Inspection on 13/06/05 for Lavender Lodge Nursing Home

This inspection was carried out on 13th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Lavender Lodge Nursing Home 08/08/06

Lavender Lodge Nursing Home 17/10/05

Lavender Lodge Nursing Home 08/11/04

Lavender Lodge Nursing Home 14/06/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Lavender Lodge Nursing Home Bruntile Close Farnborough Hampshire GU14 6PR Lead Inspector Val Sevier Unannounced 13/06/05 10.00am 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. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lavender Lodge Nursing Home Address Bruntile Close, Farnborough, Hampshire, GU14 6PR 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) 01252 571569 01252 375852 Highfield Care Homes No 2 Limited Nigel Chorley Jopson CRH 68 Category(ies) of DE, DE(E), OP registration, with number of places Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. A total of 25 service users may be accommodated in the DE and DE(E) categories at any one time. 2. A maximum of 13 service users in the DE category may be accommodated at the home. 3. All service users in the DE category must be at least 55 years of age. Date of last inspection 08/11/04 Brief Description of the Service: Lavender Lodge is a care home providing nursing care for older people and can accommodate 68 persons having recently undergone work extending the home. The accommodation is situated over three floors and all rooms are single ensuite. The external accommodation consists of two patio areas. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over six hours. The manager Mr Jopson was available on the day and staff assisted the inspector with the visit. All staff spoken with were helpful and informative and positive about their role at the home. The inspector viewed 5 service user care plans and it is to these that the report refers. There were 67 service users present on the day of inspection the inspector was able to speak with several of them. What the service does well: What has improved since the last inspection? The décor of the home has improved with the corridors being painted and carpeted giving a lighter atmosphere and a brightness enabling residents to move around more easily. The residents seem to be calmer and the atmosphere seemed cheery. The action needed to be taken after the last inspection has been carried out with information about wishes regarding death and dying being recorded and all records now stored safely. Request for action by the home from the last visit had been carried out. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 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. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 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 Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 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) 3 and 4. The home has a good understanding of residents needs using the assessment process. The staff have a good knowledge of residents support needs and positive relationships have been formed between the staff and residents and this is supported by the training the staff have received. There is enough information made available for people to make choices about moving to the home. EVIDENCE: The inspector looked at 5 care plans and each individual had had an assessment prior to moving to the home. The assessments are comprehensive with information about physical and psychological needs of the individuals. It was observed that the information gained through the assessment had been used to complete the care plans. There was also evidence that assessments and information had been used as well from other professionals such as social services and health. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 9 The inspector was able to observe interaction between the staff and residents at the home. The manager had explained that staff had undertaken training in dementia and communication and this was evident in the observed interaction. Staff spoken with had an understanding of the needs of individuals and said they felt able to ask the manager or Registered Mental Nurse if they were unsure Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 10 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 and 10. There has been a gradual improvement in the care plans and the information since the last inspection, and there is now a consistency in them. From the last inspection it was seen there has been a big improvement in the management of medication. Staff were seen to behave appropriately with residents identifying their emotional and physical needs. EVIDENCE: The inspector viewed six care plans in conjunction with a sample of medication records and others health-monitoring tools used at the home. When looking that the care plans it was seen that other professionals were also involved as necessary. There were risk assessments and action to reduce risk. The care plans had been reviewed regularly and evidence that relatives had also been involved in this. Daily notes had been written enabling the inspector to have a picture of the daily life at the home for some. The inspector spent some time looking at medication storage administration and stock control. The medication is sent to the home monthly from the local chemist and the start date was the day of the inspection all medication seen Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 11 was dated 13th June, the stock records were unclear however as the medication had come to the home on the Friday 10th and not checked in until the 11th. Discussion was had with the chemist and manager regarding improving dispensing and records. From medication records sampled staff had been completing them. It was noted on several records that ‘as required’ had been written with no date and it was unclear when this instruction had been given. This was discussed with the manager and sister that orders the medication. Residents because of their mental health frailty were not able to convey fully their feelings but many seemed content. Visually they were seen wearing clean clothes and those that needed glasses had them on their person. Staff were observed speaking and assisting the residents with dignity and respect. It had been seen on care plans that the preferred choice of name had been recoded and staff were heard to speak to residents by the name they wished. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 14 and 15. The social needs of the residents at the home are as varied as they are individuals and although there is an activity person not all needs are met. The home is encouraged to resolve this in order to accommodate as many needs as possible. Dietary needs of residents are well catered for with a varied selection of food that meets resident’s tastes and choices. EVIDENCE: There is currently one activities person working at the home five days a week 9-5. This person undertakes group and individual activities for all residents across three floors. There was some evidence on care plans that social and recreational interests had been recorded. The activity plan indicates that the activity person divides her time between the different lounges and needs, with the residents with dementia being situated on the middle floor of the home. The residents who spend time in the ground floor lounge and dining room explained that they had helped with the patio flower boxes and pots. They also explained that they were happy with the activities especially the trips out. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 13 Visitors sign in at the home and information for them and others is available in the hallway by the signing in book. There are no residents at the home that look after their own financial affairs but it was noted that staff encourage and enable residents to participate in making choices about their lives day to day. The menu is available daily in the hallway. The residents are offered a choice of meal and their preference is recorded with copies kept. Residents can choose where to have their meals, residents spoken with said they liked the meals. A new chef has recently started work at the home, the manager believes that the quality of the meals has improved. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 14 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. The complaint process in the home is satisfactory and relatives/advocates views are listened to. The home has a satisfactory adult protection policy, and staff have an awareness of it. EVIDENCE: The home has a complaints policy and there is a record of complaints received and action taken by the management to answer these concerns. Staff spoken with knew about the action they should take if they were concerned about how residents were cared for. They had received training within the last six months. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 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 standard(s) 19 and 26. The standard of the environment within the home on the whole is good providing residents with an attractive and homely place to live. However the paving outside on the patio and the bathroom upstairs are potential hazards to residents. EVIDENCE: The environment has improved at this home with refurbishment and additional rooms added. It was noted that the middle floor where residents with dementia are accommodated has had carpets fitted in the corridors. The rooms look homely with the exception of a leak in the corridor form the ceiling, which the manager was aware of and was waiting to be repaired that day, and the bathroom, which had several tiles missing. Another bathroom had splits in the chair hoist and the bath was worn where the chair seems to hit it. The patio area on the ground floor has been decorated with pot plants and baskets, which the manager said the residents had done. However the paving slabs were very uneven. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 16 The laundry has had some work done to it with a door closure having been fitted and the hand-washing sink moved. The laundress said that her work environment felt improved now. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 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 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 and 30. The level of staff and training programme would seem to meet the needs of the residents. The standard of vetting and recruitment has declined with not all appropriate checks being carried out; this potentially leaves residents at risk. EVIDENCE: The inspector was able to see the rotas for the week of the inspection and older ones. All indicated that the staffing at the home to meet residents needs consisted of three nurses, one on each floor and ten care staff on duty from 8 – 8 and with two nurses and five staff on at night. Hotel services and an activity person support them. The staff spoken with felt that there was adequate staff and that holiday and sickness are always covered to ensure residents needs are met. The cook finishes work at 3.30 another member of staff then prepares what has been left for tea. This was the one point staff commented on in a negative way. The home has a clear recruitment policy that covers all the elements for the protection of residents including criminal records checks and references. Staff files that were read evidenced that this policy was not being met fully as there was a reference missing, references were seen from family members and copies of proof of identity were also missing. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 18 The manager has a training programme for the forthcoming year including mandatory training and areas needed to meet resident’s needs. Staff confirmed that training was available and they felt the information was used to assist them in caring for the residents. Mandatory and other training for needs and personal development is available, the home is supported in offering training. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 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 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, 36, 37 and 38. The home is run quite well with these exceptions. The lack of staff support through supervision could potentially place residents at risk. The lack of reported visits by the responsible individual and the way in which the resident’s accounts are maintained puts them at risk of abuse. Mostly health and safety is considered well. The cook must have up to date competence in food handling. EVIDENCE: The manager has been at the home now for approximately nine months and has undertaken training to keep himself up to date professionally. Mr Jopson has nearly completed the NVQ 4 Managers award. Staff spoken with said that there are meetings approximately every two months, minutes were seen to be available for all staff to read. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 20 The manager undertakes an audit every other month with the alternate months the audit is done by the Regional Manager. Regulation 26 visits are infrequent and need to be monthly. The audit covers all aspect within the home with action being followed through verbally or in writing to staff and reassessed at the next audit. The manager has noted a gradual improvement in some areas using this process. The home looks after personal account monies for most residents several of these accounts were sampled to see that records were kept and balances matched. In one case there was £1 unaccounted for. The manager undertook to go through all thoroughly. Staff supervision and appraisals were discussed with the manager and none have taken place since last September. The CSCI have received regular notification regarding incidents at the home. However no reports from monthly visits by the Responsible Individual have been received since February 2005. The inspector viewed the fire records. Fire safety had visited the home in May 2005 and had asked for 6 pieces of work to be carried out. The manager showed that these had been done. The records kept by the home have been maintained; however there was no evidence that when something had been identified for action that this was followed through. The home has two staff trained to give manual handling training. Staff are to undertake food hygiene training throughout the year. The cook’s food hygiene certificate is out of date. Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 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 x 2 x 2 2 2 2 Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 22 No 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(2) Requirement The registered person must ensure that the patio slabs are safe for residents to walk on. The registered person must ensure that the bathrooms are safe to use. The registered person must ensure that the bath seats and equipment are safe to use. The registered person must ensure that recruitment procedures are followed. The registered person must ensure that the procedures for looking after residents monies are followed. The registered person must ensure staff receive supervison six times a year. The registered person must undertake Regulation 26 visits and send a copy of the report to the CSCI. The registered person must ensure that the cook undertkakes the full food hygiene course. Timescale for action 31/07/05 2. 3. 4. 5. 19 19 29 35 23(2) 23(2) 19 Sch2 20(3) 31/07/05 31/07/05 31/07/05 31/07/05 6. 7. 36 37 12 26 31/07/05 31/07/05 8. 38 16(2) 31/07/05 Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 23 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 Lavender Lodge Nursing Home H54 s12197 lavender lodge v232815 130605.doc Version 1.30 Page 24 Commission for Social Care Inspection 4th Floor, Overline House Blechynden Terrace Southampton Hants, SO15 1GW 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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