Inspection on 07/09/05 for Radway Lodge

This inspection was carried out on 7th September 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

Radway Lodge 06/05/08

Radway Lodge 17/08/06

Radway Lodge 11/01/06

Radway Lodge 05/01/05

Radway Lodge 27/04/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Radway Lodge Vicarage Road Sidmouth Devon EX10 8TS Lead Inspector Teresa Anderson Unannounced 7 September 2005 10:00hrs 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. Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Radway Lodge Address Vicarage Road Sidmouth Devon EX10 8TS 01395 514015 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) The Radway Partnership Mrs Sheila Mary Tallon Care Home 15 Category(ies) of OP Old age (15) registration, with number of places Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5 January 2005 Brief Description of the Service: Radway Lodge is a detached house situated in a central position in the town of Sidmouth. The home provides accommodation with personal care for up to 15 older people. Bedroom accommodation for residents is on the ground and first floor and all the bedrooms are for single occupation. There is a stair lift to the first floor. There are some steps throughout the home that makes access difficult for service users who are wheelchair dependant. There is a communal lounge and a dining room on the ground floor. There are pleasant gardens and outside seating areas. On road parking is available. Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours as part of the normal programme of inspection. The inspector saw the majority of the building and spoke with approximately 7 residents, 3 members of staff and the Responsible Individual. Records in relation to three residents were looked at in depth. These records included assessment and care plans, financial records, medication, meals, staffing and training. In addition records in relation to recruitment and fire safety were inspected. What the service does well: What has improved since the last inspection? What they could do better: Recommendations and Requirements were issued regarding the following: Whilst staff clearly demonstrated a ‘zero tolerance’ to and a sound understanding of issues relating to abuse, they were less clear about who they should inform outside the home and who should do what if abuse occurred. In addition housekeeping staff should receive training in the protection of vulnerable adults. The Responsible Individual was referred to ‘The Alerter’s Guidance’. Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 Page 6 Staff are required to keep a record of all medication entering the home and to record all medication administered to residents (as in guidelines issued by The Royal Pharmaceutical Society). The cook on duty should receive Food and Hygiene training as she has not done this for approximately 10 years. In addition the kitchen should be fitted with fly screens. The slabs at the front and side of the house should be made safe. An Immediate Requirement was issued requiring the Responsible Individual to contact the Fire Authority in relation to the number of propped open fire doors and fire doors which do not close properly. 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. Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Residents benefit from admission and assessment practices which ensure that the home is able to meet their needs. EVIDENCE: Radway have a policy of meeting with all prospective residents during which time a comprehensive assessment is undertaken. Assessments and care plans demonstrated that information is gathered from the resident and family, and where possible from involved health and social care agencies. Whilst some residents could not remember being visited before deciding to live at Radway Lodge (which is not unusual) they said they are happy with their choice. Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 and 10. The care for residents is well planned and delivered in a respectful way. Care includes support and advice taken from healthcare professionals. Some records in relation to drug administration are not being attended to. EVIDENCE: Care plans are clear and easy to read and follow. They detail the actions to be taken to meet needs. They are reviewed regularly and include references to referrals made and visits from health care professionals. Residents said that staff cared for them in a way they liked and preferred and many said how healthy they feel. They said that staff always knock on bedroom and bathroom doors and whilst ‘some are better than others’ staff are respectful. Medication records demonstrate that records are not kept in relation to medicines received into the home and that on at least three occasions medication was not administered or was not signed for following administration. Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 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) 15 Residents do not receive a varied diet. EVIDENCE: Comments regarding the food served at Radway Lodge varied from ‘very good’ through ‘alright’ to ‘too much of the same’. Records show that a two weekly menu is offered. In practice this means that every two weeks residents get the same meals as the previous two weeks. Many commented that the quality was usually good but the variety wasn’t. Food is well presented, eaten in nice surroundings in a place of the residents choosing. Jugs of orange and fresh fruit are placed in the lounge for residents to help themselves and drinks are also available in bedrooms. Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 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 and 18. Residents are well protected by procedures in relation to dealing with complaints, but they would be better protected if staff better understood procedures in relation to abuse. EVIDENCE: Neither the home nor CSCI have received any complaints about this home. Residents said that if they had any problems they would speak with the staff or manager. Staff clearly demonstrated a sound understanding of abuse and have a ‘zero tolerance’ to it. Care staff have received in house training and senior staff have received training from Devon Social Services. Housekeeping staff have not received training. The home has a Whistle Blowing policy and staff said that if they witnessed or were told of an abusive incident they would report this to a senior member of staff. However, the senior staff spoken with were unclear about the procedures which should then be followed. Residents said they felt safe and interactions observed between staff and residents were respectful and sensitive. Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 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, 25 and 26. Residents are potentially being put at risk from a poorly maintained area of garden and from a lack of action in relation to flies in the kitchen. EVIDENCE: On the whole Radway Lodge is well maintained, clean and hygienic. Residents say the cleaners do a good job and that their clothes are always well cared for. Policies and procedures are in place for the safe handling of waste and soiled articles and staff were observed following these procedures. The programme of covering the radiators to prevent accidental scalding has recently been completed. However, an area at the front/side of the home does have some lose slabs which do pose a potential risk to staff and residents. In addition, on the day of inspection, methods for controlling flies in the kitchen were not working. Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30. There is a good match of staff skills, numbers on duty and training to meet residents needs. Recruitment procedures provide safeguards to protect the residents. EVIDENCE: All staff receive induction and foundation training and approximately 25 of the staff have gone on to successfully complete NVQ training. Additional training has been provided in Osteoporosis, catheter care and appraisal and supervision. Thirteen staff hold a first aid certificate. The home have had to cover some shifts with agency staff due to sickness and holidays. However, to promote continuity the home use the same agency and try to get the same staff. Residents made no comment about agency staff. Staff files show that recruitment procedures are followed and that all staff undergo Criminal Record Bureau and Protection of Vulnerable Adult checks. Residents were very complimentary about the staff and their abilities. Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 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 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) 32, 35 and 38. Residents are protected from financial abuse but are put at risk by poor working practices in relation to fire containment. They are also potentially at risk because some staff have not received updated training in relation to Food Hygiene. EVIDENCE: The provider and deputy manager show great empathy towards residents and their families and give clear leadership, guidance and direction to staff. All residents praised the staff and said they liked living at the home. Records inspected indicated regular safety and fire checks are carried out and staff confirmed that regular fire instruction and drills had taken place. Emergency lighting is checked monthly. However, number of fire doors were propped or wedged open and some did not close properly. Staff were aware of infection control practice and confirmed that gloves and aprons were always available to ensure that correct procedure are followed. Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 Page 15 However, one cook identified that she had not received training in Food Hygiene since approximately 1995. Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 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 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 2 COMPLAINTS AND PROTECTION 2 x x x x x 3 2 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x 3 x x 3 x x 1 Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 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 9 Regulation 13 (2) Requirement The registered person must make suitable arrangements for the handling and administration of all medicines received into the care home. (This relates to the need to ensure that all medicines received into the care home are recorded and that all administrations of medication are signed for or the reason for non administration recorded). The registered person must ensure that the premises are kept in a good state of repair both internally and externally. (This relates to the lose slabs at the front/side of the house). The registered person must, after consulation with the fire authority, make adequate arrangements for the containing of fires. (This relates to the need to ensure that fire doors are not propped open and close properly). Timescale for action 9/10/05 2. 19 23 (2) 9/10/05 3. 38 23 (4) Immediate requiremen t issued. Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 Page 18 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. 2. Refer to Standard 15 18 Good Practice Recommendations The registered person should ensure that residents receive a varied diet. The registered person should ensure that staff understand the procedures to follow when responding to suspicion or allegation of abuse or neglect and that housekeeping staff receive training in the protection of vulnerable adults. The registered person should ensure that the kitchen is kept hygeinic by providing some method for dealing with flies in the kitchen. The registered person should ensure that training is provided for housekeeping staff (where needed) in Food Hygeine. 3. 4. 26 38 Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY 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 Radway Lodge d54 D06 S22011 Radway Lodge v245950_020905 Stage 4.doc Version 1.40 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. 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