Inspection on 13/05/05 for Kathleens Lodge

This inspection was carried out on 13th May 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 01/09/05

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 Jennifer Wright Announced 13 May 2005, 12:00 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. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 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 01273 453617 Mr Anthony Robert Brown Miss Angela Louise Brown Mr Anthony Robert Brown Care Home (CRH) 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 V220460 130505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Kathleen’s Lodge is a care establishment registered to accommodate up to 20 service users in the category of old age. It is a detached property located on a large main road in Shoreham.Kathleen’s Lodge is a large house covering three floors consisting of 14 single bedrooms, and 3 double bedrooms. In addition Kathleen’s Lodge has a resident’s bar, and garden and patio to the rear of the property. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection carried out by the Commission for Social Care Inspection since Mr. and Miss Brown became the owners of Kathleens Lodge. This was an announced inspection, the first of a minimum of two statutory visits that an inspector must make to each care home during the course of a year. A second inspection, which will be unannounced, will be undertaken later in the year. During this inspection the Inspector toured the building, visited every room, and joined the residents for lunch. As well as talking to Mr. and Miss Brown the Inspector spoke at length to all of the residents, plus two visitors. Six staff members were also spoken to on the day of inspection about how they find working at Kathleens Lodge. The Inspector examined records about care being provided to residents; as well as records of any accidents or concerns or complaints, to make sure that the residents at Kathleens Lodge were being taken care of. At this inspection Kathleens Lodge was audited against the National Minimum Standards for Older Persons. The majority of elements in each of the standards were met. 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? This was the first inspection under the new owners. It was seen at this inspection that the exterior of the front of the property had been recently Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 Page 6 decorated. There was evidence of new bed linen, and of recent repairs to parts of the interior of the property. 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. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 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 Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 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, 5 and 6 Prior to moving into Kathleens Lodge, people were given sufficient information about what the home offers to enable them to make a choice as to whether or not they want to live there. Before moving into the home, the Manager or a senior staff member will visit them in their own home or hospital, where possible, to make sure they are suitable. People can have a “trial stay” before deciding if they want to live at Kathleens Lodge. EVIDENCE: Some of the residents spoken to on the day of inspection confirmed that they had been given information about Kathleens Lodge, and that they had been invited to visit the home before they came to stay. The majority of residents were not able to remember if they had or not. Several residents told the Inspector that they knew what to expect from Mr. and Miss Brown and the staff members, and had no complaints whatsoever about the way they were being looked after. The Inspector looked at the care records of five of the residents, and found them all to be satisfactory. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 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) 7,8,9,10and 11 Where possible residents are involved with the drawing up of their care plans. All residents are informed of all services available under the National Health Service, and specialist equipment is provided where necessary. Correct medication procedures were seen to be in place, to protect the people living at Kathleens Lodge from harm, including where residents chose to take control of their own medication. From direct observation on the day of inspection and from the comments made by many residents, it would appear that the staff respect the privacy and dignity of the people living at Kathleens Lodge. EVIDENCE: The Manager informed the Inspector that where residents are not able to be involved with the drawing up of their care plans, then the residents relative or advocate is involved. Records of drug administration and the inspection of the drugs cabinet demonstrated that the correct procedures, relating to medication, were being adhered to. Staff members spoken to by the Inspector confirmed that they had received the appropriate training, and it was seen that this training is ongoing. The Inspector was informed that family or friends are Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 Page 10 offered a spare bedroom, if available, or a comfortable chair in the residents room, at the end of the residents life. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 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 People living at Kathleens Lodge are able to make the day-to-day decisions about how they want to live their life. Where necessary staff members take time to ensure that the people who live there, some of who may be a little confused, are involved in all that is happening to them. There is a range of activities for those who wish to participate, and residents are encouraged to maintain contact with all their old friends and family, wherever possible. Kathleens Lodge offers a choice of menu, with people able to eat either with other residents or in their own room should they prefer. EVIDENCE: It was seen that there are a variety of activities on offer at Kathleens Lodge, including Bingo, sing-a-longs, manicuring, quizzes and art and craft. Although the majority of people told the Inspector that they “were happy with the way the home was being run” some residents wished that they could “go out somewhere”. On the day of inspection the Inspector shared a meal with the residents, which was very tasty, attractive in appearance, plentiful, and clearly enjoyed by all. One resident told the Inspector that “the food is good, and if you don’t like it, you can have something else”. There was much noise, together with laughter, in the dining room, throughout the meal, with the residents deciding to join in with what was going on, or choosing to ignore all the noise and get on with their meal. From direct observation, the Inspector Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 Page 12 noted that the mealtime appeared to be unhurried, with residents being afforded sufficient time to eat their meal. Where it was necessary staff members were seen to help residents in a sensitive and unobtrusive manner. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 Page 13 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 18 Regular training sessions for staff, a complaints/concerns book, a “suggestion box” in the hall, plus policies and procedures regarding abuse, ensure that, as far as is possible, the people who live at Kathleens Lodge are protected from bad practice. EVIDENCE: A copy of the homes Complaints Procedure was available for residents and visitors, should they wish to complain. Residents and staff members spoken to confirmed that Mr. and Miss Brown were always available, and said that the Manager was a “good listener”. The current West Sussex Multi-Agency Policy and Procedure for protecting vulnerable adults from abuse was seen to be available in the home, which also have their own policies available, to safeguard residents from abuse. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 Page 14 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) 19,22,23,24,and 26 On the day of inspection Kathleens Lodge appeared clean and well maintained, and the location of the home is suitable for the residents who live there. The home was seen to provide aids, ramps and assisted bathing facilities. The resident’s rooms are suitable for their needs, and are homely. Some decoration and renewal of furnishings may be needed in the future. EVIDENCE: During a tour of the home and by looking at maintenance records, the inspector could conclude that residents live in a reasonably well-maintained and safe environment. The residents have access to a communal dining room, part of which is only accessible up steps, and sitting room, which were comfortably furnished and had a homely atmosphere. There is a passenger lift for those residents whose rooms are upstairs. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 Page 15 There are enough toilets and assisted baths to meet the needs of residents. During the course of the inspection the majority of rooms were visited to ensure that the environment was safe and comfortable for people who live there, and it was noted that many residents had brought personal possessions into the home, including small items of furniture, ornaments and photographs. On the day of inspection, Kathleens Lodge was seen to be clean, and free from offensive odours. Policies and procedures were available for staff regarding control of infection, and the safe disposal of clinical waste. Residents told the inspection how much they liked their bedrooms, and said that “there is a good care worker on at night”. Residents confirmed that should they need to ring their call bell, then a member of staff would always come. Screens were provided in bedroom shared by residents. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 Page 16 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, 29,30 . Kathleens Lodge is adequately staffed with employees who appear competent to care for older people. National Vocational Qualification is on going and further development training is expected. All training is recorded on staff member’s files. EVIDENCE: The duty rotas indicated that enough staff are on duty over the 24 hours period to meet resident’s needs. This number and skill mix of staff appear was appropriate. Staff spoken with said they were happy working at the home and felt well supported by the Manager. One member of staff said “if I come up with any ideas, they are listened to by Mr. and Miss Brown, and acted upon where possible“. The Manager informed the Inspector that care workers are working towards their NVQ 2 and NVQ 3. Many of the staff have worked at Kathleens Lodge for a long time. Residents told the Inspector that “there is always someone around when you nee them”. Visitors told the Inspector that staff members had made them most welcome. Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 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 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, 33,35 and 38 Mr. Brown, who has been recently registered as the Manager of Kathleens Lodge, is experienced in working with older people. Records needed for the safe running of a care home are kept up to date. Policies and procedures are available for staff members to refer to, to ensure the safety of the people who live and work at Kathleens Lodge. EVIDENCE: Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 Page 18 On the day of inspection the Inspector observed a good relationship between residents, staff members and management. All the residents confirmed to the Inspector, that both Mr. and Miss Brown are extremely approachable, and “do their best”. Staff members that the Inspector spoke to said that they enjoyed working at Kathleens Lodge and were grateful for the training that was on offer to them. Residents told the Inspector that they “felt comfortable” living at Kathleens Lodge and got on well with all the staff.” Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 Page 19 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 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x 3 3 3 x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x 3 x x 3 Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 Page 20 NA 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 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. 1. Refer to Standard Good Practice Recommendations Kathleens Lodge H60-H11 S62113 Kathleens Lodge V220460 130505 Stage 4.doc Version 1.20 Page 21 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. 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