Inspection on 13/07/05 for Shedfield Lodge

This inspection was carried out on 13th July 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Shedfield Lodge 14/05/08

Shedfield Lodge 22/05/07

Shedfield Lodge 24/05/06

Shedfield Lodge 26/01/06

Shedfield Lodge 05/01/05

Shedfield Lodge 13/09/04

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 Shedfield Lodge St Annes Lane Shedfield Southampton SO32 2JZ Lead Inspector Kathryn Kirk Unannounced 13 July 2005 12:00 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. Shedfield Lodge Version 1.10 Page 3 SERVICE INFORMATION Name of service Shedfield Lodge Address St Annes Lane, Shedfield, Southampton, Hants SO32 2JZ 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) 01329 833463 Mr R. B. Geach, Mrs Christina Geach, Mr A. R. Geach CRH 33 Category(ies) of DE (E) Dementia - over 65 (20), MD(E) Mental registration, with number Disorder - over 65 (10) OP - Old age (33) of places Shedfield Lodge Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: The additional room registered 9C must not accommodate any service user with dementia on admission. Date of last inspection 5 and 6 January 2005 Brief Description of the Service: Shedfield Lodge is a residential care home. It is registered to provide support and accommodation for up thirty three people over the age of sixty five. Within this number, up to twenty people can have dementia on admission and up to ten can have a mental disorder, excluding learning disability or dementia.The home is situated on the outskirts of the village of Shedfield. It is a large period house in its own grounds. It is adjacent to an equestrian centre. Communal areas include a dining room, two lounges and a conservatory. Service users also have access to garden areas. The layout of the home is such that some of the bedrooms would not be suitable for any person with mobility problems. Twenty three of the bedrooms are single. Six of these have en suite facilities. The remaining five bedrooms are double. Three have en suite facilities. Shedfield Lodge Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. It took place on 13 July 2005 and lasted for five hours. The inspection was carried out by Kathryn Kirk and Isolina Reilly. There were thirty service users in residence on the day of inspection. Six were spoken with at length and several others were spoken with during lunchtime. Discussions took place with the manager, who was present throughout, and with six staff. One of the proprietors was present at the end of the inspection when the conclusions of the inspection were summarised. There was a tour of communal and some individual areas. Some documentation was also reviewed. Prior to the inspection written feedback was received about the service from three service users and from one visitor. The manager had also completed a pre inspection questionnaire. What the service does well: What has improved since the last inspection? Information that is gathered as part of the care planning process has improved and gives a more rounded picture of service users needs and expectations. The keyworker system has further improved the quality of care offered to the individual. Training opportunities for staff are plentiful. The manager is a trainer in moving and handling and so is able to ensure that all staff are up to date in this area. Shedfield Lodge Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Shedfield Lodge Version 1.10 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 Shedfield Lodge Version 1.10 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 and 6 Appropriate information is obtained prior to admission so that an informed decision can be made about the homes ability to meet the need of prospective service users. EVIDENCE: The manager confirmed that a care management assessment would be requested for any service user who is referred through care management arrangements. Two service users asked said that the manager had come to visit them before they moved to Shedfield Lodge and both said that they were asked a lot of questions about their care needs. One service user said that they visited before they decided to move in and said that they were introduced to everyone. Two others said that they were unable for health reasons, to visit but that their relatives had done so on their behalf. Two completed assessment forms that had been filled in by staff at the home were seen on file. These included basic personal information for example, next of kin and GP details. They also included information about any medical condition, details of treatment, details of personal care needs, likes and dislikes and personal safety and risks. There was documentary evidence that Shedfield Lodge Version 1.10 Page 9 service users have initial care plans, which are developed from the assessment. The manager said that these are reviewed six weeks following admission. Two completed ones were seen on file. It was evident from a tour of the building that because of its layout, that some bedrooms would not be suitable for service users with certain identified needs. Through discussion with the manager it was evident that any restrictions in terms of the building are carefully considered before a decision is made regarding the ability to meet need at Shedfield Lodge. Intermediate care is not provided. Shedfield Lodge Version 1.10 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 standard(s) 7,9 and 10 The system of care planning and review is appropriate and provides the basis for care to be delivered, as long as sufficient detail is recorded. Medication systems are largely in place although greater attention must be given to ensuring that records for the administration of medicines within the home are accurate. Privacy and dignity is respected. EVIDENCE: Three care plans were examined in detail and were discussed with the service user to whom they related. One service user said that staff often talk to them about how they wish to be looked after. There was evidence that the three care plans have been reviewed monthly. Completed care plans seen contained all necessary information to enable staff to provide appropriate care, although one lacked sufficient detail. Any areas of identified risk were also found be documented and reviewed. Actions of staff were seen to be recorded in a care plan diaries. This also feeds into the reviewing process. One service user said that they felt that their care plan accurately reflected their needs. Shedfield Lodge Version 1.10 Page 11 The manager said that it is the intention that every service user would have a completed life profile. This will detail preferences regarding daily routines communication issues, family history, important events and places from an individuals past and information regarding spiritual needs. This will feed into the care planning process. The manager has recently instigated a keyworker system, whereby a named staff member is given special responsibility for a small number of service users. The provision of care continues to be the responsibility of all care staff, but staff said that they feel that this system has improved the quality of care offered to individuals. Policies and procedures relating to the receipt recording storage handling administration and disposal of medication were seen. Policies and procedures were also seen regarding service users who wish to administer their own medication and those who wish to use herbal remedies. Records were seen regarding the disposal of medication and of medications received by staff at the home. These had been completed satisfactorily. Administration sheets had not been signed in all cases and no reason or explanation for the gaps had been recorded. The medication cabinet was viewed and all medications were seen to be stored satisfactorily, with the exception of two inhalers, which were out of their boxes and unlabelled, and some fibrogel which had come as a multipack and did not have individual labels. Staff were strongly advised to check that all medicines are correctly labelled by the pharmacist. Staff confirmed that all staff who administer medication have been trained in this area. Three service users responded in written feedback that they felt that staff treat them well and that their privacy is respected. All service users asked on the day of inspection were of the same opinion. One visitor said that they were able to visit their friend in private. Service users asked also confirmed that this was the case. Staff were observed to talk with service users in a friendly and respectful manner and to use the term of address preferred by service users. Staff were observed to knock on bedroom doors before entering and service users asked said that they always did so. Screening was observed to be provided in shared bedrooms. Shedfield Lodge Version 1.10 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 standard(s) 15 Food is of good quality and is plentiful and service users preferences as to where their meals are taken is respected. More consideration needs to be given to increasing choice and to how service users are made aware of the choices available. EVIDENCE: Service users said that they are offered breakfast in their bedroom. On the day of inspection lunch, which is a cooked meal, was being taken by the majority of service users in the dining area. Two service users were observed to be eating in the sun lounge. They subsequently confirmed that this was their choice. Records show that service users are also provided with tea which is a light meal and that they are offered a hot drink and biscuits in the evening. Lunch was roast lamb and fresh vegetables. It looked appetising and one service user asked described their meal as excellent. All others asked said that the food was very good. All asked said that there was always sufficient quantity. One service user who said that they were vegetarian confirmed that they had been offered an appropriate alternative. Through discussion with staff it was evident that the home can also cater for those on special diets, for example diabetes. A lunch chart was also see, this gave details of whether small medium or large portions were requested and whether any food was needed to be chopped up or liquidized for particular service users. Shedfield Lodge Version 1.10 Page 13 A six week menu was seen. This provides details of set meals every day. There is no alternative offered for the main meal although staff said that menus are discussed with each service user the day before and a choice is provided if requested. One service user confirmed that this was the case. Two other service users spoken with were of the impression that a choice was not available and did not know what was due to be provided that lunchtime. It was observed that there was no written menus available on the day of inspection and discussion took place with the manager and senior staff as to how this information could be advertised in a meaningful way. Senior staff agreed to continue to work towards improving the current system. Shedfield Lodge Version 1.10 Page 14 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 The complaints procedure is effective in that service users feel confident that their views will be acted upon. EVIDENCE: There is a copy of the complaints procedure on display in the hallway. This identifies how to make a complaint and gives a response time of a maximum of twenty eight days. The procedure needs slight amendment to update information about the Commission for Social Care Inspection .The manager agreed that this would be done. The complaints log was seen . This includes information regarding complaints investigation and any actions taken. Six service users asked said that they had not made any complaints about the service but said that they felt that they would be listened to if they did. Shedfield Lodge Version 1.10 Page 15 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 are generally satisfied with the environment, although input is needed to ensure that unpleasant odours are eliminated from two areas and there needs to be replacement of some worn soft furnishings. Although there is evidence that the building complies with fire regulations, further advice should be sought to ensure that the fire arrangements for two bedrooms are appropriate. EVIDENCE: Communal areas of the home were toured and four bedrooms were also seen. The grounds of the home were observed to be very well maintained and service users spoken with said that they found them to be extremely attractive. They are accessible to service users and some said that they enjoyed looking out at them and /or sitting in them. The home is a period house and has some décor which is in keeping. Here are two large lounges and various smaller seating areas throughout the home. The larger of the lounges has a conservatory attached. It was observed that although most of the furniture was of reasonable quality there were some Shedfield Lodge Version 1.10 Page 16 chairs, particularly in conservatory area that were worn. Some were also observed to be very low, although service users asked said that they managed to get in and out of them. Staff said that it is the intention to replace some of the chairs, although no programme of routine maintenance was available. It was discussed with the proprietor that this could form part of the business and financial plan that is being devised. Two bedrooms, although very clean were found to have an offensive smell. Staff discussed methods that had already been tried to alleviate the smell, although this had not been successful. Two service users spoken with said that their bedrooms were always clean and tidy. And others said that they found their bedrooms and the lounges to be comfortable. One bedroom was observed to have a balcony. It was advised that this be risk assessed and the manager agreed that this would be undertaken. Radiators were observed to be covered, although not all pipework had been. The manager agreed to ensure that this work would be undertaken. There was a call bell system in place in each bedroom. Staff responded very quickly when this was tested. Staff confirmed that tests are undertaken every week to ensure that the system is working correctly. It was noted that the call bell could be turned off at a central board rather than at source. A letter was seen from the Hampshire Fire and Rescue Service dated 23/7/04 which confirmed that the home had had a satisfactory inspection. It was discussed however that further advice should be taken regarding two bedrooms that have direct access to a stairwell. Laundry facilities are sited so that soiled articles are not carried through areas where food is prepared or stored. It was observed that only part of the floor in the laundry was impermeable. The manager and proprietor agreed to rectify this. Washing machines have a sluicing facility, to ensure that linen is thoroughly cleaned and to control the risk of infection. Handwashing facilities were observed to be prominently sited in all areas inspected and liquid soap and paper towels were provided. Two Service users asked said that staff use protective gloves when assisting them with their personal care. Shedfield Lodge Version 1.10 Page 17 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) 29 and 30 Some elements of the recruitment procedure need to be amended urgently to ensure that satisfactory checks are made on staff. There is evidence that a lot of training for staff has been arranged and this includes training around dementia and mental health issues. EVIDENCE: Two staff files were viewed. These both contained evidence of identity in the form of photographs, copies of passports and in one case a copy of birth certificate. Job application forms had been completed. In both cases the staff, who had been recently employed had not received a response to a criminal records bureau check. In one case the application form had not been sent off because of a difficulty of getting sufficient appropriate identification. The manager said that staff without completed checks do not work without supervision. It was discussed with her, however that staff should not be employed before a satisfactory CRB check had been received. It was made an immediate requirement that this should be done. There was evidence that the manager started to follow this up on the day of inspection. Both staff files viewed contained evidence that staff had completed an induction programme during the first six weeks of employment. This programme covers basic health and safety issues, adult protection, core values of the home and information about the service users and their care. Records show that seven care staff hold an NVQ level 2 or above and that six care staff are currently undertaking this award. Records also show that twelve staff have a first aid certificate. Shedfield Lodge Version 1.10 Page 18 The manager said that she has nominated sixteen staff to be trained in food hygiene and seventeen staff to be trained in health and safety through courses run by Swindon College. It was discussed with the manager that as the home is registered to provide care for up to ten service users with mental health needs and for up to twenty service users with dementia, there needs to be evidence that staff are offered training in these areas. A letter was seen which details training opportunities in dementia awareness. The manager said that this would also cover other areas of mental health and said that it was certain that this training would take place although a start date had not yet been arranged. Some staff spoken with had already had training in dementia awareness and two were starting to study for a certificate in this topic. Other courses that have been studied by some staff were terminal care and for senior staff a course in supervision. The manager, who is in the process of applying for registration has obtained an NVQ level 4 in care and also produced documentary evidence that she is a trained as a moving and handling instructor. Shedfield Lodge Version 1.10 Page 19 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) 34 There needs to be a business and financial plan in place for the home, which is reviewed annually. EVIDENCE: At the last inspection it was a requirement that a business and financial plan for the building must be available. This was discussed with the proprietor who is still in the process of completing this document. Although other standards within this section were not assessed fully, the current system of staff supervison was discussed with the manager, which has improved to include practice issues and career development and training needs. The manager said that she intends to develop a system of staff appraisal. This standard will be considered in greater detail at the next inspection. The manager has continued to develop quality monitoring systems for the home. This will also be further discussed at the next inspection. Shedfield Lodge Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 8 x 9 2 10 3 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 x 2 STAFFING Standard No Score 27 x 28 x 29 1 30 2 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 2 x x x x Shedfield Lodge Version 1.10 Page 21 Yes 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 Requirement Timescale for action 1/8/05 2. 3. 4. 19 29 34 23 19 25 That all medication administration sheets must be signed for or reasons given for medicines not administered Action must be taken to 1/8/05 eliminate odours from two bedrooms A satisfactory POVA or POVA first Immediate check must be obtained for two staff members A business and financial plan for 30/9/05 the establishment must be produced This is an outstanding requirement 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 19 Good Practice Recommendations That the fire officer be consulted over fire arrangements for two bedrooms. Shedfield Lodge Version 1.10 Page 22 Commission for Social Care Inspection 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Shedfield Lodge Version 1.10 Page 23 - 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!