Inspection on 26/01/06 for Shedfield Lodge

This inspection was carried out on 26th January 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

Shedfield Lodge 14/05/08

Shedfield Lodge 22/05/07

Shedfield Lodge 24/05/06

Shedfield Lodge 13/07/05

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 Hampshire SO32 2JZ Lead Inspector Kathryn Kirk Unannounced Inspection 25th January 2006 10:00 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 Shedfield Lodge DS0000012320.V279158.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. Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Shedfield Lodge Address St Annes Lane Shedfield Southampton Hampshire SO32 2JZ 01329 833463 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) Mr Robert Barrie Geach Mrs Christina Geach, Mr Andrew Robert Geach Mrs Karen Samantha Batten Care Home 33 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (10), Old age, not falling within any other category (33) Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The additional room registered 9C must not accommodate any service user with dementia on admission. Two named service users over the age of 60 may be admitted in the MD category. 13th July 2005 Date of last inspection 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 DS0000012320.V279158.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection to take place in the year April 2005-March 2006. It was carried out by Kathryn Kirk on 25/1/06 and 9/2/06 and it lasted for a total of five hours. There were thirty service users in residence at the time of the inspection. Nine service users and four staff members spoke of their experience of living and working at the home. One visitor and one visiting health professional also gave their views. Time was also spent with the manager. Some documentation was reviewed and four bedrooms and communal parts of the home were seen. Only standards that were not assessed at the time of the last inspection were considered during this inspection, along with previous requirements and recommendations made. As such to gain a more detailed overview of this service, this report should be read in conjunction with the report dated 13/7/05. This inspection indicates that all requirements from the previous inspection have been met and that the service has made a number of improvements. There are no requirements or recommendations made as a result of this inspection. What the service does well: What has improved since the last inspection? Seating has been upgraded in both lounges. The range and number of activities provided has increased. Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 Page 6 Choice has increased at mealtimes. Odours have been eliminated in two bedrooms. Changes have been made to the recruitment procedure to ensure that Criminal Records bureau checks can be undertaken speedily. The manager has successfully completed her registered manager award and has completed the process to become registered with CSCI. The system of medication has changed and timing of administering any evening medicine is earlier and so is less disruptive to the night time routine of some service users. The range of training has improved and gives staff that opportunity to increase their understanding about medical conditions affecting service users. 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. Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 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 Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 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): No standards were assessed on this occasion EVIDENCE: Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 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 the following standard(s): 8 and 9 Health care arrangements are appropriate. Medication systems have improved. EVIDENCE: One visiting health professional said that they have no concerns about the health care in the home. A GP visits the home once a week and staff provide a list of those needing a routine appointment. Records show that staff check blood pressure or pulse rate if required by the doctor. In this way service users health can be monitored. The home also has regular links with other health professionals for example community psychiatric nurses. Service users asked said that they felt that the staff contact the GP on their behalf when necessary. A leaflet on display in the home states that a chiropodist visits every six weeks. Service users confirmed that they do see a chiropodist at the home and also that they have seen an optician and a dentist. There has been a change in the system for administering medication since the last inspection. This includes a change in the timings of giving evening Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 Page 10 medicines. During the first visit on 26/1/06 one visitor said that their relative was being woken up sometimes at 10pm so that they could have their evening medication. This has changed now to 9pm for all service users, unless there is a need to administer a medication at a specific time. Staff said that they found this more effective because some service users were less sleepy. There were no gaps in the recording by staff in the medicine administration records (MARS) sheets. This is an improvement from the last inspection. Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 Page 11 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 and 14 The programme of activities has improved. Family contact is welcomed. Residents are encouraged to exercise choice and staff ensure that wishes are acted upon. EVIDENCE: Staff have increased the range of activities available to service users. There is now an organised activity for around an hour every weekday. These range from specialist services provided by a day service for people with dementia, (two times a week) to events run by staff. This includes cake decoration, art and craft and bingo sessions. On one of the days of inspection a singer was performing in one of the lounges. The majority of service users asked said that they enjoyed the activities provided. One said that they preferred to stay in their room and said that staff respected this choice. Staff were observed to be interacting positively with residents during both visits. The home has a good supply of large print books and a leaflet on display states that a mobile library visits every month. A church service is held every month and staff said that the Methodist church choir also visits every month. Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 Page 12 A hairdresser comes every week and residents said that they enjoyed this. Two residents were observed to be in the kitchen helping with the washing up after a meal. Both said that they regularly did this and that they enjoyed it. One visitor said that they were welcomed into the home by staff and this was also observed to be the case. Service users confirmed that they can see their visitors in their bedrooms, in private if this is their wish. The choice in meals has improved since the last inspection and service users can now choose a vegetarian or traditional meal at lunchtime. There was evidence that service users views and wishes are being acted upon, for example minutes seen of a residents meeting identified that some wished for a full English breakfast. This has now been arranged every Friday and the hours worked by the cook have been increased to accommodate this. Residents asked were happy with this change in routine. Records show that nine service users attended the most recent service users meeting. Individual questionnaires were also seen which had been devised to enable others to give their views of life in the home. Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 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): 18 Appropriate procedures are in place to protect service users. EVIDENCE: All service users asked that were able to answer said that they feel safe at Shedfield Lodge. Policies and procedures are in place regarding the protection of vulnerable adults. The manager said that she ensures that adult protection issues, including whistle blowing procedures are included in induction sessions for new staff. These issues are also addressed during supervision sessions. Training materials and questionnaires for staff relating to this topic were seen. Staff asked were aware of whistle blowing procedures and had a good understanding of what was expected of them should they have any concerns. There were some episodes of challenging behaviour involving some service users that have been recorded. Action taken was that next of kin have been informed, CSCI have been notified, and there has been liaison with appropriate health care professionals. It was discussed with the manager that any such incidents also need to be referred to social services under existing protocol. She agreed that this would be done. Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 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 The environment has improved EVIDENCE: Since the last inspection, an unpleasant odour has been eliminated from two bedroom areas. Most soft worn furnishings have been replaced and service users commented on how comfortable the new chairs were. The fire officer has also been consulted and advice followed about fire arrangements for certain areas of the home Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 Page 15 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 and 30 Staffing levels are appropriate to meet current need. The increased range of training available will help staff to work more effectively with service users. EVIDENCE: The home has a rota. This was seen. It showed that a minimum of four staff are on duty during the day and that additional staff are on duty at peak times, for example in the morning. There are two waking nights staff and an additional staff member sleeps in at night. There are four ancillary staff, a cook, two cleaners and a maintenance person. Service users asked said that there were sufficient staff on duty at all times to respond to their needs. All staff providing personal care are over 18. There is a low turnover of staff and staff asked described morale as high. During both visits to the home it was observed that staff were deployed effectively throughout the building, so that no area was without supervision for any length of time. Staff were observed to be interacting with residents in a respectful and caring manner. The manager said that seven care staff have obtained an NVQ in care to a minimum of level 2. Six staff are studying for this award. Since the last inspection records show that two staff have undertaken training in dementia awareness and that four staff have been nominated to attend this course. Nine staff also attended a two hour study session about dementia in August 2005. Two staff have also been nominated for a course in managing aggression. Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 Page 16 The manager said that a community psychiatric nurse is going to talk to the staff in March about managing aggression, dementia, schizophrenia and obsessive-compulsive disorder. The manager said that there is already written information available for staff about these conditions within the home. The manager said that she is in the process of ensuring that all staff have up to date training in health and safety areas. Since the last inspection written confirmation has been provided that the homes system of applying for CRB clearance has been changed to enable the application to be made more speedily. Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 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, 33, 35 and 38 The home is well managed. Service users are consulted appropriately about life at the home. Systems are in place to ensure that health and safety issues are promoted as far as possible. EVIDENCE: The registered manager is Karen Batten. She has recently completed her registered managers award. She demonstrated during the inspection that she is effective in her role and that that she is committed to further improving the service. Staff described her as helpful and supportive. Service users who were able to comment said that they felt that they were consulted about how routines are arranged in the home. There was evidence that service user meetings are held, and that visitors and service users also have the opportunity to complete quality assurance questionnaires. Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 Page 18 A monthly report is compiled by one of the registered providers about the conduct of the care home. A copy of the written report is sent to CSCI. Staff confirmed that a small amount of service users money that is held on their behalf is stored individually and securely. They also confirmed that service users sign for money to confirm that they have received it. Records showed that money was taken direct from the allowance for one service user to pay the hairdresser. Staff said that the service user was aware of this practice but agreed to discuss it with them further and to obtain more evidence of her agreement to this. The following records were sampled which related to health and safety issues: The fire alarm was checked 9/1/06 The lift shaft was serviced on 12/1/06 The call system was serviced on 23/11/05 The environmental health officer visited the home in August 2005, and staff said that issues identified have been addressed. One service user asked said that they were aware of what action they should take in the event of the fire alarm going off. Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 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 X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 Page 20 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. Refer to Standard Good Practice Recommendations Shedfield Lodge DS0000012320.V279158.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Hampshire Office 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. 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