Inspection on 13/02/06 for High Peak Lodge

This inspection was carried out on 13th February 2006.

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 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

High Peak Lodge 14/09/07

High Peak Lodge 13/03/07

High Peak Lodge 01/09/05

High Peak Lodge 02/02/05

High Peak Lodge 29/07/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE High Peak Lodge Bedford Square Leigh Lancashire WN7 2AA Lead Inspector Lindsey Withers Unannounced Inspection 13th February 2006 08:20 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 High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service High Peak Lodge Address Bedford Square Leigh Lancashire WN7 2AA 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) 01942 262021 01942 261811 European Care (UK) Limited Adele Kettle Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39), Terminally ill (3) of places High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 39 service users to include:up to 39 service users in the category of OP (Older People) up to 3 service users in the category of TI (Terminal Illness under 65 years of age) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 1st September 2005 2. Date of last inspection Brief Description of the Service: High Peak Lodge is a purpose-built care home, located close to Leigh town centre. High Peak Lodge is registered to provide nursing and personal care services to 39 male and female residents over the age of 65, three of whom may be terminally ill. Private accommodation for residents is provided in single rooms, all of which have en suite toilet and wash hand basin. There is pleasant communal space comprising lounges and a dining room, as well as quiet areas near the staircase on each floor. Car parking for visitors is located to the front and side of the home. High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a 4 hour period and was unannounced. The main focus was on those areas not assessed during the previous inspection, so that over both visits all key standards were looked at. Part of the time was spent with the Manager and the Administrator going through the paperwork that has to be kept to show that the home is being run properly. Part of the time was spent in the main lounges and dining areas looking at routines and methods of care. One person was visited in her own room. The Inspector had good conversations with three members of staff and four residents. The Inspector spoke to other staff and residents over the course of the inspection. What the service does well: What has improved since the last inspection? The paperwork that makes up the plan of care for each resident has been updated and changed. Each person’s care – both that which is necessary and that which is preferred – is written down. The package of care is arrived at following assessment and review, and after consultation with the resident and his or her family. There is now clear written proof to show that the care of each person is changed to match the changes in his or her needs. High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 6 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. High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: This section was not assessed on this occasion. High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, and 9. Improvements to the care planning process, combined with regular review, ensures that residents’ needs will be identified, and that they can be assured will be met. The home has a policy and procedure for dealing with medication which staff were familiar with. Residents can be sure their medication will be properly and safely managed. EVIDENCE: A number of requirements were made at the last inspection that related to residents’ care plans and meeting needs. Since then, the documentation in care plans has been improved. There was clear evidence in the sample of care plans that were looked at on this occasion to show how an individual’s needs and expectations are identified, and how they are being met. The risk management process for each person linked to the main elements of care, and helped to inform the final dependency assessment. Each part of the care plan had been reviewed on a monthly basis, and the written entries indicated that a measured approach to the review had been taken. There was also clear evidence to demonstrate that residents and their families had been involved in developing the care plan and in the review process. Minor errors were noted High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 10 on one file (for resident LR) that had occurred just after the New Year when two incorrect dates had been recorded. Otherwise, documentation was wellmaintained, gave good evaluations and explanations, and was up to date. The review of medication on this occasion focussed on the way that medication was administered. At High Peak Lodge, nurses are responsible for all procedures relating to medication. The RGN on duty was able to explain the process that she followed. She said that medication is administered only when the resident is with the nurse, for example in the dining room or lounge, or when the nurse takes the medication to a resident in his or her own room. Care staff do not administer medication, though at busy times they may stay with a resident while the medication is taken, following which they would report back to the nurse for the recording to be completed. Each person’s medication is signed off at the point it is administered. Medication is not prepared for several residents in advance; the RGN said this would bring unacceptable risks into the process. The RGN was familiar with her obligations under her registration with the Nursing and Midwifery Council that related to medication, and with the guidelines set by the Royal Pharmaceutical Society. Residents’ care plans showed that where staff had been concerned about a person’s health, the GP had been contacted for a review of medication to be undertaken. High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: This section was not assessed on this occasion. High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Improvements to the complaints procedure will inspire confidence in residents and their relatives, who can be sure complaints will be dealt with in a positive and serious way. Emphasis on the protection of vulnerable people during induction, training, supervision and appraisal ensures that residents are protected from all forms of abuse. EVIDENCE: The Manager reported that since the last inspection, an audit of complaints has been introduced each month end to make sure that any received have been properly investigated and the complainant advised of the outcome. Privacy and dignity issues identified at the last inspection have been linked by the Manager to abuse and the protection of vulnerable people. All members of staff attended a one day training course and all will be attending a half-day refresher each year thereafter. This course is City & Guilds approved and links to the national occupational standards for care workers. The most recent recruits (4 in total) had covered this topic, together with whistleblowing, in their induction programme but had yet to attend the formal training sessions. Each new recruit also receives written information and is required to sign to confirm that they have understood the content. Abuse and whistleblowing are also covered through supervision sessions and during appraisal. High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25, and 26 High Peak Lodge is a well-maintained home where the residents’ safety can be assured. The home is clean and comfortable, and there are good procedures to make sure the environment is hygienic and to control the spread of infection. EVIDENCE: During this unannounced inspection, the home was found to be very clean and in good, well-maintained condition throughout. High Peak Lodge offers hotel-style services and the home’s furnishings and decoration reflect this. The home employs a maintenance man who keeps the decorating in good order and the building in a good state of repair. Contractors are brought in to do more specialist work as the need arises. As a result, the home is very well presented. Residents can spend time in their own rooms as they choose, or sit with friends and colleagues in one of the main lounges. Communal rooms are light and High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 14 airy, with small tables and lamps, bookcases and dressers, to create a pleasant environment in which to sit. The home was warm, yet well-ventilated throughout. Water temperatures are tested regularly and controlled at safe levels, and window restrictors are checked and kept secure. Records are maintained to show that this work is done. Windows and water temperatures checked during this inspection were in order. The home has strict procedures that relate to hygiene and the control of infection. This was seen in practice during the course of the inspection. Staff working in domestic house-keeping roles take pride in what they do, and are properly trained so they are competent to do the work they are employed to do. High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, and 30 Staff are employed in sufficient numbers and with appropriate skills so that the needs of residents are met. The home’s recruitment process is robust, ensuring that only suitable people are employed. Staff receive training appropriate to the work they are employed to do. They are encouraged to develop their skills so that they reach their full potential. This ensures residents are cared for by competent people. EVIDENCE: There is a good ratio of care staff to resident. At least one registered general nurse (RGN) is on duty on each shift. The Manager does not work during the weekend and is supernummary to the rota. However, like other nurses employed at High Peak Lodge, she does cover shifts where there are gaps on the rota. The care team is supported by domestic and ancillary staff in sufficient numbers to make sure that good standards relating to food, cleanliness and hygiene are achieved. An activities organiser is employed, who devotes her hours to this task only. Staff are encouraged to undertake National Vocational Training at levels 2 and 3. Other training is offered that is relevant to each area of work within the home, as well as mandatory training that links to health and safety. Nonmandatory training has included dementia awareness, drug administration, and protection of vulnerable adults. Specialist training can be designed for the home by its training provider, if it is required. The training programme for the new year from April 2006 was in the process of being developed. Among others, consideration is being given to courses and awareness sessions relating High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 16 to stroke, diabetes and Parkinson’s disease, which all staff will be given the opportunity to attend. Training is also delivered in-house by competent members of staff. The benefit of such training is that it can be delivered “on the job” rather than staff having to attend courses. The home has a robust recruitment process, which ensures that only those staff who are deemed suitable to work with vulnerable people are recruited. Successful candidates may not commence their employment until clearance has been received from the Protection of Vulnerable Adults list and the Criminal Records Bureau. Following employment, new members of staff work through an induction programme in a supervised capacity, and do not work unsupervised until they are considered capable to do so. The Manager advised that there will be some changes to the home’s management in the coming weeks due to the retirement of the Deputy Manager (after many years of service at the home) and recruitment to the post. However, the Manager said she felt confident that residents would not be affected by the change. High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, and 38. High Peak Lodge is managed by a qualified, experienced and competent person. Her management and leadership approach focuses on the residents, and on providing them with a quality of life that meets their needs and expectations. Residents can be assured by the home’s systems that their financial interests will be safeguarded. The safe working practices adopted by the home protect and promote the health, safety and welfare of residents and staff. EVIDENCE: The home’s Manager, Adele Kettle, has been in post for almost a year and has worked at the home since it opened. Ms. Kettle is a Registered General Nurse. She is proving to be a competent manager whom staff felt they could rely on. Ms. Kettle now has completed the Registered Manager’s Award and was High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 18 awaiting the result at the time of this inspection. During the past year she has concentrated her learning around the Registered Manager’s Award, but has also found time to keep her mandatory training up to date. Changes in the organisation’s management structure will mean that she will have a new Regional Manager in Kate Peet, a person Ms. Kettle said she respected and whom she was looking forward to working with. The Manager’s style is one of inclusiveness. In conversation she refers frequently to “the staff team” and firmly believes that best results are achieved when staff are working together and understand their goal. Staff say that they can approach the Manager with any issue, and this was seen in practice during the inspection. Residents knew who the Manager was and happily entered into conversation with her, speaking freely. The home has a number of ways in which it looks at the quality of the service, both by internal and by external means. The regular internal audits look at, for example, health and safety, care planning, staff attendance, etc. European Care, the organisation to which High Peak Lodge belongs, also conducts a number of audits. A copy of the report is sent to the CSCI for information. The home was recently awarded 5 stars – up from 4 last year – by the RDB, an independent quality assessment organisation. Feedback on customer survey questionnaires was available for inspection and showed very positive responses. Information relating to customer surveys and feedback by the RDB and by the home are kept at the main reception desk for visitors to the home to look at. Staff get the opportunity to express their views in the regular meetings, and relatives and residents at regular get-togethers. One such relatives and residents’ meeting was being held on the afternoon of this inspection, for which an agenda had been prepared. The notes of meetings are kept in formal Minutes. The Minutes of relatives and residents’ meetings at kept at the main reception desk. The home has a good record of meeting timescales for improvements identified by the CSCI and other regulatory bodies. The records of money held on behalf of three residents was looked at and were found to be in order. The Administrator said that money was held for very few residents; the responsibility for financial matters generally fell to each person’s family or social worker. No keyholder to residents’ money is available over the weekend and the problems that could arise as a result of this practice were explored. The Manager said that residents normally hold a little of their own money, for example, to use if they needed anything from the shop. If residents do go out from the home, they usually go with families, in which case, residents do not High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 19 need any money. The Manager said that she or the Administrator could return to the home to release money if it was needed. However, the Manager could not remember such an occasion ever occurring. Safe working practices have been adopted by the home, and practice is monitored through induction and supervision. Staff receive regular training and updates in safe working practices, including first aid, fire safety, food hygiene, infection control, and moving and handling. Training is delivered by an external training provider. The maintenance man keeps meticulous records to show what checks are made that relate to health and safety. There is a cycle of safety checks: some are done weekly, others monthly or periodically throughout the year. These records are audited by European Care to make sure that the home is complying with health and safety legislation. Accident, injuries and incidents are recorded and reported appropriately. The records are audited to see if care practice needs to be changed, for example, for someone who might have developed a pattern of falls at a particular time of the day. High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 3 3 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 3 3 3 X 3 X X 3 High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 High Peak Lodge DS0000005682.V269888.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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. 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