Inspection on 28/06/05 for Filsham Lodge Residential Care Home

This inspection was carried out on 28th June 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 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

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

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

Filsham Lodge Residential Care... 13/12/05

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 Unannounced 28 June 2005 9:30 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 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 H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Filsham Lodge Address 135 -139 South Road Hailsham East Sussex BN27 3NN 01323 844008 Telephone number Fax number Email 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 and Mrs T Ravichandran Mr and Mrs N Suganthaumaran Mrs Olive Dunford Care home 39 Category(ies) of Dementia - over sixty-five (65) years of age registration, with number (DE(E)) 39 of places Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1 That only service users with a dementia type illness are admitted to the home 2 The number of service users will not exceed thirty-nine (39) 3 Service users must be aged sixty-five (65) years and over on admission Date of last inspection 7 July 2004 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 two stair lifts 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 5 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 H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over eight hours in June 2005. The purpose of the inspection was to assess compliance with the requirements of the previous inspection and to generally monitor care practices. It found significant improvements within the home and clear evidence that a lot of time and effort had gone into addressing many of the shortfalls identified during the last inspection. Fifteen of the seventeen National Minimum Standards that were inspected had been met or partially met. Service users and relatives spoken to during the inspection expressed overall satisfaction with the home, the staff and the service provided. A tour of the premises took place and documentation, including service user and staff files was inspected. Five of the service users’ relatives, three of the staff on duty and seven of the thirty eight residents were spoken to. What the service does well: What has improved since the last inspection? More information is now readily available for prospective residents and their relatives in the form of an updated ‘Statement of Purpose’ and a newly developed and comprehensive ‘Service User Guide’. Other important documentation to be improved since the previous inspection includes the pre-admission assessment format and the individual service user’s care plan. Both of these are vital in ensuring that people are only admitted to Filsham Lodge once their personal, social and psychological care and support needs have been identified and are able to be met in a structured and consistent manner. Morale amongst the staff team has improved and individual members of staff have clearly benefited from a more open and inclusive atmosphere within the home. Specific training, including dementia awareness has also increased both levels of skill and confidence. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 6 Recent improvements to the physical environment have also been made, including a major overhaul of the electrical system and a full review of the hot water temperature regulators, throughout the home. The appearance of the building has been enhanced by the raised flower bed built by the front entrance to the home, which itself has been made more easily accessible. New appliances have been provided since the previous inspection, including a washing machine with sluice facility, a carpet cleaner and a dishwasher. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 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 standard(s) 1, 2, 3, 4 5 Recently updated documentation ensures that prospective service users and their relatives have sufficient information about the home and the services provided. The admission procedure is comprehensive and thorough, ensuring that service users are admitted only on the basis of a full needs assessment undertaken by people competent to do so. EVIDENCE: The Statement of Purpose and Service Users Guide have been developed and significantly improved since the previous inspection. They now provide comprehensive information about the home for the benefit of existing and potential service users and their relatives. It was noted however that the Service Users Guide does not contain details of the home’s complaints procedure. This was discussed with the manager who will ensure that this is addressed. Following a referral to the home, the manager undertakes a full assessment to identify the individual’s needs and ensure that the home is able to meet them. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 9 A detailed pre-admission assessment form has been developed and includes information relating to the individual’s personal, medical, social and psychological care needs. From discussion, it is evident that the manager and the proprietors are fully aware of the importance of a thorough needs assessment, as part of the admission procedure. Prospective service users and their relatives are encouraged to visit the home and have the opportunity to look around and meet members of staff and existing residents. This was confirmed by several relatives, spoken to during the inspection: ‘It’s a big decision to make but we knew as soon as we walked through the door that this was the right place’. ‘It was clean and comfortable and everyone seemed so friendly – and that’s very important’. Each service user is provided with a written contract containing a statement of terms and conditions of residence. In files that were examined it was noted that the contract is signed by the service user, or a relative or representative, on their behalf. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 10 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 standard(s) 7, 8, 9 & 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. Policies and procedures for the control and administration of medication are effective with clear and comprehensive systems being in place to ensure service users’ medication needs are met. Service users benefit from the provision of appropriate and respectful support with their health and personal care needs. EVIDENCE: Significant improvements have been made in the care planning process since the previous inspection. As required, specific training has been provided for staff in developing and maintaining care plans. The manager confirmed that this external training has been applied to internal processes. Another positive development sine the last inspection has seen some much needed delegation of responsibility. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 11 The deputy manager and senior care staff are now directly involved in care planning and cascading information, including the importance of effective communication and general record keeping. Care plans that were viewed were found to be generally well maintained and up to date. They showed clear links with the individual’s assessed needs and contained details of action to be taken by staff to ensure consistency of care. There was also evidence of plans being regularly reviewed and updated. However there was little evidence of service users or their relatives being involved in this process. It is required that this issue be addressed. Service users’ health care needs are met. The manager confirmed that service users are registered with GP’s and have access to allied health professionals as required, including District Nurses and continence advisors. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 12 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 standard(s) 12, 13 & 15 Social and recreational activities are generally not well managed and do not provide sufficient variety and interest for people living in the home. The dietary needs of service users are well catered for with a balanced and varied menu available that meets individual tastes and preferences. EVIDENCE: Service users’ recreational and leisure interests are recorded in individual care plans, as part of the assessment process. However it is evident that this information is not currently used to form the basis of a structured programme of activities. An established and experienced ‘Activities Co-ordinator’ has recently left Filsham Lodge and her replacement has yet to settle in to her new post or demonstrate her aptitude for the role. It was noted during the inspection that in each of the lounges, a television was on constantly, irrespective of whether anyone was watching. The volume was often distracting and intrusive. A service user’s relative also commented on this, adding that programmes left on were often designed for children or were otherwise inappropriate. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 13 On admission to the home, service users are encouraged to personalise their room by bringing in their own possessions and small items of furniture. Visiting at the home is unrestricted. This was confirmed by a service user’s relative who stated that she is made welcome whatever time she visits. An experienced, full time chef maintains a rolling menu, which reflects service users’ preferences and seasonal variations. Meals are varied, balanced and nutritious and specialist diets and alternative options are available. During lunch, staff were observed providing discreet assistance with feeding, where necessary. Comments from service users and their relatives expressed a high level of satisfaction with the meals provided. ‘You couldn’t fault the food here’. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 14 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 standard(s) 16 & 18 The home has a satisfactory complaints system and service users and their relatives feel confident that their views and any concerns are listened to and acted upon. Service users are safeguarded from abuse through robust policies, procedures and relevant staff training. EVIDENCE: During the inspection, a service user’s relative confirmed that the manager and staff are very approachable and will always try to deal with any concerns immediately. A clear and accessible complaints procedure has been developed, as required since the previous inspection. It also includes up to date contact details for the CSCI. A copy of the complaints procedure is to be included in the service users’ guide. The home ensures as far as is practicable that service users are safeguarded from all forms of abuse. Recently developed policies and procedures relating to Adult Protection, including a policy on ‘Whistle Blowing’ are in place. The manager confirmed that new staff are made aware of such policies and procedures during their induction training. New policies and procedures or any significant policy changes are discussed at team meetings. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 15 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 standard(s) 19, 20, 22, 23 & 26 The standard of the physical environment has improved and provides service users with an accessible, safe and homely place to live. Service users benefit from pleasant accommodation that is clean, comfortable, well maintained and decorated to a satisfactory standard. EVIDENCE: Filsham Lodge is generally well maintained and recent improvements to the physical environment, including a more accessible front entrance, demonstrate the manager’s and proprietors’ commitment to raising standards within the home. Service user’s individual and collective needs are clearly met in a comfortable and homely environment. The location and layout of the home is safe, accessible and suitable for it’s stated purpose. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 16 The proprietors confirmed that a complete overhaul of the home’s electrical systems had been carried out since the last inspection. Thermostatic regulators had also been fitted or upgraded to all hot water outlets accessible to service users. Levels of cleanliness were found to be generally high throughout the home. With the exception of two service users’ rooms the premises were free from offensive odours. Infection control procedures are in place and are generally adhered to, however it is required that the issue of effective continence management be addressed. It was noted that many of the appliances had recently been replaced, There are now two new industrial washing machines, with sluice facilities, in place; a dishwasher and an industrial carpet cleaner. All service users’ rooms on the ground floor have been fitted with electronic ‘door guards’ and the proprietor confirmed that this would be extended to all rooms in the near future. In certain service users’ rooms it was noted that condensation had formed within the sealed double glazed windows, severely restricting the view out. This was pointed out to the manager, who is to ensure that the sealed units are replaced. Since the previous inspection, a full and comprehensive assessment of the premises has been carried out by a qualified Occupational Therapist. Her subsequent report on the suitability of the premises, including any adaptations and specialist equipment used was generally very positive. It was noted that all five recommendations made in the report have since been addressed. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 Thorough and robust recruitment procedures help to ensure the safety and protection of service users. There are sufficient trained and competent staff on duty at all times to meet the assessed care and support needs of the service users. EVIDENCE: The manager operates a thorough and robust recruitment procedure and all prospective staff are seen and interviewed by her before commencing work in the home. Staff files that were examined were found to contain all necessary information, including two written references, and satisfactory Protection of Vulnerable Adults (POVA) and Criminal Record Bureau (CRB) checks. Care staff employed in the home have the relevant skills and are deployed in sufficient numbers to meet the assessed needs of the service users. Both am and pm shifts are covered by a minimum of five staff with additional twilight workers from 6am – 10am and 8pm to midnight. There are 3 waking night staff on duty each night. As well as induction and core skills training, all staff have recently undertaken specific training relating to dementia awareness. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 18 Several members of staff spoken to during the inspection were able to confirm this: ‘They’re pretty hot on training now. There’s always something going on’. ‘The dementia training was good. I think most people found it found it very useful’. Any new policies and procedures or amendments to existing ones are discussed at the monthly ‘Standards of Care Meeting’, which the manager was pleased to say is generally well attended. She also confirmed that staff are required to sign to acknowledge that they have received and read copies of key policies. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 36 & 38 Current quality monitoring systems are inadequate and do not include seeking the views of service users’ relatives. Staff are aware of and adhere to policies and procedures relating to health and safety, ensuring the health, safety and welfare of all service users and staff. EVIDENCE: From discussions with manager and proprietors, it is evident that the home does not currently operate an effective quality monitoring system. In order to monitor service provision and to obtain useful and important feedback, satisfaction questionnaires for both service users and their relatives are to be developed and introduced. Formal staff supervision is not currently provided, as required. From discussions with the manager, it is evident that further work relating to the structure and recording of supervision sessions is still to be done to address this important issue and to ensure compliance. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 20 Despite the number of requirements made at the previous inspection, the manager and proprietors are keen to emphasise that he health, safety and welfare of service users and staff within the home is a high priority and taken very seriously. A ‘Health and Safety’ information pack has been developed and is provided to all employees. Staff now also receive regular training and refresher courses in many aspects of health and safety, including manual handling, fire safety and first aid. A training matrix has been introduced, with details of specific training provided for each member of staff. This is now displayed outside the manager’s office. COSHH assessments are in place and up to date. As previously documented, since the last inspection a major overhaul of the home’s electrical systems has been carried out and certificates confirming this were made available. Water temperature regulators have also recently been fitted or replaced for all hot water outlets, accessible to service users. Window restrictors and radiator guards are fitted as required and environmental risk assessments are in place. Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 21 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 3 x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x x 2 x 3 Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 22 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. 1. Standard 1 Regulation 5 Requirement It is required that the Service Users Guide be amended to include details of the homes complaints procedure. It is required that the service user and their relative have the opportunity to be involvred in developing and reviewing their individual care plan. It is required that a 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 all parts of home are kept clean and free from offensive odours. It is required that a system of quality monitoring is developed and implemented, to include consultation with service users and their relatives. (Previous timescale of 26.03.2005 was not met). It is required that formal supervision be developed and introduced for all staff. (Previous timescale of 26.03.2005 was not met). Timescale for action 31.07.2005 2. 7 15 (1) (2) 31.07.2005 3. 12 16 (2) (n) 31.08.2005 4. 5. 26 33 23 (2) (d) 24 (1) (3) 31.07.2005 31.08.2005 6. 36 18 (2) 31.08.2005 Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 23 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 Good Practice Recommendations Filsham Lodge H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection 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 H59 H10 S62001 Filsham Lodge V218048 280605 stage 4.doc Version 1.20 Page 25 - 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. 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