Inspection on 03/05/05 for Lovat House

This inspection was carried out on 3rd May 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

Lovat House 11/04/07

Lovat House 04/10/05

Lovat House 13/09/04

Lovat House 22/04/04

Lovat House 27/10/03

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 LOVAT HOUSE 6 Crescent Road Wokingham Berks RG40 2DB Lead Inspector Steve Webb Unannounced 3/5/05 10.15 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. LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lovat House Address 6 Crescent Road Wokingham Berks RG40 2DB 01189786750 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) Mr Ian Tappin Ms Fiona Honeyman Care Home Old age 26 Category(ies) of Old age, not falling within any other category registration, with number of places LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13 September 2004 Brief Description of the Service: Lovat House is a twenty-six bed home providing residential care to older people. This is a long-standing home, operating in a converted Edwardian detached house (with later extensions), in a residential street in Wokingham. Ownership transferred to the current proprietors, Mr and Mrs Tappin in 1988. The home is close to local amenities. Residents are accommodated on three floors all served by a passenger lift. The building has been subject to extensive improvement over the past two years, and work is now complete in most areas. Additional en suite bedrooms have been provided and improvements made to bathrooms, toilets, kitchen, laundry, dining and lounge space as well as to the general internal layout and environment. The rear garden has been very attractively landscaped to provide full accessibility, with level paths, raised beds of aromatic plants and both sunny and shady areas. The side and front gardens are also soon to be landscaped once the building works have been completed. Entertainment and activities are provided to residents, and various faiths are catered for by visiting clergy. LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on 3/5/05 between 10.15am and 5.00pm. The inspection included discussion with one of the proprietors and several staff members, examination of key records, a tour of the home and conversations with five residents, as well as taking lunch with residents. It was a positive inspection during which the observed interactions between residents, visitors and staff were warm and informal. The staff demonstrated a good awareness of the needs of individuals. What the service does well: 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. LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 Page 6 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 LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 Page 7 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 An appropriate assessment process takes place before a resident moves into the home, to establish that their needs can be met. EVIDENCE: Standard 6 is not applicable as the home does not provide intermediate care. Following an initial enquiry, the prospective resident and their relative are invited to visit the home. The manager or deputy manager, then visit the prospective resident (with a colleague), at home or wherever they are living to carry out a pre-admission assessment to a written format. If the manager considers the individual’s needs can be met by the home, they are again invited to visit the home, and terms are agreed. The resident moves in and an initial care plan is devised from the preadmission assessment information. After two weeks the full assessment is completed and the full care plan then also produced. Appropriate risk assessments are completed. Examination of a sample of four files confirmed these steps were in place. LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 Page 8 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 and 9 Service user’s needs are set out in individual care plans, though some appeared to be overdue for review. One service user is able to manager his own medication. Service users would be protected by the written medication procedures, but despite detailed training, gaps observed in recording expose service users to potential harm. EVIDENCE: Examination of a sample of care plans indicated that each resident had a care plan in place. Some had been reviewed as recently as January 2005, but some had no indication of a date of recent review. The date of review should be indicated on each care plan to enable effective scheduling of reviews, and care plans should be regularly reviewed. Care plans focus on the individual care needs of residents, and are supported by a range of other records including daily notes, risk assessments and personal care record sheets. However, the latter seem to be used rather inconsistently and in parallel with other systems such as a ‘bath book’ and another combined daily record. LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 Page 9 The personal care record sheets are a more appropriate record, as they are individualised records, which can be shown to a resident or their relative without breaching the confidentiality of others. All staff have received comprehensive medication training from an external trainer and there is an appropriate policy/procedure in place. Despite this, there were a number of gaps in the medication administration records on MAR sheets, and some inappropriate handling of medication during administration, was noted, despite this issue having been raised previously with staff. Medication quantities received in the home are recorded on MAR sheets, and a returns log is also used, both of which contribute to the medication audit trail. It is suggested that a system of checks of the MAR sheets by the incoming shift leader, be introduced to ensure any errors and omissions are addressed promptly. The home’s medication management procedures are inspected regularly by the pharmacist, most recently in December 2004, and reports were on file. Only one of the current residents is able to manage their own medication. LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 and 13 Service users cultural and social needs are effectively met by the home, and they are able to maintain contact with family, friends and the community. EVIDENCE: The home has outside entertainers twice a month, and this is detailed on a notice in the corridor. In addition a staff member is employed for two hours, two days per week to provide activities for residents. An ex-staff member also visits the home three times per week as a befriender, and spends time chatting to residents. The home also has a visiting physiotherapist who provides weekly gentle exercise as a group activity as well as individual sessions as required. There is a lot of interaction and banter between staff and residents on a daily basis, which helps to create a lively atmosphere. One resident is still able to go out unaided and does so most days. Some others are taken out by staff for short walks or wheeled in a wheelchair. Some are taken out by visiting relatives or friends. The spiritual needs of residents can be met via a visiting ecumenical minister or a local priest. Most residents have regular contact with either family or friends, and visiting family were seen to be made welcome. Each bedroom has a phone point and residents can have their own phone in their room. LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Service users have access to an appropriate complaints policy and a procedure, which will be complete, once the new complaints log has been reinstigated. EVIDENCE: The home has an appropriate complaints policy in place. However, during the disruption of the building works, the complaints log had been mislaid and could not be located for inspection. The proprietor purchased a new log-book for this purpose during the inspection, and undertook to enter the necessary headings and a copy of the complaints procedure therein. The proprietor confirmed that there had been no new complaints since the previous inspection. LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 Service users live in an environment where staff have worked hard to maintain safety during the extensive building works, and ongoing maintenance is undertaken promptly. The home is clean and presents a homely and attractively furnished and decorated environment for residents. Bedrooms are personalised. EVIDENCE: During the extensive building works, attention has been given to maintaining the safety of residents. Areas have been secured to prevent access at times and warning notices have been posted where this has not been practical. Staff have been vigilant in knowing the whereabouts of service users, and the contractors have also been supportive of the home’s need to maintain the safety of service users. Completed areas such as the lounge and dining room have been decorated and furnished to a good standard, although the current carpets in most communal areas are temporary, pending completion of the building works. The proprietor LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 Page 13 has engaged a contractor to visit regularly to maintain the standards of decor and carry out any necessary repairs. The newly landscaped rear garden is fully wheelchair accessible and provides level paths and seating areas in both sun and shade. The side and front garden areas remain to be landscaped in the near future once building work is completed. The home was clean and almost entirely free of any unpleasant odours, and a special deodorising machine had been purchased to address the odour in one bedroom. A new carpet-shampooing machine had also just been purchased. Individual bedrooms are individualised with pictures, photos, ornaments and also some items of furniture. Where the proprietor has noted a need for further improvement, action is planned to address this. For example, one bedroom is due to have a skylight installed to make it lighter. LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 Page 14 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 and 30 Resident’s needs are met by an appropriately trained and experienced team of mostly long-standing staff. Staffing levels are sufficient for current occupancy. EVIDENCE: The home maintains accurate rotas which include annotation linking individuals to their specific responsibilities for each shift as defined by detailed shift plans. There are still three care staff on duty at all times throughout the waking day, since some rooms are still not in use owing to the building works, but an additional staff member is being recruited ready for when further residents can be admitted. At night there are two waking staff on duty each night. Staff demonstrate a good level of knowledge about the individual lives, needs, likes and dislikes of residents and there is a lot of informal conversation between residents and staff as well as banter and humour. Residents confirmed that the staff were always very attentive and kind. One of the proprietors has her Registered Manager’s Award, and the manager has also completed this and is awaiting her certificate. The manager also has NVQ level 4. The deputy and eight care staff have completed their NVQ level 2 and are awaiting certificates. All staff have received detailed medication training, fire safety training, food hygiene and moving and handling training, from appropriate trainers. There is a collective training profile for the team to enable monitoring of their needs. The staff team are mainly well established and staff retention is good. LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 Page 15 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) 38 The health, safety and welfare of residents and staff are promoted by the home, though the fire risk assessment needed review to ensure it remains relevant, given the extensive building works. EVIDENCE: The necessary safety checks and servicing of equipment are carried out as required. A service of the fire alarm was due, and the proprietor undertook to arrange this. In the manager’s absence, the fire drill log and weekly alarm test records could not be located. The records of the last two fire drills and the last 2 months of alarm testing should be copied to the inspector. The home has a fire risk assessment though this should be reviewed to ensure that it is still applicable given the extensive building works carried out. As already noted, staff receive relevant health and safety-related training. Accident records are detailed, and all incidents, however minor, are recorded in case injuries emerge subsequently. LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 x COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x x x 2 LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 Page 17 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 7 Regulation 15 Requirement A schedule of regular review of care plans is required and the date of review needs to be recorded on the care plans. Staff must be reminded of correct medication handling and recording procedure. The records of recent in-house fire alarm testing and fire drills must be copied to the inspector. The homes fire risk assessment must be reviewed to ensure it remains appropriate, give the building work undertaken. Timescale for action 3/8/05 2. 3. 4. 9 38 38 13 17 23 3/6/05 3/6/05 3/7/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 9 Good Practice Recommendations Consider the introduction of a system of MAR sheet checks by senior staff as part of handover. LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 2nd Floor 1015 Arlington Business Park Theale Reading RG7 4SA 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 LOVAT HOUSE H52-H01 11399 Lovat House V 217450 Stage 4.doc Version 1.30 Page 19 - 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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