Inspection on 09/05/06 for Saxby Lodge

This inspection was carried out on 9th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Saxby Lodge 10/10/05

Saxby Lodge 18/05/05

Saxby Lodge 19/10/04

Saxby Lodge 17/05/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Saxby Lodge 124 Victoria Drive Bognor Regis West Sussex PO21 2EJ Lead Inspector Mrs A Peace Unannounced Inspection 9th May 2006 08:30 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 Saxby Lodge DS0000014703.V290211.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. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Saxby Lodge Address 124 Victoria Drive Bognor Regis West Sussex PO21 2EJ 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) 01243 828615 Mrs Eileen Teresa McCarron Mr Timothy Gerard McCarron Mrs Eileen Teresa McCarron Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 2005 Brief Description of the Service: Saxby Lodge is a privately run establishment providing board, accommodation and personal care for up to nineteen people over the age of 65. It is a large detached property set in its own grounds close to local shops and railway station and about two miles from the seafront. Accommodation is provided in single rooms, four of which have an ensuite toilet. The home does not have a vertical lift so only residents that can manage the stairs can be accommodated in any of the four rooms on the first floor. Facilities include a lounge/diner and a conservatory on the ground floor and a lounge on the first floor. There is a small garden for the residents to enjoy. The proprietor/manager is Mrs Eileen McCarron. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place on 8th May 2006 over 5 hours. The Providers Mr and Mrs McCarron both take a full and active part in running the home and are committed to providing a very good standard in the home, both were present during the inspection. Mrs McCarron, 4 staff and 10 residents were interviewed during the visit to find out how it is to live and work in the home. One visitor was also spoken with and said they were very pleased with the standards in the home. All comments made throughout the inspection were positive. A general tour of the home was undertaken and the majority of residents’ rooms visited. Case tracking from records to care given was carried out for a number of residents. Staff records and relevant records relating to the management of the home were examined. The midday meal was also sampled and found to be delicious. The majority of the records were in order, where there were minor gaps this was discussed with Mrs McCarron at the end of the inspection. Two letters had been sent to the Commission prior to the inspection, the comments in the letters were very positive and complimentary about the home, the providers and the staff. One of the letters said that “the staff acted beyond the call of duty and looked after my mother like a queen and visitors are always greeted with a cup of tea and a smile”. It was clear from their comments and by observation that residents are encouraged to make choices about their daily lifestyles, for example going to bed and getting up when they wished. Staff training is ongoing and it was noted that the majority of staff were either National Vocational Qualification (NVQ) trained or were awaiting to start the training. Mrs McCarron is presently undertaking the Registered Managers Award. The home met the requirements of the local fire and environmental health services. There were no requirements made at the time of this inspection. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 6 The conclusion of the inspection is that residents enjoy a good quality of life, at the home and are looked after by a committed and dedicated and caring staff team. The overall outcomes for residents are good. What the service does well: What has improved since the last inspection? Rooms are redecorated and refurbished as they become vacant and new chairs for the lounge have been provided. New laundry equipment has been purchased. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 7 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. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 8 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 Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. Residents and their families have the information they need to make an informed choice about where they live and are suitably assessed before placing. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The fees for the home range between £325-£435 per week. The statement of purpose/service user guide was available around the home and Mrs McCarron said that there had been no need at present to amend the document because there had been no changes. A copy of the latest inspection report was available in the home. Each resident is given a contract when they enter the home. Most of the residents had family or friends who were able to act upon their behalf. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 10 The Proprietor/Manager Mrs McCarron assesses all residents before they join the home either in their own home or in hospital. These completed assessments are kept in the care records and resident’s needs had been updated appropriately. Residents have an opportunity to visit the home or have a trial stay to see if the home will meet their needs. The home does not take anyone in for intermediate care. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 11 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): 7,8,9,10,11. Resident’s needs are reflected in the assessments and care plans. The medication procedure is safe and staff are trained to administer medication. Residents are able with assistance to make choices about their lives and the staff protect their privacy and dignity. Staff treat residents and family with care and sensitivity at the time of death. The quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are well written and contain all the information necessary to look after the residents. They are reviewed and updated regularly. The inspector Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 12 tracked care records to care given and spoke to the residents and could confirm that the staff care for the residents to a good standard. Some of the comments were that “I could not be looked after any better”, “nothing is too much trouble”, “we are very well looked after” “the owners and the staff really do care about us”. General practitioners, district nurses, opticians, dentists and other professionals visit the home when requested and records are kept of all such visits. Medication was stored safely and records are well kept in regard to the administering and disposing of them. Staff are well trained and the majority had attended an outside course on ‘Care and Control of Medicines’, records indicted that another two staff were due to go on the training. Through speaking with residents, staff and a visitor the inspector could confirm that both day and night staff do respect the privacy and dignity of residents at all times. Sadly a resident had recently passed away and during the inspection a relative did ring the home and from the telephone conversation and comments from residents the inspector could confirm that the staff had acted respectfully and in a sensitive manner. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Residents stated that they are happy with their lifestyle, are able to keep in contact with their family and friends and able to have choice and control over their daily tasks. Good home cooked food is provided. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does provide some activity for the residents if they wish to join in, and some did say that they did not wish to and they were encouraged to do as they wish. Residents said they can get up and go to bed when they wished to. There is a fortnightly ‘Movement to Music’ session, massage, monthly visits from outside entertainers, weekly visits from a local catholic church and a quarterly visit by a Church of England vicar. Residents are able to go out with Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 14 their families or friends and visitors are made welcome at the home this was confirmed from letters sent to the Commission and by speaking to a visitor. One letter said that she was always greeted by staff with a smile and always offered a cup of tea. A lady with a from ‘Pat-a-dog’ comes into the home and visits many of the residents. regular visits. Occasional outings are arranged by a local voluntary organisation. Staff spend time with residents just chatting or playing board games and daily papers are available in the lounge. Two chefs work at the home and cover the seven days. The chef working during the inspection was noted to take tea and biscuits around to individual residents and chatted to them when able. The main meal served on the day was home made Cottage Pie with fresh vegetables followed by home made jam sponge. The Inspector sampled the meal which she found it to be well presented, well cooked and delicious. The menus indicated that nutritious good home cooked food is served, alternatives are available at all times and the chef was aware of the likes and dislikes of residents. There was a list in the kitchen of the resident’s individual choices for breakfast. The Inspector asked about the timings of meals and because the evening meal is served at 5.30pm and the breakfast from 7.30 am it seemed a long time between meals. She was told that residents have a hot drink and biscuits about 7.30-8pm and also some residents liked sandwiches or toast later on. This was confirmed by speaking with staff and residents. This again confirmed that residents are well looked after at the home. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18. Complaints are handled in accordance with the home’s procedure and residents have stated that their views are listened to and acted on. Residents are protected from abuse. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service EVIDENCE: All staff have attended Adult Protection Training, a copy of the West Sussex Protection for Vulnerable Adults is available in the office but the home’s procedure contradicted this. Mrs McCarron said that this would be changed immediately to reflect the West Sussex procedure. Many of the residents vote by post in elections. There have been no complaints made about the home to the CSCI and the complaint book in the home had no complaints recorded since the last inspection. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. Residents live in a comfortable, homely, clean and comfortable environment and there are sufficient facilities and equipment to meet their needs. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service EVIDENCE: Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 17 The location and layout of the home is suitable for its stated purpose. It is well maintained both externally and internally and meets service users needs in a comfortable and homely way. The Inspector toured the premises and found the service user’s rooms to be fresh and clean, beds had been made and washbasins and toilets were clean and fresh. Residents rooms are personalised by the addition of small items of furniture pictures ornaments and photographs. The communal accommodation consisting of two lounges a dining room and a conservatory is homely, comfortable and well decorated. New chairs have been bought since the last inspection. The front garden is tidy, attractive with garden furniture for residents to sit out. The building complies with the requirements of the local Fire Service and The Environmental Health Department and maintenance records were available for examination. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 18 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): 27,28,29,30. There are sufficient staff employed to ensure that resident’s needs are met. The home has a sound recruitment policy and all checks are made for permanent staff. Staff training is provided and staff are competent to do their jobs. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From observation and discussions held during the inspection the Inspector concluded that the staffing levels are appropriate to the assessed needs of the service users presently accommodated. Care staff were noted to be supported by an appropriate number of ancillary staff. All staff employed at the home have undergone Criminal Records Bureau (CRB) checks to ensure safety for the residents, copies of these were available for inspection. To meet this standard Mrs McCarron was reminded to ensure that any other people who come to work in the home with the residents must also undergo the necessary safety recruitment checks to ensure the safety of the residents. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 19 Staff training had been undertaken in all areas and the evidence showed that all staff are offered training relevant to their work. There have been no new staff recruited since the last inspection so a random selection of staff records were examined and the majority found to be in order. There were only two minor gaps identified and Mrs McCarron said that these would be addressed immediately. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38. The way the home is run is beneficial to the resident’s needs. The home is managed by a well-qualified, caring and competent manager. Resident’s financial interests are safeguarded and the health and safety of residents are promoted and protected. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 21 Mrs McCarron the Provider/Manager is a first level nurse and an experienced manager, she is aware of the need to obtain a recognised management qualification and said that she has started to undertake the Registered Managers Award. Staff confirmed that there were clear lines of accountability within the home. On the day of the inspection the Inspector noted there to be an open and friendly atmosphere within the home and a visitor said this was always the case. Staff said they felt well supported in their roles. To meet this standard a full quality assurance and monitoring system should be commenced in the home, the need for this was discussed during the inspection. Policies and procedures were appropriately available. The Inspector confirmed that Insurance cover is available in the home. Service users are encouraged to manage their own affairs with the help of relatives or advocates if necessary. Secure facilities are available and the financial records and petty cash accounts were examined and discussed, the inspector concluded that the process is robust. Mrs McCarron was advised to use external advocates when necessary. To fully meet the standard, staff should be formally supervised 6 times a year and this should be recorded, this was discussed with Mrs McCarron during the inspection. The Inspector could confirm that supervision is given on an informal basis continually and that an appraisal system is operated. The Inspector concluded that supervision systems are robust within the home but they do need to be recorded for the standard to be fully met. The Inspector concluded that service users rights and best interests were safeguarded by the home’s record keeping. Staff training records were available to indicate that staff have received training in appropriate health and safety procedures. Records indicated that further training has been planned for fire safety, first aid and food hygiene. The providers should ensure that the windows only open to ensure adequate ventilation but still ensure the safety of residents. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 22 Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 23 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 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 3 3 2 3 3 2 2 2 Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 3 4 Refer to Standard OP18 OP33 OP36 OP38 Good Practice Recommendations The home’s protection of Vulnerable Adults Procedure should be in line with the West Sussex Vulnerable Adult procedure. The quality assurance system should be expanded to meet requirements. Records should be available to evidence formal staff supervision sessions. Electrical wiring should be checked at intervals recommended by The Health and Safety Executive. Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 Saxby Lodge DS0000014703.V290211.R01.S.doc Version 5.1 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!