Inspection on 01/09/05 for Kathleens Lodge

This inspection was carried out on 1st September 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 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

Kathleens Lodge 14/08/06

Kathleens Lodge 13/05/05

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

CARE HOMES FOR OLDER PEOPLE Kathleens Lodge 416 Upper Shoreham Road Shoreham by Sea West Sussex BN43 5NE Lead Inspector Mrs Jennifer Wright Unannounced 1 September 2005, 10:15 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. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Kathleens Lodge Address 416 Upper Shoreham Road, Shoreham by Sea, West Sussex, BN43 5NE 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) 01273 452905 Mr Anthony Robert Brown Miss Angela Louise Brown Mr Anthony Robert Brown Care Home (CRH) only (PC) 20 Category(ies) of Old age, not falling within any other category registration, with number (OP), (20) of places Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13 May 2005 Brief Description of the Service: Kathleen’s Lodge is a care establishment registered to accommodate up to 20 residents in the category of old age. It is a detached property located on a main road in Shoreham. Kathleen’s Lodge is a large house, covering three floors, consisting of 14 single bedrooms, and 3 double bedrooms. Kathleen’s Lodge has a resident’s bar, and garden and patio to the rear of the property, and spaces for parking at the front. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, the second of a minimum of two statutory visits that an inspector must make to each care home during the course of a year. The first inspection, which was announced, was undertaken earlier in the year. At this inspection the Inspector looked at standards that were not looked at during the previous inspection, as well as any outstanding issues from the last report. During this inspection the Inspector toured the building, visited every room, and joined the residents for lunch. As well as talking to Mr. Brown, the registered Manager, the Inspector spoke to many residents, plus two visitors, and a visiting health professional. Three staff members were also spoken to on the day of inspection about how they find working at Kathleen’s Lodge. The Inspector examined records of care being provided to residents; as well as records of any accidents, issues, concerns or complaints, to make sure that the residents at Kathleen’s Lodge were being taken care of. There has been a recent adult protection referral, and the home has worked well with the local Social and Caring Services to resolve the situation. At this inspection Kathleen’s Lodge was audited against the National Minimum Standards for Older Persons. The majority of elements in each of the standards assessed were met. There was one requirement made following this inspection. The Inspector would like to thank everyone who cooperated with her on the day of this inspection. What the service does well: What has improved since the last inspection? Parts of the building had been refurbished, and the Inspector saw that the gardener was planting many bulbs for the residents to enjoy in the Spring. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 6 At the last inspection some residents said that they would like to go out more, and it was seen that those residents who wish to go, are now regularly taken for drives out, with a stop for a cup of tea or an ice cream. Residents told the Inspector how much they enjoyed these trips. The Inspector was told of the introduction of a new Induction Training Book for staff members. 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. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 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 Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 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) 2, 3, and 4 The statement of the terms and conditions contained all the requirements of the National Minimum Standards. Prospective residents are invited for coffee, lunch, and where possible, for a short stay prior to admission. Kathleens Lodge does not take emergency admissions, or offer intermediate care. EVIDENCE: Comprehensive assessments are carried out prior to, and upon admission, and resident’s health, personal and social care needs are set out in an individual plan of care. There is an up to date Statement of Purpose and Service Users Guide that gives residents, and their relatives, information on the home. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 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) 8,9 and 10 Residents are informed of all services available under the National Health Service, and specialist help is requested where necessary. Correct medication procedures were seen to be in place, to protect the people living at Kathleen’s Lodge from harm, including where residents chose to take control of their own medication. EVIDENCE: Care plans were inspected and found to be comprehensive and up to date. Monthly reviews are held, to ensure that the resident’s care plan is constantly updated. Health professionals are consulted, as need dictates. A visiting health professional said they had no concerns with regard to the care being provided by Kathleens Lodge. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 10 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 and 15 The resident’s health, personal and social care needs are set out in an individual plan of care. Residents are able to make decisions about how they live their lives, with assistance as needed. Food is home cooked, with a choice offered. EVIDENCE: From discussions with residents, their families and the Manager, Kathleens Lodge was seen to help residents maintaining contact with their family and friends. One visitor spoken to on the day of inspection told the Inspector that they visited their friend every week, and that their friend was “very happy” in the home. On the day of the inspection, the Inspector shared a meal with residents, who told the Inspector that the food was “very nice”. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 11 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 and 17 Residents and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse, and resident’s legal rights are protected. EVIDENCE: A visitor spoken to on the day of inspection said they would feel “very comfortable” going to the Manager if they had a complaint about anything. The Manager informed the Inspector that there were no outstanding complaints at the time of the inspection, and the home had cooperated with Social and Caring Services in a recent adult protection allegation. The Manager informed the Inspector that Kathleens Lodge’s policy was to support those residents who had no one independent to act in their own interests, and details of how residents can contact an advocate were seen to be available to residents. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 12 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) 20, 21 and 25 There is sufficient communal space, plus the required number of assisted baths or showers to meet the National Minimum Standards. There is outdoor space for residents to use, however access for totally dependent wheelchair users would be difficult. Kathleens Lodge offers separate sitting and dining areas. EVIDENCE: All rooms were visited by the Inspector to ensure that the environment was safe and comfortable for residents. It was noted that some redecoration and refurbishment is still required, fire doors are to be adjusted so that they close tightly, and locks on resident’s doors are to be made safe for them to use. The Manager informed the Inspector that these matters would be addressed as part of the home’s ongoing maintenance plan. There is no sink in the laundry, and staff members told the Inspector that they have to wash their hands in the kitchen. A requirement is made in this report for this matter to be addressed. The Inspector was assured that alcohol wipes would be provided for staff members to use, in the interim. Residents spoken with told the Inspector that they were very happy with their rooms. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 13 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) 28 The Manager is very aware of the need to have staff members who are competent to do their job, to ensure that residents are in safe hands at all times, and is aware of the action, as the registered Manager, that he must take, if they are not. EVIDENCE: Residents told the Inspector that there always appear to be enough people on duty to assist them when they need it, and that their bell is always answered when they ring it. A visiting GP confirmed that there appeared to be adequate staff around. The recording of those staff members attending fire training is to be revised. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 14 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) 34, 36 and 37 Residents live in a home, which is owned and managed by a person who is fit to be in charge. The home is run in the best interests of the people who live there. The health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The inspector saw that insurance cover is in place to meet the National Minimum Standards. The Manager informed the Inspector that there is a business and financial plan for the home, which would be made available upon request. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 15 Records of accidents, injuries and incidents, involving staff members and residents are recorded and reported appropriately. Apart from the fire training records, the records seen were kept up to date, and secure. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 3 3 x x x 3 x STAFFING Standard No Score 27 x 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x x x x 3 x 3 2 x Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 17 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 19 Regulation 23 Requirement That a sink be installed in the laundry room to enable staff members to wash their hands Timescale for action 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. Refer to Standard Good Practice Recommendations Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection 2nd Floor, Ridgeworth House, Liverpool Gardens Worthing West Sussex BN11 1RY 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 Kathleens Lodge H60-H11 S62113 Kathleens Lodge V247249 010905 Stage 4.doc Version 1.40 Page 19 - 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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