Inspection on 17/10/05 for Lavender Lodge Nursing Home

This inspection was carried out on 17th October 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

Lavender Lodge Nursing Home 08/08/06

Lavender Lodge Nursing Home 13/06/05

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 Inspection 17th October 2005 10:00 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 Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 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. Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Lavender Lodge Nursing Home Address Bruntile Close Farnborough Hampshire GU14 6PR 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) 01252 571569 01252 375852 Lavenderlodge@highfield.care.com Southern Cross Care Homes No 2 Limited Nigel Chorley Jopson Care Home 68 Category(ies) of Dementia (13), Dementia - over 65 years of age registration, with number (25), Old age, not falling within any other of places category (68) Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A total of 25 service users may be accommodated in the DE and DE(E) categories at any one time A maximum of 13 service users in the DE category may be accommodated at the home. All service users in the DE category must be at least 55 years of age Date of last inspection 13th June 2005 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 DS0000012197.V258534.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted three hours. During this time the inspector was able to speak with the manager several staff and 4 residents. All standards have now been seen for this home a full picture of the home can be seen across the two reports. There were 8 requirements for action from the last visit and these have been completed. What the service does well: What has improved since the last inspection? What they could do better: The manager must ensure risks of cross infection are minimised such as preventing staff from using combs between residents. A carpet for a bedroom floor was seen to be split and is a potential trip hazard. These residents Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 Page 6 unable to use a nurse call bell chord should have clear risk assessments so that their needs are clearly planned for and are met. 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 DS0000012197.V258534.R01.S.doc Version 5.0 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 Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 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): 1, 2 and 5. Standard 6 does not apply at this home. The statement of purpose and service users guide are good providing prospective residents and existing residents with detailed information about the home enabling an informed decision to be made. The home actively encourages people to visit the home as part of the decision making. EVIDENCE: The information contained in the service users guide and statement of purpose gives readable and full information on the home, how it offers it services and support to residents and relatives. All information now reflects the change in ownership to Southern Cross. The documents gives a lot of information so that readers are able to use it to decide if the home is for them or not. The last report is available for people to see and is in the front foyer of the home. Visits to the home by prospective residents and or their representatives are encouraged and felt by the home an essential part of the decision making process. Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 Page 9 Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 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 the following standard(s): 9 and 11 There are some good policies and procedures dealing with medicines but poor care practices could put the residents at risk from cross infection. The method of disposal of medication is clear and staff are aware. The arrangements for understanding an individual’s needs in their final weeks give a very clear guidance for staff in caring for those who are dying. EVIDENCE: The medication disposal was discussed with the manager due to changes in policy on how this should be done. The home has a new policy to reflect the changes and staff were aware of these changes. The manager explained the homes policy for the care of those that are dying and the inspector was able to see examples of the care plans used at this time. It is very comprehensive including the personal, physical, spiritual and psychological needs associated with dying, it also addresses the needs of the family who are supported to be involved in the planning and if they wish delivery of care. Other professionals are also available to support the home and the residents, as needed for example the Macmillan Nurses. Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 Page 11 During the walk about the home the manager and inspector saw a member of staff use the same comb on two individuals, the manager took the member of staff side and spoke about dignity and possibility of cross infection through this practice. The manager said that this would also be discussed with all the staff. Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 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 the following standard(s): 12 The home meets expectations and requests from residents where possible. EVIDENCE: Residents were seen to be taking part in activities in the main lounge and some had one to one in their rooms. The inspector was able to speak with 4 residents and some had chosen to stay in their rooms to watch television or read. Others were free to move about the home and some were being nursed in bed. Those spoken with said that the home met their expectations, that they had been made aware of what happened in the home, and that they were able to make suggestions for things. Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 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, 17 and 18 The manager has established a sense of openness at the home so that staff, relatives and residents can voice their concerns. The rights of residents were protected. EVIDENCE: There have been no complaints made since the last inspection to either the CSCI or the home. Residents spoken to were aware of how to complain and said they felt comfortable in speaking with the manager or a member of staff about any issues. The manager said that relatives seem comfortable in approaching him with concerns; the inspector recommended that these concerns and any action taken are recorded. The manager advised that the electoral register has been completed and that residents are supported to make their votes. There has been one allegation regarding adult protection at the home since the last visit. Social services were involved and the allegation was unsubstantiated. The manager has changed some things since this investigation to improve and monitor the way in which care is delivered. The manager undertakes the training of the staff in this area, and staff spoken with were aware of the whistle blowing policy and the training. Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21, 22, 23, 24 and 25 The standard of the environment is good providing residents with an attractive, safe and homely place to live with equipment provided to assist staff in meeting needs, and beds appropriate for the needs of the residents. EVIDENCE: The manager accompanied the inspector on a walk about the home. Beds are being replaced with a new one being bought each month. The patio slabs have been re-laid and made safe this was a requirement from the last visit. The bathrooms have also been made safe with new bath seat and tiles repaired. A carpet in a bedroom door way had started to split causing a trip hazard. It was observed that some rooms had a long chord attached to the nurse call system whilst others did not. The manager explained that some residents were unable to use the system due to mental frailty; the manager was recommended to have a risk assessment for all residents related to the nurse call system. Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 Page 15 There was one room that had a strong smell of urine, the domestic staff were aware and had cleaned several that day and were on their way to that one. The inspector had had the opportunity to speak with the domestic staff and they spoke with pride of keeping the home odour free. They knew about products and equipment and which rooms needed attention Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 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 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): 28 and 29 The improvement in the recruitment process means that the service users are now supported and protected by them. The home provides and assists staff with a good training programme in order to meet resident’s needs. EVIDENCE: Three files of staff were seen and the home has followed guidance on recruitment to ensure the safety of the residents with all the relevant checks being carried out. The home assists staff in applying for an NVQ qualification that is suitable for them and offers support in the home. A new company now assesses staff and they are to visit the home monthly, the manager says that the target of 50 is now achievable. Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 Some aspects of safety need to be addressed such as consistency in fire checks and hot surfaces. Overall there is good leadership and a positive management approach in the home. EVIDENCE: The manager has now completed his Registered Managers Award. The manager holds relatives and residents meetings and keeps in touch with those that do not or cannot regularly visit the home with a newsletter. Since the last inspection when action was needed in the care of personal accounts the manager begun a weekly audit of the accounts and records, this is now monthly and no further issues have arisen. Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 Page 18 It was seen on staffing files that supervision is undertaken with staff when training and development needs are addressed and action taken to meet these needs. The CSCI have had regular Regulation 26 records of provider visits, sent with the exception of September, the home has copies of all these visits and action needed. One has already been carried out this month and a second is due next week. The inspector viewed the fire records and it was seen that the monthly checks on emergency lighting have been carried out however there were gaps in the records for the weekly checks of fire doors and alarms in July and August and there was no record for the week before the inspection. Moving and handling training is taking place on the 19th October 2005 and half of the staff have had food hygiene awareness. The cook has changed since the last visit and the new person has their full food hygiene certificate. Whilst walking around the home it was noted that several rooms were very hot. On touching the radiators, which had covers on them they were very hot to touch and posed a hazard to the residents. The manager said that they had had problems with the boiler and an engineer had been out the week before the inspection. The manager decided to turn off the radiators that were deemed to be too hot until someone was able to see to them. Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 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. 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 3 3 X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 2 X STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 2 Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 23(4) Requirement The registered person must ensure that regular checks are undertaken on fire equipment. Timescale for action 30/11/05 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 Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton 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. Extracts may not be used or reproduced without the express permission of CSCI Lavender Lodge Nursing Home DS0000012197.V258534.R01.S.doc Version 5.0 Page 22 - 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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