Inspection on 12/01/06 for South Lodge

This inspection was carried out on 12th 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

South Lodge 07/08/06

South Lodge 21/07/05

South Lodge 02/02/05

South Lodge 16/08/04

South Lodge 11/03/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE South Lodge Susan Day Home Runnacleave Road Ilfracombe Devon EX34 8AQ Lead Inspector Victoria Stewart Announced Inspection 10:00 12 January 2006 th 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 South Lodge DS0000022159.V258596.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. South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service South Lodge Address Susan Day Home Runnacleave Road Ilfracombe Devon EX34 8AQ 01271 862528 01271 862024 cherry@susanday.freeserve.co.uk 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) The Trustees Mrs Cherry Wild Care Home 33 Category(ies) of Dementia - over 65 years of age (33), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (33), Old age, not falling within any other category (33) South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21 July, 2005 Brief Description of the Service: The Susan Day Home is situated in the Ilfracombe area of North Devon. It is a large residential home registered for thirty-three older people, who may also have a dementia type illness or mental health needs. The home mainly caters for people living in the close local area but can take people from outside of the area too. The home is centrally situated in Ilfracombe and is within a few minutes walk from local shops, the sea front and quay. The building is a three-storey Victorian villa, with added extensions and adaptations to meet the needs of the people who live there. The home has an attractive front garden with a fountain and a choice of seating, including a summerhouse. All the bedrooms are single and en-suite, apart from one room. There is a lounge, dining room and two conservatories on the ground floor. Two further sitting rooms are sited on the first floor. A large passenger lift provides access to all areas of the home. The home is run by a voluntary organisation and is managed by members of a committee, which regularly meet at the home. South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out as part of the normal programme of inspection for the current year. The inspection took place over 5 hours and the registered manager; officer in charge, staff and residents took part in the process. One member of the management committee also visited the home and spoke briefly with the inspector. There were 32 residents in the home on the day of inspection and the inspector spoke or saw all of them, either in the communal areas or in their private rooms. The inspector also spoke with 2 relatives. This report is written with evidence gained from talking with residents, staff and management, looking at a selection of records (including resident files, staff files and those files relating to health and safety) and undertaking a tour of the home. In order to gain a full picture of the Susan Day Home, this report should be read together with the earlier inspection report of 21 July 2005. Everyone at the home made the inspector welcome and positive discussion took place with the management of the home and the inspector. What the service does well: What has improved since the last inspection? No requirements or recommendations were identified at the last inspection. South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 6 The home is maintained and furnished to a high standard. There is an ongoing programme of refurbishment which is carried out on a rolling basis. The home is shortly to update the dining room which will make the area much improved for residents to enjoy their meals. 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. South Lodge DS0000022159.V258596.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 South Lodge DS0000022159.V258596.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): 3,6 The home ensures it can meet the needs of prospective residents before they are admitted to the home. The home does not have the facilities or services to look after people who require more than personal care. EVIDENCE: Four resident files were looked at. These all contained initial assessments which held good information to enable staff to meet residents’ care needs. These were completed either by social services representatives or by the home’s representative. All residents appeared to have their care needs met on the day of inspection. A senior member of staff may visit prospective residents at home or hospital and complete a brief assessment as part of the care planning process. Residents are encouraged to visit the home prior to admission and spend informal time there. This allows the prospective resident to become familiar with the home, staff and other residents and help them settle in quicker should they decide to live there. South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 9 South Lodge DS0000022159.V258596.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): 7,8,9 10 fully met the standard at the last inspection and was not assessed during this visit The home ensures each resident has a plan of how to meet care needs in place, but this information is not always freely available for staff to access. The home ensures the diverse and individual needs of the residents are recognised and well met. Whilst the medication practice at the home is generally satisfactory, some aspects of practice require review in order to ensure that residents are not placed at unnecessary risk. EVIDENCE: Four resident files were looked at. Each resident has an individual file, which contains both care planning information, risk assessments and confidential information. These files are held securely in the office so only authorised staff have access to them. However, in the absence of a senior member of staff, for example on night duty, access to these files is restricted. This means that care staff cannot ensure they are carrying out the care as planned. However, brief personal care details are kept in resident private rooms if necessary. The home South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 11 also maintains a daily record book that contains all the day-to-day information necessary on each resident and also an additional record of professional visits for example the General Practitioner or the District Nurse. The keeping of information in different places means that information relating to each resident is not held together in one file, with some of it needing to be duplicated. . This was discussed on the day of inspection and improvements suggested by the inspector. Some care plans showed evidence of review but others did not contain a signature or date and staff confirmed that they might not have been appropriately reviewed. All the residents’ care needs appeared to be being well met on the day of inspection and the residents were very complimentary of the way in which cares staff work. Residents confirmed that they are treated as individuals and their care needs met appropriately. This was observed by the inspector on the day of inspection and confirmed by information held in care files. Senior members of care staff undertake the administration of medicines and are appropriately trained. The medication records were looked at and these were found to be satisfactory with the exception of: • The storage of some creams, lotions or eye drops. A number of these were found to be open and in use in the drug cupboard. Not all of these contained a resident name and were therefore at risk of being used for more than one resident. Also, not all these applications contained an opening or discard date for staff to know when they expire. The home has a list of homely (over the counter) medications, which are available for resident use. However, the way in which these are dispensed was not clear with no formal procedure of how and when to give them. • Two residents’ files that self medicate were looked at. One contained an appropriate assessment and disclaimer to lessen the element of risk but the other did not. The inspector noted that on at least one occasion, a member of staff had assessed a wound following a fall by a resident. This practice must stop immediately and the practice of assessing wounds and prescribing suitable dressings must be done by a qualified professional. Wound dressings must also then only used on the person for whom they are prescribed. South Lodge DS0000022159.V258596.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): 12,13,14,15 fully met the standard at the last inspection and were not assessed during this visit EVIDENCE: South Lodge DS0000022159.V258596.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): 16,18 The home is good at identifying and rectifying informal complaints before they become a serious concern. EVIDENCE: The home has an appropriate complaints procedure. No formal written complaints had been received since the last inspection. The management of the home ensures that all concerns are listened to and acted upon, but these are not recorded and therefore do not provide a record. Residents confirmed that they are listened to and no complaints were made during the inspection. Staffs understanding of the need to protect residents from abuse is ensured by the home providing the appropriate training in the protection of older adults. South Lodge DS0000022159.V258596.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): 19,20,21,22,23,24,25,26 fully met the standard and were not assessed during this visit. Residents enjoy the benefit of living in a home, which is both a comfortable and nice place to live. EVIDENCE: A continual plan of refurbishment and redecoration continues both inside and outside of the home which is maintained to a high quality. South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 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): 28,29,30 27 fully met the standard at the last inspection The home has a safe recruitment procedure which safeguards the protection of residents living at the home. EVIDENCE: The home has a high proportion of staff trained to NVQ levels 2 and 3 standard. One member of staff is undertaking NVQ level 4. All staff receive induction training to enable them to care for residents. Four staff files were looked at. These all contained the information necessary to be held at the home and confirmed that staff had been recruited appropriately. South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 16 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 The home is well run and managed, with the manager well supported by her senior staff. Whilst good informal systems for the views of residents exists, the home has not yet introduced a formal method of self-review and consultation. The accurate and safe accounting and financial procedures of the home safeguards residents. EVIDENCE: The home has a good organisational structure with the manager, head of care and officers in charge providing the management of the home. These senior members of staff ensure the home runs on a day-to-day basis and each have roles and responsibilities delegated to them, for example one member of staff takes responsibility for resident care and another for staff supervision and training. South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 17 The home does not currently have a formal quality assurance monitoring system but relies on the good informal processes in place. Examples of some of the comments given by residents to the manager were discussed, and some of these should be recorded. The members of the management committee meet on a monthly basis when regular topics such as health and safety and training are discussed. Whilst these meetings occur regularly and minutes are taken, none of the committee monitors the quality assurance of the home by carrying out a formal tour of the premises, interviewing staff, relatives or residents to gain feedback. The manager stated that resident meetings are not held routinely but take place approximately every 3 months with an agenda circulated. Visitors and relatives are invited to attend and share their views but in practice only one third of residents and their relatives/friends choose to attend. Staff meetings are held on a monthly basis and information and exchange of views take place. This is supplemented by information passed over at the daily handover, information on the notice boards and information given to each employee if necessary. Supervision regularly takes place with all staff employees, which enables any problems to be identified and resolved. The home holds money for some residents, which is used for their day-to-day expenses, such as chiropody and hairdressing. No resident bank accounts are held at the home. Residents are able to look after their own valuables and the home provides a -secure area in their private rooms. Records relating to residents assessments and care files, staff files, resident finances, staff fire training and accident reporting were looked at. The latter two records did not hold all the information required and this was discussed on the day of inspection with suggestions as to how these should be improved upon to meet the standard. The manager ensures that the health, safety and welfare needs of residents and staff are as far as possible met by providing adequate training, facilities and services. South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 18 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 3 2 3 South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 19 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. 1 Standard OP9 Regulation 13, 2 Requirement The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. With regard to: • Ensuring that all types of medication is appropriately labelled, stored and used as directed 12/02/06 Timescale for action 2 OP9 13,2 The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. With regard to: Developing a policy for the administration of homely remedies, if used, and obtain agreement for individual resident use from the General Practitioner 12/04/06 South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 20 3 OP9 13,2 The registered person shall make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. With regard to: Referring any wounds that require formal assessment and dressing to the appropriate professionals and use prescribed dressings only 12/03/06 4 OP33 24 1,2 The registered person shall establish and maintain a system for reviewing and improving the quality of care provided at the care home, shall supply to the Commission a report in respect of any review conducted by him and make a copy of the report available to service users. The home should introduce and maintain a formal system of quality assurance, which ensures that the quality of care delivered is monitored and reviewed at appropriate intervals. With regard to: Introducing a regular and formal programme of self review and quality assurance which ensures that the quality of care delivered is monitored and reviewed 01/07/06 South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 21 5 OP33 26 2,3,4,5 Where the registered provider is an organisation or partnership, the care home shall be visited in accordance with this regulation by the responsible individual or one of the partners as the case may be, another of the directors or other persons responsible for the management of the organisation or partnership or an employee of the organisation or the partnership who is not directly concerned with the conduct of the care home. With regard to: Ensuring that a member of the management committee carries out a regular monthly visit which includes the information required under Regulation 26 and a copy forwarded to the CSCI in order to monitor the standards in the home The registered person shall maintain in the care home the records specified in Schedule 4 – A record of every fire practice, drill or test of fire equipment (including fire alarm equipment) conducted in the care home and of any action taken to remedy defects in the fire equipment. With regard to: • Ensuring that the fire book is kept up to date and a record of formal fire training and monitoring of equipment kept 12/03/06 6 OP37 17, 2 Sch 4, 14 12/02/06 South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 22 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 OP7 Good Practice Recommendations It is recommended that the care planning system be reviewed and records held in one place. Care staff should have access to these at all times, with any confidential information held secure It is recommended that the home keeps a record of all informal complaints/issues of concern made by residents or relatives to demonstrate their investigation and outcome It is recommended that the home gives a duplicate receipt to relatives showing the amount of money handed over for individual resident use 2 OP16 3 OP35 South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Exeter Suites 1 & 7 Renslade House Bonhay Road Exeter EX4 3AY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI South Lodge DS0000022159.V258596.R01.S.doc Version 5.0 Page 24 - 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!