Inspection on 15/11/05 for Fulwood Lodge Nursing Home

This inspection was carried out on 15th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Fulwood Lodge Nursing Home 15/05/06

Fulwood Lodge Nursing Home 04/05/05

Fulwood Lodge Nursing Home 10/11/04

Fulwood Lodge Nursing Home 29/06/04

Fulwood Lodge Nursing Home 09/03/04

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

CARE HOMES FOR OLDER PEOPLE Fulwood Lodge Nursing Home 379a Fulwood Road Ranmoor Sheffield South Yorkshire S10 3GA Lead Inspector Mrs Janis Robinson Unannounced Inspection 15th November 2005 08:30 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 Fulwood Lodge Nursing Home DS0000021778.V261521.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. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fulwood Lodge Nursing Home Address 379a Fulwood Road Ranmoor Sheffield South Yorkshire S10 3GA 0114 230 2666 0114 230 1713 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) Silver Healthcare Limited Mrs Susan Farrington Care Home 42 Category(ies) of Old age, not falling within any other category registration, with number (42) of places Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. One service user who is under the age of 60 and who is named on the application to vary registration dated 05/02/04, may reside at the home. 10 of the beds registered OP for Older People aged 65 years and over, may alternatively be used for the category PD Physical Disability, for people aged 60 years and above and whose disability is related to the ageing process. 4th May 2005 Date of last inspection Brief Description of the Service: Fulwood Lodge is a three-storey home registered to provide nursing care for up to forty-two older people. Thirty single and six double bedrooms are provided, each with en-suite toilet facilities. Each floor has a communal lounge, the ground and first floors are provided with communal dining areas. A central kitchen and laundry serve the home. Sufficient bathing facilities are in place. The home is situated within easy access to shopping centres, pubs, post office and clubs. The bus service to the town centre is a short walk away. The home has pleasant grounds and a car park. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 6 hours from 8.30 am to 2.30 pm. A partial inspection of the environment took place. Records were inspected, including care plans, staff recruitment and training, residents’ monies, contracts, accident books, discharge records, menu and the staff rota. The inspector spoke with a proportion of the staff on duty, eight residents and one visitor to the home. Three staff were formally interviewed. Care practices were observed. Discussions with the homes manager took place. The majority of standards were assessed and met at the last inspection. What the service does well: The majority of the comments made by residents and the visitor to the home were positive. Residents said they were `well looked after’, and the staff were `kind’. Visitors spoken with commented that they were happy with the care their relative received and had no concerns. Each resident had been provided with a contract, which included all of the required information, to inform them of their rights and obligations. Trial visits to the home took place to allow prospective residents and their representatives to look around the home and stay for a meal before choosing to move in. Care plans were in place for all residents, which set out in detail the staff action required to ensure all assessed needs were met. Residents’ health was monitored and access to health care professionals was facilitated. Choices were offered to residents, and the routines at the home were flexible. The home had an open visiting policy. A varied menu was provided. The home had a complaints and adult protection policy in place, to ensure any complaints or allegations were taken seriously and appropriate action taken. The home was well decorated and well maintained, to provide a pleasant environment for residents. The bedrooms seen were individually personalised. Sufficient staff were provided to care for service users. A thorough recruitment procedure was in place, to ensure appropriate checks were carried out to keep residents safe. Staff undertook periodic training to keep them up to date. All of the people spoken with had confidence in the homes manager. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 6 Residents’ monies were managed safely. Systems were in place to supervise staff. Health and safety within the home was maintained. What has improved since the last inspection? What they could do better: One resident said that on the night before this inspection, one member of night staff had not provided aspects of care as identified as needed. Whilst written adult protection procedures were in place, a copy of local multi – agency procedures were not available, to ensure staff were fully informed. Minor improvements to the decoration in some areas, and some repair work, were required to ensure residents continued to live in a comfortable and well maintained home. Some corridor areas had damage to the decoration. One section of a corridor was not fitted with a handrail, to afford safety. Some lighting in communal areas was not domestic in design. External doors from the dining room were difficult to open. Some paving slabs on a patio area were uneven, posing a possible hazard. The recommended 50 of the care staff team trained to NVQ level 2 in care had not been achieved. The manager had not achieved NVQ level 4 in care. Staff recruitment records did not evidence that gaps in employment history were explored. Some staff required updates in aspects of mandatory training. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 7 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. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 8 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 Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 9 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): 2,3,4 and 5 Contracts had been undertaken with residents to inform them of their rights. Assessments of needs were undertaken prior to admission to ensure that the needs of prospective residents could be met. Staff undertook periodic training to keep them up to date and access to specialist services was arranged, in order that all assessed needs were met. Trial visits were encouraged to enable prospective residents to look around the home, meet residents, staff and give them the information needed to make informed choices. EVIDENCE: Contracts had been undertaken with all residents. Those sampled contained the full range of information required, and included information on the fee charged, the rights and obligations of both parties and the period of notice. The resident or their representative had signed the contracts. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 10 Assessments of needs were in place, and copies of social workers assessments were obtained prior to admission, if available, so that a decision could be made about whether the residents’ needs could be met. All of the residents spoken with felt the home met their needs. One resident said ‘I am well looked after’, and a further resident said ‘The staff are good’. Access to specialist services was supported, to ensure all assessed needs were met. Staff confirmed that residents were able to look around the home, stay for a meal and meet residents and staff, who provided them with the information they needed before choosing to move in. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 11 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 and 11 Each resident had a care plan, to give staff the information needed to ensure all care needs were met. Health care was monitored, assessed and met. Staff respected residents privacy and appeared respectful towards residents, however, staff needed to ensure that care plan guidelines were followed at all times. Each care plan contained a section on death and dying, to ensure residents wishes were sought and carried out. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 12 EVIDENCE: Since the last inspection care plans had been updated to ensure they contained sufficient detail to fully inform staff. Two plans were inspected. They contained all of the information required. They included information on all aspects of personal, social and health care needs. The plans included information on the staff action required to ensure assessed needs were met. The plans contained detail of all health care contacts, appointments and treatments, and access to these was available to ensure health was maintained. Moving and handling, and falls risk assessments had been undertaken for all residents to keep them as safe as possible. One member of staff was a qualified tissue viability nurse. Skin risk assessments were undertaken and equipment to aid tissue viability was available. Regular weight checks took place. The manager had a system in place to audit and monitor care plans to ensure they contained relevant, up to date information. Qualified staff reviewed the plans each month. Staff were observed respecting privacy by knocking on doors before entering. The interactions between staff and residents appeared respectful and caring. Residents made positive comments about their care. Residents said` the home is good, you could not wish for more’ and `staff are very good to me’. However, one resident said that they had recently become more dependent, and required additional help from staff. They reported that during the night prior to this inspection, one member of staff had not provided this extra assistance. Staff must ensure that they remain up to date with identified needs and always follow the guidance identified. The wishes of residents were sought regarding death and dying, which were recorded in plans to ensure these were carried out. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 13 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 and 15 Residents were able to make choices about how they spent their time. A range of activities was offered, to promote choice and maintain interests. The home had an open visiting policy, in order to develop and maintain good relationships with residents’ family and friends. The home provided a varied menu and choices were offered to respect personal preferences. EVIDENCE: Residents said they were able to get up and go to bed when they chose, and were seen to use different areas of the home according to their preference. A range of appropriate social opportunities both in and outside of the home was available. Three shopping trips had been organised to take place before Christmas. On the afternoon of this inspection a clothing party took place. . Details of other forthcoming activities were on display to inform residents and their visitors. Residents confirmed that they were able to see their visitors in private. Those spoken to said their visitors could come at any time, and the home helped them maintain contact. A visitor said that they were always made to feel welcome. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 14 Residents were able to bring personal items with them into the home. All of the bedrooms inspected were individually personalised and very homely. This was important to residents as it helped them retain control over their immediate environment. The menu was varied and a balanced diet was provided to maintain residents health. All said the food at the home was good, and choices were offered on a daily basis. Alternatives to the two choices on the menu were available. On the day of this inspection one resident had chosen a different meal to the two choices on offer and this had been made available. Residents told the inspector that they could have a cooked breakfast if they chose. One resident said `you can have anything you want’, a further resident said that they had been underweight before moving to the home, but were now gaining weight. Staff confirmed that they had access to food supplies at all times. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 15 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): 16 and 18 A clear and accessible complaints procedure was in place, to ensure residents’ rights were protected and any concerns listened to and taken seriously. An adult protection procedure was in place, to ensure residents safety was promoted. Local multi-agency adult protection procedures were not available at the home. EVIDENCE: Each resident and representative had been provided with a copy of the homes complaints procedure. A copy was also on display in the entrance area of the home. This contained relevant detail and informed the reader of who to contact outside of the home to make a complaint, should they wish to do so. All of the residents said they had no concerns and could go to the manager and staff to sort out any worries they had. The Commission for Social Care Inspection had received one anonymous complaint. This was investigated during the inspection and no evidence was found to uphold the complaint. An adult protection procedure was in place. Staff undertook training on adult protection during their induction to equip them with the skills needed to respond appropriately to any allegations. A copy of local multi-agency adult protection procedures was not available at the home. These were required to ensure staff were fully aware of all available information. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 16 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): 19,20,22,24 and 25 The home was clean and generally well maintained. Communal areas were comfortable and homely. All of the bedrooms were well personalised. The lighting in some communal areas was not domestic in design. A handrail was not provided in one part of a corridor. The heating could not be individually controlled in some bedrooms, to afford residents rights and choices. Minor repair work was required to paving slabs and the dining room doors. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 17 EVIDENCE: An inspection of a proportion of the home was undertaken. The home was well decorated and well maintained. Communal areas appeared comfortable and were provided with pictures and ornaments to create a homely environment. Bedroom furniture was of a good standard and bedrooms were individually personalised. The home had access to a handyperson, to help maintain the environment. Minor damage to some corridor areas was due to general wear and tear. A rolling programme of redecoration was in place. Since the last inspection eight bedrooms had been redecorated and provided with new flooring. A programme to provide bedroom doors with locks had commenced, and ten rooms had a door lock fitted. The heating in some bedrooms could not be individually controlled, to provide residents with choice. Whilst handrails were fitted to one side of the majority of corridors, one section of a corridor had no handrail to assist the more mobile residents. The corridor carpet on the first floor was aged and marked in places. Replacement of this carpet needed to be identified within the homes refurbishment plan. The lighting in some communal areas was fluorescent in design, which did not add to the homely atmosphere. The external doors from the ground floor dining room were very difficult to open. The patio area had some uneven paving slabs, posing possible hazards. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 18 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): 27,28 and 29. Agreed levels of staff were being maintained. Some staff undertook NVQ training to improve their skills. Recommended levels of NVQ trained staff had not been achieved. A recruitment procedure was in place, some additional information was needed to ensure all of the required information was obtained. EVIDENCE: The homes rota indicated that agreed levels of staff were being maintained. Residents spoken with felt that enough staff were provided. A programme of NVQ training was in place, to ensure staff developed the skills required to carry out their duties. Of the thirty-six care staff, three staff had achieved NVQ level 2 in care. Five further staff were undertaking the training at levels 2 and 3. A policy and procedure for staff recruitment was in place. Five staff files were inspected. These contained all of the required information and included proof of identity, CRB checks, a contract and two written references. However, whilst application forms obtained information on previous work history, evident gaps had not been explored. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 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 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): 31,32,34,35,36,37 and 38 The manager was qualified nurse and was undertaking NVQ level 4 in management. Staff and residents found her approachable and supportive. Insurance cover was in place. The home had a business plan to ensure financial viability. Residents’ finances were safely managed. A system of staff supervision was in place. Records were stored securely. Health and safety systems were maintained. Staff undertook mandatory training. Some updates to maintain staff skills were required. EVIDENCE: At the time of this inspection the manager was undertaking NVQ level 4 in management. All of the staff spoken to said the manager was approachable and supportive. Residents said that they `could talk to her about anything’. Insurance cover was provided and a relevant certificate was on display in the reception area. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 20 Residents financial systems were inspected. Individual records of financial transactions were recorded, and all receipts were retained. Residents received interest on their bank accounts. Money was stored securely. The system of staff supervision, to support and develop staff, had been improved. Each member of staff had undertaken a contract for supervision and records indicated that these were taking place at the required frequency. Yearly appraisals took place. Records were stored securely at the home, and residents had been informed of their rights to access their care plan. A health and safety policy was in place. Systems were checked and serviced to maintain a safe environment. Weekly fire alarm checks were recorded. A mandatory staff-training matrix was in place, to ensure staff were up to date with all relevant training. The manager had undertaken an audit of training needs and identified gaps. Relevant training was planned to ensure refresher training was undertaken. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 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. 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 X 2 X 3 2 X STAFFING Standard No Score 27 3 28 2 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 X 3 3 3 3 2 Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 22 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 OP10 Regulation 12 Timescale for action All staff must ensure they remain 31/01/06 up to date with residents changing care needs and provide care as identified within individual plans. A copy of local multi-agency adult protection procedures must be available at the home. All parts of the home must be Safely maintained. The uneven paving stones outside the dining room must be made safe. The dining room door must be repaired so that it opens easily. The first floor corridor carpet must be identified for replacement within the homes long-term refurbishment record. Handrails must be fitted to the corridor area where none exist on either side. (Previous timescale of 01/10/05 not met) The heating system must be updated to enable residents to control the heating in rooms. (Previous timescale of 01/11/05 not met) DS0000021778.V261521.R01.S.doc Requirement 2 3 OP18 OP19 13 13 31/01/06 31/12/05 4 OP19 23 31/01/06 5 OP22 23 31/01/05 6 OP25 16 01/03/06 Fulwood Lodge Nursing Home Version 5.0 Page 23 7 OP29 18 8 OP38 18 Staff recruitment files must evidence that gaps in employment history have been explored. All staff mandatory training must be provided as identified within the matrix. 31/01/06 31/01/06 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. Refer to Standard OP28 OP31 Good Practice Recommendations A minimum of 50 of the care staff team must be trained to NVQ level 2 in care. The manager must achieve NVQ level 4 in management. Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Fulwood Lodge Nursing Home DS0000021778.V261521.R01.S.doc Version 5.0 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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