Inspection on 27/11/06 for Lincoln Lodge

This inspection was carried out on 27th November 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 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

Lincoln Lodge 06/08/07

Lincoln Lodge 10/01/06

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 Mrs Geraldine Allen Unannounced Inspection 27th November 2006 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 Lincoln Lodge DS0000027392.V322310.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. Lincoln Lodge DS0000027392.V322310.R01.S.doc Version 5.2 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.V322310.R01.S.doc Version 5.2 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. 10th January 2006 Date of last inspection Brief Description of the Service: Lincoln Lodge is a care home providing personal care and accommodation for 25 older people. Mr B Poore owns the home. The home is located on the seafront at Hunstanton, close to shops, pubs, the post office and other local amenities. Lincoln Lodge was originally a hotel and accommodation is spread over four floors with the majority of rooms having a sea view. The home has a small passenger lift to all floors. All bedrooms provide single occupancy and 9 have en-suite facilities. There are two lounges and a dining room on the ground floor with a sun lounge on the first floor. Fees for the home are currently between £281:00 and £345:00 per week. There are additional charges for items such as hairdressing, private chiropody, newspapers and telephone. Residents and/or their representatives are advised of the home’s charges and any changes to the fees in writing. Lincoln Lodge DS0000027392.V322310.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the day of Monday 27 November 2006. The manager, Mrs MacGovern, was on duty on the day of inspection. Mr Poore was also present at various times throughout the day. Information was obtained from a variety of sources. Prior to the inspection, Mrs MacGovern had completed an annual pre-inspection questionnaire. A total of 21 relatives/visitors and 16 residents completed and returned CSCI questionnaires. On the day of inspection, information was obtained by looking at a variety of records, speaking with residents, visitors and staff. A tour of the building also took place and lunch was eaten with residents in the dining room. Four requirements have been made as a result of this inspection, 2 of which are repeated. The requirements need urgent action to avoid enforcement action being considered. Three recommendations have also been made that are based on best practice. At the last inspection, this home was assessed as adequate. At this inspection, Lincoln Lodge was seen to provide good personal care in a pleasing environment. Residents described high levels of satisfaction with the care provided. However, there needs to be improvement in the management elements of the home so that they reach the same high standard as the care provision. As a result, this home remains assessed as adequate although improvements have been evidenced since the last inspection. What the service does well: Residents benefit from good admission procedures that include the provision of information about the home and contracts of terms and conditions of residence. Staff treat residents with respect and speak to them in a dignified way. The interactions between residents and staff were observed throughout the day. These interactions were appropriate and clearly based upon friendship and trust. The home is well maintained and the environment very pleasing. Residents have easy access to all parts of the home and accommodation offers plenty of choice of where they spend their time. Lincoln Lodge DS0000027392.V322310.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Lincoln Lodge DS0000027392.V322310.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 Lincoln Lodge DS0000027392.V322310.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive information that helps them make a decision to live at the home. Residents or their representatives receive a contract of the terms and conditions of residence. Changes to the contract are notified in writing. All residents have an assessment of their needs completed before they move into the home... This home does not provide intermediate care. EVIDENCE: All residents have an assessment of their needs completed prior to admission to the home. Residents receive a contract relating to their stay at the home and any changes are notified in writing. The home provides a copy of the Service User Guide to all residents on admission. This home does not provide intermediate care. Lincoln Lodge DS0000027392.V322310.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. 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 this service. Care plans were in place and based on good needs assessments. Care plans reflected the individual care needs of residents. Confidentiality was not protected because of the practice used to record daily events. Staff are welltrained and competent ion the safe control and administration of medicines. Residents are treated with respect and their privacy protected. EVIDENCE: The care of 3 residents was reviewed as part of this inspection. Each resident was also spoken to in private. A care plan was in place that reflected the care needed for each person and was based on assessments of their needs. There was evidence of good practice. All entries in care plans need to be dated and signed. Daily records were kept in a diary that does not protect their confidentiality. Staff are well-trained in the safe control and administration of medicines. Residents have access to a wide range of health and social care professionals. Residents felt staff respected their privacy and dignity. Lincoln Lodge DS0000027392.V322310.R01.S.doc Version 5.2 Page 10 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. 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 this service. Residents are supported to maintain contact with relatives and friends and are able to access events in and outside of the home. Residents are encouraged to make choices about their daily living and staff respect these. Residents are provided with nutritious and varied meals. EVIDENCE: Residents and visitors were spoken to and confirmed that visitors are welcome at the home at any time. Some residents felt that staff did not have enough time to sit and talk with them. Residents said there were activities taking place and they could join if they wished. One resident attends a local club on a weekly basis. Residents said they were able to make choices about their daily living and felt staff would respect these. A meal was eaten with residents in the dining room. Residents said they enjoyed the food and had choices at all meal-times. Fresh produce was used and meals cooked on site. Lincoln Lodge DS0000027392.V322310.R01.S.doc Version 5.2 Page 11 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. 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 this service. The home has a complaints procedure that is displayed in the home and is well known. Staff are trained in respect of abuse awareness. Interaction between residents and staff were appropriate. EVIDENCE: The home has a complaints procedure that is well known. The procedure is displayed in the entrance hall. Staff have received training about abuse awareness. Practice was observed and was appropriate. Interactions between residents and staff were friendly and respectful. Lincoln Lodge DS0000027392.V322310.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained and in a good state of decoration. Residents are able to access all areas of the home safely. Personal space was individualised with personal belongings. Aids and adaptations were provided where necessary. The laundry was well organised. The home was clean, tidy and no unpleasant odours were detected. EVIDENCE: A tour of the premises was conducted. All areas were clean, tidy and odour free. Resident’s bedrooms were individualised with many personal items. Aids and adaptations were in place in both communal and personal areas. Residents have access to all areas of the home. Communal areas were well furnished and in a good state of decoration. Lincoln Lodge DS0000027392.V322310.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers to meet the needs of residents. They receive training relevant to the resident’s needs. Recruitment processes need to be improved to ensure 2 references are obtained for all staff. EVIDENCE: Three staff were spoken to in private and generally felt they received good training to help them fulfil their role. The staff rota shows staff are employed in sufficient numbers to meet resident’s needs. Recruitment procedures were generally good but the home must ensure that a minimum of 2 references are obtained for all appointments. Staff receive training that reflects the needs of residents. Lincoln Lodge DS0000027392.V322310.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Mrs MacGovern has not completed the Registered Manager’s Award to date. The home has completed a quality assurance assessment and copies of the summary need to be sent to all stakeholders. The home does not look after any monies for residents. Staff are not receiving formal supervision as set out in the National Minimum Standards. Health and safety matters are taken seriously. All entries in the accident records must be dated. EVIDENCE: Mrs MacGovern has not yet commenced her Registered Manager’s Award and there is no date arranged. The home’s quality assurance has been completed and copies of the summary will be sent to residents, relatives and CSCI. At the time of inspection, the home was not looking after any monies for Lincoln Lodge DS0000027392.V322310.R01.S.doc Version 5.2 Page 15 residents. Staff are not receiving supervision as set out in the National Minimum Standards. Progress is however being made as 2 senior staff will assist Mrs MacGovern in this task. There was evidence that the home is well maintained and health and safety matters are taken seriously. However, all entries in the accident records must be dated. Lincoln Lodge DS0000027392.V322310.R01.S.doc Version 5.2 Page 16 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 3 3 3 x X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 3 Lincoln Lodge DS0000027392.V322310.R01.S.doc Version 5.2 Page 17 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 OP10 Regulation 12(4)(a) Requirement Timescale for action 26/01/07 2 OP29 19 3. OP36 18.2 The registered persons must ensure that all records kept in relation to residents protect their privacy and confidentiality. The registered persons must 26/01/07 ensure that staff are only employed at the home on compliance with Schedule 2. Two references must be obtained for all staff working at the home. The registered persons must 26/01/07 ensure that staff receive formal supervision at least 6 times a year. This requirement is repeated. 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 all entries in the care plans and other records relating to resident’s care are signed and dated. DS0000027392.V322310.R01.S.doc Version 5.2 Page 18 Lincoln Lodge 2 3 4 OP33 OP38 OP31 It is recommended that a copy of the home’s quality assurance audit summary is sent to all residents, relatives and CSCI. It is recommended that all accident records are dated at the time of completion. The registered persons must ensure that the manager completes the Registered Managers Award. Lincoln Lodge DS0000027392.V322310.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Lincoln Lodge DS0000027392.V322310.R01.S.doc Version 5.2 Page 20 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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