CARE HOMES FOR OLDER PEOPLE
Sharnbrook Lodge 17a Park Road North Houghton Regis Bedfordshire LU5 5LD Lead Inspector
Andrea James Unannounced Inspection 22nd November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 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. Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Sharnbrook Lodge Address 17a Park Road North Houghton Regis Bedfordshire LU5 5LD 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) 01582 866708 Mr John Philips Mrs Miriam Philips Mrs Jean Flanagan Care Home 12 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (12), of places Physical disability over 65 years of age (12) Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 24th May 2005 Brief Description of the Service: Sharnbrook Lodge is a privately owned residential care home with a 12-bedded occupancy level. The home is registered for older people with due care of old age, physical disability and dementia. The large detached property is situated on Park Road North that provided direct access from Luton, Dunstable and Houghton Regis. The home is in close proximity to local shops and other amenities. The home has parking at the front of the building with a large garden at the rear of the building that can be accessible by service users. The home has one lounge, and a dining area within a conservatory all situated on the ground floor. Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 22nd of November2005, 7 months after the last inspection. The registered manager was present for the duration of the inspection, which lasted for 3.5 hours. The inspection followed a case tracking methodology where a sample of the service users were randomly selected and their files were inspected in detail. The inspector was able to speak to service users, relatives, staff and the management team in order to gain information for the inspection report. This report must be read in conjunction with the previous report to gain a full knowledge of the home’s performance throughout the inspection year. What the service does well: What has improved since the last inspection?
The home had made great efforts in addressing the outstanding requirements from the last inspection and as a result 5 of the 8 requirements were met. The home had improved their assessment processes for existing service users and as a result the care planning processes implemented were satisfactory in identifying the changing needs of the service users. There was also evidence to suggest the care plans were reviewed and updated on a regular basis.
Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 6 The home had implemented their death and dying procedures to ensure the choices and wishes of the service users can be met satisfactorily. The service users welfare was also addressed by the implementation of risk assessment for those service users whose safety could be compromised. 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.
Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 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 Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 and 4. Satisfactory processes were in place that ensured service users received a contractual agreement of their residency at the home and service users and their relatives were provided with sufficient information to ensure they would know if the home could meet their needs. As a result service users needs were being met. New admissions to the home did not receive a comprehensive assessment of need, as a result their needs were not identified satisfactorily in their care planning procedures and their needs would not be met satisfactorily. EVIDENCE: Procedures were in place that ensured all service users received a contractual agreement that was signed by the service user or their relatives, the placing authority and the home. Service users spoken to say they agreed to move into the home and felt that the care staff was able to meet their needs. Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 9 The manager was also proactive in identifying the changing needs of the service users. One service user whose needs had changed was being assessed by external professional to ensure the home can adequately meet her needs. There was evidence to suggest service users needs were being assessed. The manager had developed a new assessment tool, which met with the requirements of the standard but had failed to implement it for new service users who had moved into the home. Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 10 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): 7,9 and 11. Processes were in place to ensure the service users needs were being met through satisfactory care planning and medication procedures, as a result service users received good standards of care. The home had satisfactory death and dying procedures but some service users wishes in the event of their death were not recorded. This could result in the wishes of the service users not being upheld in the event of them dying. EVIDENCE: The home had made improvements to the care plans for all the service users. Some still needed further development but the care plans demonstrated a comprehensive need of the service users. The care plans could however be developed to ensure all the needs of all service user including those with behavioural difficulties are recorded and that all care plans record the expected outcome of all the needs identified. The home’s medication procedures were satisfactory. The staff that were allowed to administer medication were trained to do so.
Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 11 The home had developed a death and dying policy but had failed to ensure all service users wishes were recorded in the event of their death. The manager said some service users wishes were recorded. Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 14. Good processes were in place to ensure the more able service users were allowed to exercise choice over their lives but limited opportunities were available for some service users in respect of mental stimulation, general activities and recreational interests, as a result some service users needs were not being met. EVIDENCE: The home ensured that some service users were able to go out into the community on a regular basis to visit families or places of interests. There was also an activities programme available but this was only carried out with some service users. Care staff said it was difficult to motivate some service users. Several service users spent a lot of time in their rooms and as a result received very little stimulation. On the day of the inspection the care staff were observed to be effectively communicating with some service users while others were seen to be sleeping or just sitting. Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 14 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 and 25. The home was in the process of making better the environmental standards and as a result additional laundry facilities, lounge space and toileting facilities were being built to further accommodate the service users. Access to the outdoor facilities were not safe for the service users, as a result service users were restricted from accessing the surrounding grounds of the home. EVIDENCE: The provider of the home was in the process of building an additional 12 bedrooms to the existing building, which would encompass a large dining facility, better laundry rooms etc. This should present better environmental standards for the service users. The service users all had comfortable bedrooms that were decorated to meet individual needs and likes.
Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 15 The building work has restricted the service users from accessing the surrounding grounds safely. The service users spoken to said they understood that it was necessary and knew it was for a temporary time. The home had built a new ramp that appeared unsafe for service users to access when wet or icy. Identified carpeted areas of the home also needed to be cleaned to ensure the environmental standards remain welcoming and homely. Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 16 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29 and 30. The home had satisfactory processes in place that protected the service users welfare these included good recruitment procedures and competent care staff, as a result service users were in safe hands. Further development was required for staff to achieve their NVQ level 2 in care qualification. EVIDENCE: The home recruited one member of staff since the last inspection. The file inspected showed that satisfactory recruitment procedures were in place to protect the service users welfare. The care staff spoken to said they received regular training. These included areas of training related to meeting the changing needs of the service users. 3 of the 14 care staff had achieved their NVQ level 2 in care and another 4 had embarked on the course. The manager explained that the college had limited assessors and as a result the care staff were not able to complete their course in the scheduled time. Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 17 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 and 38. The home was managed effectively to ensure service users care needs were being met and the registered provider, provided support to enable the smooth running of the home, as a result both service users and care staff spoke positively about the managers ability to manage the home. Some aspects of health and safety in the home needed to be improved to ensure service users safety. EVIDENCE: The manager had implemented various procedures that ensured the smooth running of the home. She was proactive in meeting the needs of the service users and had made improvements in the amount of training offered to the care staff.
Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 18 The manager was also receiving more support from the registered providers but this was not recorded. The home had several doors that were wedged open. The ramp to the front of the building could cause danger to service users in bad weather. Incontinent materials were stored in communal bathrooms due to lack of storage in the home, which could result in trip hazards for service users. The home continued to fail to provide satisfactory laundry equipment to ensure service users clothing are launderered in correct procedures according to meeting the Infection Control Legislations. The home did not have a sluicing facility. The home had limited storage facilities and as a result various incontinent materials were being stored in communal bathrooms, which could cause service users safety to be compromised. Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 x 2 2 x x x x 3 x STAFFING Standard No Score 27 x 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x x x x 2 Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP12 Regulation 16 (2) (m) 22(1) Requirement Arrangements must be made to ensure that all service users receive adequate stimulation to ensure they are motivated. Correct procedures must be in place for reporting, recording and investigating complaints. Previous timescale: 30.07.05 Appropriate risk assessments must be completed for all service users to ensure their safety to the front and rear of the building while the building work is being undertaken. Arrangements must be made to ensure the service users have sufficient living space to use for dining and lounging. Arrangements must be made to ensure a minimum of 50 of the care staff obtain their NVQ level 2 in care. Arrangements must be made for a sluicing facility to be made available in the home to prevent the spread of Infection. Previous timescale: 16.03.04/10.09.04/30.02.05 /30.06.05
DS0000014966.V266867.R01.S.doc Timescale for action 30/01/06 2 OP16 30/01/06 3 OP19 23 (2) (o) 30/01/06 4 OP19 23 (2) (a) (e) (g) 18 (1) (c) (i) 23 (2) (b) (k) 30/01/06 5 OP30 30/06/06 6. OP38 30/04/06 Sharnbrook Lodge Version 5.0 Page 21 7. OP38 23(a) 8 OP38 13 (4) (c) 9 OP38 13 (4) (a) Arrangements must be made for all internal doors to be kept shut when not in use and if acceptable by the fire officer, magnetic door closures be fitted to those doors which remains open. Previous timescale: 10.08.04/30.02.05/30.06.05 Arrangements must be made to ensure incontinent materials are stored securely, to ensure safety of all service users. Arrangements must be made to make safe the slopping ramp installed to the front of the building to ensure service users safety. 30/04/06 28/02/06 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 4 5 Refer to Standard OP3 OP7 OP7 OP11 OP31 OP31 Good Practice Recommendations Arrangements should be made to ensure all service users receive a comprehensive assessment on admission to the home. Arrangements should be made to ensure the behavioural needs of the service users are recorded in their care plans. All care plans should be developed to include the expected outcomes for identified needs of the service users. Arrangements should be made to ensure the wishes of service users in the event of their death are recorded. Arrangements should be made for the manager to be appropriately supervised on a regular basis. The manager should consider embarking of further care planning training. Sharnbrook Lodge DS0000014966.V266867.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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