CARE HOMES FOR OLDER PEOPLE
Fulwood Lodge 379a Fulwood Road Ranmoor Sheffield S10 3GA Lead Inspector
Janis Robinson Unannounced 04 May 2005 9:00 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. Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Fulwood Lodge Nursing Home Address 379a Fulwood Road Ranmoor Sheffield S103GA 0114 2302666 0114 2301713 None Silver Healthcare Limited 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) Mrs Susan Farrington N Care Home with Nursing 42 Category(ies) of OP Old Age (42) registration, with number of places Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 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. Date of last inspection 10 November 2004 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 J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over seven hours from 9am to 4pm. The inspector carried out a tour of the environment, sampled records and observed interactions between residents and staff. Eight residents and three visitors to the home were spoken with. Discussions with the homes manager and other staff took place. Two staff were interviewed. What the service does well:
All of the comments made by residents and visitors to the home were positive. Residents said they were `well looked after’, and the staff were `kind’. Visitors spoken with commented that they were `very happy’ with the care their relative received and had no concerns. The home had a service user guide, which gave residents information about the home. Assessments prior to admission took place for all prospective service users, to ensure the home could meet their needs. Trial visits to the home took place. Staff had the skills needed to ensure residents’ needs were well met. Interactions between staff and residents appeared respectful and caring. Care plans were in place for all residents, which set out in some 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. 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. Staff undertook periodic training to keep them up to date. The home had a quality assurance system to obtain the views of residents and visitors. All of the people spoken with had confidence in the homes manager. Health and safety within the home was maintained. Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI 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 Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI 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) 1,3,4 and 5 The home had a statement of purpose and service user guide, which provided residents and relatives with detailed information about the home. Assessments prior to admission took place for all prospective residents, to ensure the home could meet their needs. Visits to the home prior to admission took place, where possible, to support informed choices. Staff demonstrated a clear understanding of residents needs. EVIDENCE: The homes statement of purpose and service user guide were on display in the entrance area. Each resident had been provided with their own copy, to inform them of their rights and choices. Full needs assessments, to ensure the home could meet identified needs, were carried out by the homes manager. These were in place in the care plans. Visitors to the home confirmed that they had been able to visit and look around before making a decision about their relatives care. One visitor said the home had `made us very welcome, and gave the information we needed’. The staff interviewed confirmed that they undertook periodic training, and gave examples of good practice, with regard to residents’ rights and ensuring privacy and dignity were maintained.
Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 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 standard(s) 7,8,9,10, and 11. Each resident had an individual care plan. These set out in some detail the staff action required to ensure identified needs were met. Some further detail on specific staff action was required to ensure staff had the information to meet personal care needs. Residents’ health care was met. Health was monitored and care plans were reviewed on a monthly basis to keep information up to date. Medication was securely stored and appropriately administered, to keep individuals’ safe and well. Residents’ privacy and dignity was respected. Residents’ wishes regarding dying and death required recording in all plans, to ensure these were carried out. EVIDENCE: The inspector examined three care plans. These contained a comprehensive range of information on social, personal and health care needs, and were kept up to date. Some sections of the plans contained insufficient detail to inform staff how assessed needs were to be met. For example, one care plan stated `full assistance with personal care - to offer baths’. The plan did not state how this assistance was to be given. Care plans detailed health care assessments and these were monitored to ensure they contained relevant information. Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 Page 10 Access to health care professionals, such as chiropodist and opticians, was facilitated and all contact and treatments were recorded. All of the residents spoken with said their health care needs were well met. One resident stated that they were`very happy’ with the care provided at the home, and they were`well looked after’. The medication records sampled were up to date and accurate. Medication was securely stored. Staff were observed to treat service users with respect, for example, knocking on doors before entering and respecting residents preferred form of address. All of the residents and visitors spoken with said the staff were `helpful’ and `kind’. One plan did not contain any information regarding the residents’ wishes in relation to dying and death. Where this information had been refused, or was to be sought from families at the appropriate time, this must be recorded to ensure all needs are assessed. Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 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 standard(s) 12,13,14 and 15 The routines at the home were flexible. Residents were able to spend their time as they wished. An activities worker was employed at the home to provide a range of leisure activities should residents wish to join in. There were no restrictions on visiting times and residents were able to receive visits from their family and friends at any reasonable time. A good choice of menu was offered and special dietary needs were catered for. EVIDENCE: Residents were seen to spend their day as they wished, as far as they were able. Some residents chose to join a cake making activity. Other residents were seen walking freely around the home. Staff were observed assisting residents to spend time in their room, at their request. Bedrooms contained personal possessions, to create a comfortable and homely atmosphere. Visitors spoken with said they`were welcome at any time’ and were`kept well informed’. All of the visitors spoken with were happy with the care their relative received at the home, and had no concerns. The home raised funds to enable residents to access `Dial-a-Ride’ facilities for trips out to local attractions. The homes menu was varied. Choices were offered to respect individual preferences. Special diets were provided by the home. Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 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 standard(s) 16,17 and 18 The home had a clear and accessible complaints procedure, to ensure residents rights were protected and any complaint listened to and taken seriously. Those residents who chose to do so, were supported to vote at election time. An adult protection procedure was in place, to ensure residents safety was promoted. EVIDENCE: The homes complaints procedure was on display in a communal area of the home. This contained relevant detail and gave the reader information on who to contact outside of the home, should they wish to do so. The staff interviewed were clear about the homes complaints procedure. The home kept a record of any complaint, which contained relevant detail. All of the residents, visitors and staff spoken to said the manager had an `open door’ and confirmed that `the manager would try her best to sort out any worries’. Postal votes had been organised for those residents who had expressed an interest in voting. Other residents’ families had been approached to confirm that voting in the current election was not a wish of the resident. The staff interviewed could describe indicators of abuse and were aware of the procedures to follow if abuse was suspected. Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 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 standard(s) 19,20,21,22,23,24,25,and 26. The home was clean and generally well maintained. Minor redecoration to one bedroom, bathroom and corridor areas was required to maintain a comfortable and clean environment for residents. Communal areas were comfortable and homely. Sufficient bathing facilities were provided to meet individual personal care needs. All of the bedrooms were well personalised. Some bedroom carpets were aged. The lighting in some communal areas was not domestic in design. A handrail was not provided in one part of a corridor. Locks were not provided to residents bedrooms, and the heating could not be individually controlled in some bedrooms, to afford residents rights and choices. Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 Page 14 EVIDENCE: The inspector carried out a tour of the home. In the main 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. Sufficient bathing facilities were provided, with the aids in place to assist residents’ needs. Minor damage to paintwork in one bedroom and some corridor areas was due to general wear and tear. Two bedrooms had aged and marked carpets. Bedrooms were not provided with locks, and 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. The lighting in some communal areas was fluorescent in design, which did not add to the homely atmosphere. One bathroom had a damp damaged ceiling. Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 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 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,and 30. Sufficient staff were provided to meet the needs of residents. A proportion of staff were undertaking NVQ training. Recommended levels of NVQ trained staff had not been achieved. A staff training plan was in place, to ensure staff had the skills to perform their duties and meet the needs of residents. EVIDENCE: The homes rota evidenced that agreed levels of staff were being maintained. In emergencies the homes manager covered the rota to maintain numbers. Agency staff were not used at the home, however, a group of bank staff who were familiar with the home and residents needs were available to cover staff sickness, if needed. All of the residents spoken with felt that enough staff were provided. At the time of this inspection the manager was recruiting to care staff vacancies. NVQ training took place for some staff. Of the 17 care staff, 2 had almost completed level 2 in care, 2 domestics had almost completed a relevant NVQ training course, and the homes receptionist had completed a relevant NVQ qualification at level 2. This does not meet the recommended 50 of the care staff trained t NVQ level 2 in care by 2005. Induction and foundation training were provided to staff, to develop the skills needed to care for the residents at the home. Staff received a minimum of 3 days paid training each year. Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 Page 16 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) 31,32,33,34,36,37, and 38. The manager was qualified nurse and was undertaking NVQ level 4 in management. Staff and residents found her approachable and supportive. The home had a quality assurance system in place, to obtain the views of residents and visitors to the home. Insurance cover was in place. The home had a business plan to ensure financial viability. Records were stored securely. Health and safety systems were maintained. The manager had commenced a programme of staff supervision, to support and develop staff. This needed to take place at the required frequency and cover all aspects of staff development and care of residents to ensure staff had the information and skills to carry out their duties. Risk assessments on mobilising residents needed to be audited to ensure the safety of all individuals. Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 Page 17 EVIDENCE: At the time of this inspection the manager was undertaking NVQ level 4 in management. She anticipated completing the qualification within the next two months. All of the staff spoken to said the manager was approachable and supportive. Residents said that they `could talk to her about anything’. Visitors said that the manager had an open door and found her a good listener. Questionnaires were sent out to relatives and residents to obtain their views and inform practice at the home. Insurance cover was provided and a relevant certificate was on display in the reception area. A system of staff supervision had commenced. Supervisions did not take place at the required frequency of 6 times each year. The records of staff supervision did not indicate that all of the required topics had been included in the supervision, to ensure staff developed appropriate knowledge and skills. 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. The majority of service users were mobilised in wheelchairs with footplates in use. One resident was moved without their legs resting on the footplates, posing a possible hazard to their safety. A written risk assessment evidencing that this risk had been undertaken in response to the individual residents circumstances had not been undertaken. A mandatory staff training matrix was in place, to ensure staff were up to date with all relevant training. However, some staff required training in food hygiene. Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 Page 18 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 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 3 3 2 3 2 2 3 STAFFING Standard No Score 27 3 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 2 3 3 3 x 2 3 2 Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 Page 19 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 7 Regulation 15 Requirement Care plans must include specific detail on the staff action required to ensure all aspects of personal care are met. Care plans must record the wishes of the resident regarding dying and death. Where this information has been refused, or is to be sought from family at the appropriate time, this must be recorded. All parts of the home must be in good decorative order. The identified bedroom, corridor and bathroom must be redecorated. The cause of the damp damage in the identified bathroom must be investigated and repaired. The first floor corridor carpet must be replaced. Handrails must be fitted to the corridor area where none exist on either side. (Previous timescale of 01/05/05 to fit handrails to both sides of corridors not met) An audit of bedroom carpets must be carried out. Where carpets are worn and aged, these must be replaced. A programme to provide locks to
J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Timescale for action 01/08/05 2. 11 15 01/08/05 3. 19 23 01/09/05 4. 5. 19 22 23 23 01/11/05 01/10/05 6. 24 23 01/09/05 7. 24 23 01/08/05
Page 20 Fulwood Lodge Version 1.20 8. 9. 24 25 16 23 10. 36 18 11. 38 13 12. 38 18 bedroom doors must commence. (Previous timescale of 01/05/05, to provide locks to bedroom doors not met) The heating system must be updated to enable residents to control the heating in rooms. The lighting in communal areas must be domestic in character(Previous timescale of 01/05/05 not met). Priority must be given to updating the lighting in the lounge/dining room. Staff supervision must cover all of the topics outlined in the standard, and take place at the required frequency of a minimum 6 times each year. Where residents are assessed as unable to use footplatews on wheelchairs, a written risk assessment must be undertaken. All staff mandatory training must be maintained up to date. Staff must undertake food hygeine training. 01/11/05 1/11/05 01/08/05 04/05/05 01/09/05 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 28 31 Good Practice Recommendations A mimimum of 50 of the care staff team must be trained to NVQ level 2 in care. The manager must aceive NVQ level 4 in management. Fulwood Lodge J55 21778 Fulwood Lodge V218756 04.05.05 UI Stage 4.doc Version 1.20 Page 21 Commission for Social Care Inspection 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
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