Inspection on 10/01/06 for Lincoln Lodge

This inspection was carried out on 10th January 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Lincoln Lodge 06/08/07

Lincoln Lodge 27/11/06

Lincoln Lodge 31/05/05

Lincoln Lodge 28/03/05

Lincoln Lodge 29/12/04

Lincoln Lodge 09/12/03

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Lincoln Lodge 2 Lincoln Square Hunstanton Norfolk PE36 6DL Lead Inspector Mr Christopher Handley Unannounced Inspection 10th January 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 Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 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. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lincoln Lodge Address 2 Lincoln Square Hunstanton Norfolk PE36 6DL 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) 01485 534570 01485 535163 Mr Brian James Poore Mrs Susan MacGovern Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May from time to time admit one service user who is over 60 years of age, not falling within any other category. 31st May 2005 Date of last inspection Brief Description of the Service: Lincoln Lodge is a large home situated on the seafront at Hunstanton. This home, which was originally a hotel is spread over four floors with the majority of rooms having a sea view. The home has a small passenger lift to all floors. Some of the bedrooms have en-suite facilities. There are two lounges and a dining room on the ground floor with a sun lounge on the first floor. The home provides care for up to 25 older people. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which forms part of the annual inspection programme. The Inspection commenced at 9.30 am and was completed at 2.15. A tour of the home was made, residents and staff were interviewed. A wide range of documents were examined. Three sets of care plans were read The Manager was present for the whole of the inspector and the Proprietor was present for part of the inspection. What the service does well: What has improved since the last inspection? What they could do better: • • • Small but significant areas of the care planning system need to be improved. The training needs to be improved. Significant safety measures need to be implemented, i.e. covering radiators. Since the last inspection three full time staff have left the home the Manager explained and these have been replaced by 6 part time staff. This has taken up considerable time, and as a consequence not all the requirements and recommendations made in the last inspection have been fulfilled. Both the Proprietor and Manager are aware of the importance of these matters and the potential legal consequences of not implementing these. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 Page 6 The Inspector spoke with the Manager and she has undertaken to ensure that requirements and recommendations made will be fulfilled. However, the management of the home need to: • • • • • • urgently improve the percentage of staff who have NVQ training improve the Foundation Training offered to staff ensure that the Manager is enrolled on a Registered Manager’s Award training programme ensure all radiators are covered develop the Quality Assurance scheme in the home so that it includes the residents, their relatives or visitors develop a plan for improvement in the home which is shared with the residents and the Commission. 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. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 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 Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 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): 2 All residents are provided with a comprehensive contract. EVIDENCE: All residents are provided with individual contracts, the Manager said, and showed the Inspector a copy of one. The document is clearly laid out in a print size which is easy to read. It is complete and comprehensive. The Manager explains the content of the contract to the resident and relatives who are provided with a copy. The home keeps a copy of the contract secure in the Manager’s office. Some of the residents spoken to were aware that they had a contract. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 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 All residents have an individual care plan, health care needs of residents are met. The home cannot be sure that they are fully meeting service users’ needs as they are not formally consulting with them and/or relatives. The medicine system has been improved since the last Inspection. EVIDENCE: All residents have an individual care plan, three of which were read by the Inspector. The overall management of the documentation has improved since the last inspection. As recommended, dividers have been put into the folders which improves the use and management of the documents. It was also recommended that the care plans are kept secure, and this is now done. In the plans seen there is a number of risk assessments which will aid in the provision of safety for the residents. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 Page 10 As yet the plans do not provide guidelines for staff, and this needs to be done. The plans need to be divided into four sections, namely Assessment - what are the strengths and weaknesses The plan - what needs to be done Implementation - who is going to do it, and when Review - did the plan work or not. As yet there is no indication of residents/relatives being involved in the care planning process, and the Inspector repeats this recommendation. All residents have a G.P. and should any further investigation be needed this would be done by referral via the G.P. Any nursing care required would be provided by members of the District Nursing team with whom the home has a good relationship, the Manager said. Arrangement for sight, hearing, or dental services would be arranged locally. At the last inspection it was recommended that the home should have a written policy for the prevention of pressure sores, and the Manager who appreciates the importance of prevention in this matter has since obtained one. The Inspector was shown the medicines in the home. The medicine storage was locked and the keys are held by a person who has received training in handling medicines. The home uses a Monitored Dosage system, which works well the Manager said. There were no loose tablets in the cupboard. There is one resident who self medicates, but as yet the home does not have any guidelines for this and it is recommended that they should have. The home uses Controlled Drugs one of which was counted and found to be correct. At the last inspection a requirement was made that the home should have a dedicated Controlled Record book, the Manager has obtained one since and this fulfils the requirement made. The records in this book are neatly recorded. At the last inspection a requirement was made that staff who administer medicines should undertake training for this. This training has since been carried out and the staff are commended for this. This step will enhance the safety of the medicines in the home. If the staff had any concerns about the effect of medicine on residents they would contact the prescribing G.P. The home enjoys a good working relationship with the supplying pharmacy. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 Page 11 A positive discussion took place on the location of the medicines in this home, which because of the lay out of the building is not fully satisfactory. The Manager undertook to further discuss this matter with the Proprietor. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 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): 15 The home provides a good quality of catering. EVIDENCE: The Inspector was shown the menu, and the content appears varied, interesting and nutritious. At present there are no residents on special diets, however the Manager is aware that these must be recorded if there were. There are three choices of meals, which is commendable, and the residents interviewed spoke very highly of the catering. The Inspector discreetly observed residents who were taking their midday day meal with obvious enjoyment. Drinks are available through the day. If needed the Manager said, that she would seek the advice from the Dietician. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 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 The home has a complaints procedure which is displayed in the home. Staff knowledge about Adult Abuse prevention needs to be improved. EVIDENCE: The home has a detailed complaints procedure which is displayed in the home, and in the Statement of Purpose. There have been no complaints since the last inspection the Manager said. Residents are aware of the complaints procedure but informed the Inspector that they would tell the Manager or first member of staff if they had any concerns. The Manager believes in dealing with any concerns quickly so that any worries or concerns are resolved quickly. The staff interviewed are also aware that there is a complaints procedure, but again said that if they had any concerns they would inform the Manager. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 Page 14 In the inspection dated 31/5/05 a requirement was made that staff receive training in Adult Abuse prevention. The Manager has made three separate arrangements for this training to take place, and each time, through no fault of hers, the providers of the training have cancelled at the very last moment, i.e. the morning that the training was to take place. Obviously the Manager finds this situation very unsatisfactory and has again made the arrangement for this training to take place. This requirement for the training in POVA to be improved. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 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, 25 & 26 Residents live in a well maintained environment. The residents live in a safe, comfortable, environment. The home is clean, pleasant and hygienic. EVIDENCE: The home is suitable for its purpose. The building complies with the requirements of the local Fire Service and Environmental Health Department. The standard of decoration is good and there is ongoing maintenance of the home the Manager said, and this is obvious to the observer, though there is no written evidence of this. In the inspection dated 31/5/05 it was recommended that the home should have a routine plan of maintenance and renewal of fabric, as yet this has not been done and this recommendation is repeated. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 Page 16 The heating, lighting, water supply and ventilation of residents accommodation meets the relevant environmental health and safety requirements and the needs of the residents. Rooms are naturally and individually ventilated with windows conforming to recognised standards. Rooms are centrally heated. The lighting in resident’s rooms meets the recognised standard, and in addition have copious natural light. At present not all the radiators are protected and it is required that protection be put in place. This requirement was made at the inspection dated 31/5/05 . As yet this has not taken place and the requirement is repeated and the work is to be completed within two months. The corridors were neat clean and tidy and there were no ill odours. The home has a dedicated laundry, which is so sited that soiled articles of clothing or infected linen are not carried through areas where food is stored, prepared, cooked or eaten. There are hand washing facilities in the laundry, the floor of the laundry is impermeable and the walls are washable. The home now has policies and procedures for the safe handling and disposal of clinical waste, dealing with spillages, provision of protective clothing, and hand washing. There is a sluicing facility on the washing machine which is a semi industrial type. The washing machine has a specified programme to meet disinfection standards. At present the neither the Proprietor or Manager know if the Services and facilities comply with the Water Supply (Water Fittings) Regulations 1999 and the Inspector makes it a requirement that they take steps to find out and to obtain documentary written evidence to that effect. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 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): 28, 29 & 30 The home urgently needs to increase the number of staff who have NVQ training but staffing levels are adequate. The home does not have a foundation training programme. The home has a recruitment policy and practice, which needs to be improved. EVIDENCE: The Manager said that there 3 members of staff who have NVQ II. This represents a 23 of the 13 care staff. There are no staff taking NVQ training at present. Once staff have obtained their NVQ, they are paid an increment in salary, the Inspector was informed. The Manager is aware of the need to increase the number of staff who have NVQ to 50 and it is recommended that the Manager and the Proprietor encourage more staff to undertake NVQ level II. Staffing levels were deemed adequate as residents spoke of speedy response to the call bells and stated that staff did have time to talk to them. At present the home has an Induction training programme. It does not yet have a Foundation Training programme, the Manager said. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 Page 18 In the last inspection dated 31/5/05 it was recommended that the home have a Foundation Training programme. The Inspector now requires this. The home has a recruitment policy. Two written references are taken up, police and POVA checks are carried out and interviews are carried out by the Manager. Over the past few months the Manager said that there had been a high turnover of staff and, that as a consequence she had been busy in this field of management. The Manager did not know why the increase in turnover had taken place. One of the effects of this had been, that work which she had planned to do, had not been carried out. In the Inspection dated 31/5/05 it was recommended that there should be two people who carry out interviews. In the latest interviews there was only one person carrying out the interviews, and the Inspector repeats the recommendation that there should be two people involved in staff recruitment. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 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, 36, 37 & 38 The Manager has been in post for fourteen years but she does not have the appropriate qualification. The home has a Quality Assurance scheme in place which needs to be further developed. Staff do not yet receive supervision. Residents’ rights are protected by the home’s record keeping, polices and procedure. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 Page 20 EVIDENCE: The Manager has been in post for nearly twenty years and was registered as Manager in January 1995, and the residents speak highly of her. During that time she has undertaken a wide range of training, and gained a lot of varied experience. As yet she has not taken her Registered Managers Award. This is required in order to meet the National Minimum Standards. Over the last few months there has been a comparatively high turnover of staff and a good deal of her time has been taken up with recruitment and selection. The Manager outlined the quality assurance scheme which the home has put into being. A detailed questionnaire has been sent out to people who provided a service to the home asking their views of the services provided by the home. Some of these have come back, others have not. When they have all been returned the replies will then be collated the Manager said. However the views of the service users, their relatives and visitors also need to be sought and a plan for improvement developed which is shared with the residents of the home and the Commission. As yet the Manager has not commenced the supervision programme for staff but intends to commence in February of this year. It is her intention to use dedicated documentation. Since the last Inspection the Manager has obtained a full set of procedures from a commercial company, and she and the Proprietor are commended for this purchase. These documents, along with the residents’ records, are kept safe. Residents have access to their records but none have chosen to do so the Manager said. All individual records are kept up to date and are kept secure. The Manager is currently collecting the documentation that is required by Standard 38, but has not yet got it all. When it is collected the Inspector advises that it be kept in holders which are clearly marked Health and Safety, and that it should be available for reference purposes in her absence. It is required that this information should be obtained. Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 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 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X 2 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 1 3 2 Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 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. 3. Standard OP18 OP25 OP26 Regulation 18 (1) (c) 23 (p) 13 (3) Requirement It is required that the Manager arrange training for staff in Adult Abuse awareness. It is required that the radiators are guarded or have guaranteed low temperature surfaces. It is required that the Proprietor obtain documentary evidence that the services and facilities comply with the Water Supply (Water Fittings) 1999. It is required that staff receive formal supervision at least 6 times a year. It is required that the home has all the documentation as set out in Standard 38. It is required that the management improve the percentage of staff with NVQ level II training. It is required that the management ensures that the Foundation Training for staff is in line with Skills for Care guidance. Timescale for action 01/04/06 01/04/06 01/04/06 4. 5. 6. OP36 OP38 OP28 18.2 17 (2) 18(1)(c) 01/02/06 01/04/06 01/06/06 7. OP30 18(1)(c) 01/06/06 Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 Page 23 8. OP31 18(1)(c) It is required that the proprietor ensures that the manager of the home has the necessary qualifications for registration. (Time frame for registration on course.) 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations It is recommended that the elements of the care plans, assessment, implementation and review, should be clearer and more distinct. The residents/relative should be involved in the reviews of their care. It is recommended that the home have guidelines for residents who self medicate. It is recommended that the home has a written plan of routine maintenance, renewal of the fabric, and decoration of the premises, with records kept. It is recommended that as a matter of good practice interviews should be conducted by at least two people. It is recommended that the Manager collect and collate the results of the survey of services which was undertaken and make the results known to the contributors of the survey. 2. 3. 4. 5. OP9 OP19 OP29 OP33 Lincoln Lodge DS0000027392.V277749.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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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