Inspection on 14/08/06 for Kathleens Lodge

This inspection was carried out on 14th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Kathleens Lodge 01/09/05

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 Kerry Leppard Key Unannounced Inspection 14th August 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 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. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 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 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) 01273 452905 01273 453617 Mr Anthony Robert Brown Miss Angela Louise Brown Mr Anthony Robert Brown Care Home 20 Category(ies) of Dementia - over 65 years of age (20) registration, with number of places Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st September 2005 Brief Description of the Service: Kathleens Lodge is a care establishment registered to provide care and accommodation for up to 20 residents. The home’s category of registration has recently changed to dementia, over the age of sixty five years (DE (E)). Kathleens Lodge is a detached property located on a main road in Shoreham, accommodation is provided over three floors, consisting of 14 single bedrooms, and 3 double bedrooms. Kathleens Lodge has three lounge areas and a dining area located on the ground floor. The dining area has patio doors leading to a patio area and lawned garden to the rear of the property. Spaces for parking are provided at the front of the home. The current range of fees is £389-£500 and additional charges are made for hairdressing, chiropody, toiletries, magazines, newspapers and transport. Miss. Angela and Mr. Anthony Brown are the registered providers and Mr. Anthony Brown is the registered manager in day to day control of Kathleens Lodge. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced field work visit was conducted on Monday 14th August 2006 between 9:30am and 4:30pm. Prior to the visit information was requested from the home in the form of a questionnaire and comment cards were supplied to the home for distribution to both residents and relatives/visitors. Following this visit the questionnaire was returned and eight resident and five relative/visitor comment cards were received. During the visit the inspector spoke with seven residents and a relative and spent time observing interactions between residents and staff. The inspector was unable to obtain feedback from all residents due to their level of disability. The inspector spoke with three staff throughout the process of the inspection. One of the registered providers was available to assist the inspector also. A variety of records were reviewed including, assessments, care plans, medication administration records, staff recruitment and training records. Feedback and comments from comment cards and discussions have been included in this report. What the service does well: What has improved since the last inspection? The registered provider confirmed that action has been taken to address all of the requirements made on the fire officer’s last inspection report, which included action to ensure all doors close satisfactorily and that locks provided on resident’s bedrooms doors have been adjusted to ensure they are safe for residents to use. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 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. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 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 Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Prospective residents needs are assessed before they are admitted to the home. Intermediate care services are not provided at Kathleen’s Lodge. EVIDENCE: Three care records were sampled as part of case tracking the care provided at Kathleens Lodge, two of which, were in relation to residents who had come to live at the home recently. Records indicate that a representative of the home assesses prospective residents needs and/or a social work assessment of need is obtained in order for the home to determine if they are able to meet the person’s needs. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 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, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Resident’s needs are set out in an individual plan of care. These need some more detail and to be developed with residents and/or their representatives. Resident’s health needs are met with the support of health professionals. Arrangements for protecting residents from the risks associated with self medicating need to be reviewed. Residents right to privacy is respected. EVIDENCE: Care plans are in place for each resident and one was being compiled for the most recently admitted resident who had been living at the home for a week prior to this visit. Three care records were sampled as part of case tracking the care provided to residents at Kathleens Lodge, those that were complete included information about the resident’s physical care needs and risks to their health, safety and well being including manual handling, mobility and pressure sores. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 10 In one record the inspector found a good piece of work that provided detailed information about the routines and preferences of the resident. Senior staff have responsibility for reviewing records monthly using a tick box tool to identify any changes and staff record the care provided and events regularly. Some minor points for the improvement of care records are that where needs and risks have been identified, records must indicate the action being taken to meet the need and/or minimise the risk. For example, when it is noted that a resident is disorientated actions should be recorded that clearly guide staff about how to support and assist the individual resident with this need, similarly if a risk from pressures sores is identified, records must include evidence of the action that is being taken to minimise the risk, for example specialist equipment may be in place. Records of the care provided should also be shared and agreed with the resident and/or their representative and the registered persons may wish to consider using these regular discussions as part of a programme of quality assurance, to obtain views of the service being provided by Kathleen’s Lodge (see standard 33). Records and discussions indicate that residents are supported to receive medical treatment from health professionals and residents who completed a comment card said that they always receive the medical support they need. Arrangements for the storage of medication were observed during the fieldwork visit and were found to be satisfactory. The receipt and administration of medication is recorded on Medication Administration Records (MARs), which were sampled and were found to be complete. A senior member of staff confirmed that she and other staff responsible for administering medication have received training. The home was storing controlled drugs (CDs) appropriately and had a system in place for recording observation of the administration of CDs by a second person, however this record was not complete and up to date. It is a good practice recommendation that CDs be recorded in a CD register. Where a resident wishes to retain control of their own medication the registered persons must ensure a full risk assessment is undertaken including the actions being taken to minimise risks, such as other resident’s accessing the medication, the ability of the resident to self administer in accordance with the prescriber’s instructions and the storage and disposal of unused medicines. The inspector observed that locks are provided on doors to resident’s accommodation and the staff member who accompanied the inspector on a tour of the building knocked on doors to resident’s private accommodation. In addition the visitors who completed a comment card said they are able to visit their friend/relative in private. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Activities are provided and action has been taken to ensure residents can go out if they wish. Residents maintain contact with their family and friends. Resident are supported to exercise choice and control over their lives. Residents are offered a choice of meals and eat in a relaxed environment. EVIDENCE: Activities were not observed during this visit to Kathleens Lodge, however the residents talked enthusiastically about a barbeque and musical entertainment they had enjoyed recently. Staff also told the inspector that they have games available to play with residents. Responses from residents, who completed a comment card, to the question ‘are there activities arranged by the home that you can take part in?’ varied from ‘never’ to ‘always’. The registered persons may wish to conduct a quality assurance exercise (see standard 33) to find out what kind of activities residents would like to participate in. Some feedback from residents indicates that they would like to go out of the home. The registered person advised the inspector that it has Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 12 recently been arranged for the home to have access to a minibus once a week to facilitate trips out of the home for residents. This is a positive step toward ensuring that the lifestyle in the home matches the expectations and preferences of residents. Residents told the inspector that their friends and family visit them at Kathleen’s Lodge, one resident told the inspector that she goes out with her visitors and/or they have a meal with her at the home. Those relatives/visitors who completed a comment card said the staff/owners welcome them into the home at anytime. The inspector observed that residents have a variety of communal areas to spend their time in and some choose to spend time with other residents whilst others prefer to stay in their rooms. Observations and discussions also indicate that routines in the home are flexible, for example in relation to times for getting up and retiring. Care records and discussions with staff also indicate that residents have opportunities to make choices and decisions about their care, how it is provided and by whom. Residents enjoyed tea and biscuits mid morning and cold drinks were available throughout the day. Lunch is the main meal of the day at Kathleens Lodge and on the day of this visit most residents ate in the dining room. The inspector observed the chef ask each resident their preference for lunch during the morning, the options offered were sweet and sour pork with rice or a jacket potato with various fillings followed by fruit and cream or ice cream. The meal was nicely presented and residents spoke positively about their meal when asked. During conversation with residents throughout the day one said ‘the food’s good, very good’ another commented that it was mediocre, those residents who completed a comment card said they always like the meals in the home. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 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 the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents know who to talk to if they are not happy but the complaints procedure could be better publicised. Arrangements for training staff and care planning could be improved to protect residents from abuse. EVIDENCE: Over half of the relative/visitors feedback indicates they are not aware of the home’s complaints procedure. Most residents who completed a comment card said they know who to speak to if they are not happy, how to make a complaint and that staff listen and act on what they say. Kathleens Lodge have not had any complaints in the last twelve months and the registered persons should consider publicising the complaint procedure to ensure people know how to make a complaint. Information provided by the registered person following this visit indicates that abuse awareness training has been provided to staff within the last 12 months. A staff member who had undertaken the training was clear about the procedure to follow if there is evidence or suspicion of abuse. However a more recently recruited member of staff who spoke with the inspector was not entirely clear about home’s whistle blowing procedure. This indicates the importance of induction to Skills for Care standards (see standard 30). Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 14 As noted previously in relation to care planning (see standard 7), where a risk of aggressive and/or challenging behaviour is noted care records must provide clear guidelines for staff to follow to prevent and /or respond to the behaviour for the protection of the resident and staff. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 15 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is subject to ongoing maintenance to ensure the environment is safe and well maintained for residents. The home is clean and hygienic. EVIDENCE: The home has been subject to works to improve the environment for residents and planned refurbishment and redecoration should continue to raise the standard in the home. During the tour of the building the inspector was advised that window restrictors have been put in place on windows above ground floor and some windows on the ground floor also. The registered provider/manager has confirmed that a plan is in place to convert two bathrooms to wet rooms in order to provide additional assisted facilities for residents. The registered manager also confirmed that locks on doors to resident’s bedrooms are safe for residents to use and that he has addressed all of the requirements of the fire officers last visit to the home. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 16 As yet a sink has not been installed in the laundry but as an interim arrangement staff carry hand sanitiser, this is also available on the wall around the homes as are other items of personal protective equipment including gloves and aprons. Residents who completed a comment card indicated that the home is always fresh and clean and one said ‘very clean for my liking’. During the early part of the visit offensive odour was present in some rooms, however the home employs a cleaner who was observed working her way around the building during the visit and communal areas were fresh and clean. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 17 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 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Staffing levels have been improved and are satisfactory to meet resident’s needs. 50 of staff are qualified to meet the National Minimum Standard. The home’s recruitment policy and practices do not protect residents. Training is provided but work is needed to ensure that staff receive induction training to meet Skills for Care standards. EVIDENCE: During the morning of the fieldwork visit four care staff including a senior member of staff were on duty. A cook and a cleaner were also on duty. Rotas provide evidence that generally the morning shift is covered by three or four care staff and afternoons are covered by three staff. The registered manager confirmed that two waking staff now cover night duties. The home must not use care staff for domestic tasks to the detriment of residents care and welfare. Residents responded ‘always’ and ‘usually’ to the question ‘are staff available when you need them? and all relatives/visitors who answered the question said that in their opinion there are always sufficient numbers of staff on duty. From information provided following this visit it is noted that 50 of the care staff employed at Kathleens Lodge are qualified to NVQ (National Vocational Qualification) Level 2. This meets the National Minimum Standard. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 18 Records and discussion with staff indicates that training is provided including an in house induction, health and safety topics including fire instruction (see standard 38) and manual handling, abuse awareness and training specific to the needs of residents with dementia. The inspector advised the registered person that induction to Skills for Care (formerly TOPSS) standards should be completed with all new staff to ensure they have a sound knowledge base, prior to receiving training that should be provided on a rolling programme to ensure all staff are trained to meet residents needs. The inspector sampled two recruitment records as part of this visit. Both provided evidence that the member of staff had commenced employment prior to receipt of all information required by schedule 2 of the Care Homes Regulations, specifically two written references and a Criminal Records Bureau (CRB) disclosure. Department of Health guidance states that care staff should only commence employment prior to receipt of a full CRB in exceptional circumstances and when all other employment checks have been completed. Staff should then be supervised and have begun induction training. Currently recruitment practises at Kathleens Lodge are not sufficiently robust to protect residents. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The homes registered manager is qualified and experienced. A formal Quality Assurance system that ensures the home is run in the best interests of residents has not been devised. The home does not store money on behalf of residents. The health, safety and welfare of residents and staff are not sufficiently protected through a system of auditing and risk assessing. EVIDENCE: The registered manager is qualified and experienced. He is supported by a care manager, who it was clear, knows residents at Kathleens Lodge well and is a point of contact for them about issues and concerns they may have. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 20 A formal quality assurance programme has not been implemented. The registered providers have informal processes for consulting with residents and their relatives and reacting to their requests. The inspector discussed with the registered person their responsibility for quality audit of the service and provision of this information to the Commission for Social Care Inspection. The inspector was advised that no money is being stored for safe keeping on behalf of resdients. Equipment necessary for fire safety is serviced and tested regularly. Although staff who spoke with the inspector knew the procedure to follow in case of fire, records indicate that fire training for staff is in need of updating. Accidents are recorded however through the process of case tracking three residents care the inspector found that an accident recorded in daily notes had not been tranferred to an accident record. All accidents must be recorded and audited, findings should then be linked to risk asessments and the care planning process for individual residents in order to minimise risks to their health, safety and well being. Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP19 OP29 Regulation 23 19 (1) Requirement That a sink be installed in the laundry room to enable staff members to wash their hands Staff records must include the information and documents specified within Schedule 2. Timescale for action 14/11/06 25/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Kathleens Lodge DS0000062113.V309766.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Worthing LO 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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