survey have been generally positive and express a high level of satisfaction with the home and care services provided: ‘The staff are always very polite and helpful in every way and they do a tremendous job’. ‘I think a lot of thought has been put into developing the home’. Despite a previous requirement, it is evident that formal supervision is still not being provided for care staff. This issue was discussed with the Registered Providers, who fully understand the importance and benefits for staff and ultimately the service users. The Registered Manager and Head of Care are to research specific and updated training, related to the provision of formal staff supervision. Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X 3 3 3 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 3 1 X X Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 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 OP7 Regulation 15 (2) (b) Requirement It is required that all service users’ care plans be regularly reviewed and updated to reflect significant changes in the individual’s condition or care needs. It is required that a structured programme of recreational and social activities be developed, having regard for the individual and collective needs and interests of service users. It is required that the Manager has the necessary qualifications to manage the care home. It is required that formal supervision be developed and introduced for all staff. (Previous timescales of 26.03.2005 and 31.08.2005 were not met). Timescale for action 31/03/06 2. OP12 16 (2n) 31/03/06 3. 4. OP31 OP36 9 (2) (b) (i) 18 (2) 31/03/06 31/03/06 Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 21 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 Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Filsham Lodge DS0000062001.V250073.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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