Inspection on 21/07/05 for South Lodge

This inspection was carried out on 21st July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 12/01/06

South Lodge 02/02/05

South Lodge 16/08/04

South Lodge 11/03/04

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Queensmount

Poldhu

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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 Vickie Stewart Unannounced 21st July 2005 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. South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service South Lodge (Susan Day Home) Address Runnacleave Road, Ilfracombe, Devon, EX34 8AQ 01271 862528 01271 862024 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) The Trustees, South Lodge (Susan Day Home) Mrs Cherry Wild Care Home 33 Category(ies) of MD(E) Mental Disorder over 65 [33] registration, with number OP Old Age [33] of places DE(E) Dementia over 65 [33] South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 02/02/2005 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. It is a popular home with no vacancies and a waiting list. The home is centrally situated in Ilfracombe and is within a few minutes walk from local shops, the sea front and quay. It is a three-storey Victorian villa, with added extensions and adaptations to meet the needs of the people who live there. It 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. South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out as part of the normal programme of inspection for the current year. The inspection took place over 4.25 hours and the registered manager, head of care, care staff, kitchen staff and activities organiser assisted with the process. The inspector spoke with 7 relatives, and observed all of the residents but spoke in depth to 12 of them. 2 relatives completed CSCI questionnaires. The inspector also met and introduced herself to the Committee who were attending their planned regular meeting. This was the first visit by this inspector to this home. Therefore the inspector took time to meet all of the residents, relatives and staff and become familiar with the home by taking a tour of the premises. The majority of documentation, records and files will be looked at during the next visit. The home has a welcoming, warm and peaceful atmosphere. full with 33 residents on the day of inspection. The home was What the service does well: What has improved since the last inspection? No requirements or recommendations were made on the last inspection. The home continues with a programme or redecoration and refurbishment. South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 Page 6 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 (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 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 South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 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) Not inspected on this visit. EVIDENCE: South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 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 standard(s) 8,10 Residents benefit from staff who treat them with respect. Residents’ privacy and dignity is met and promoted by the staff at Susan Day. Residents’ needs are well met. EVIDENCE: All the health and personal care needs to individual residents were being met on the day of inspection. Residents confirmed that they are well looked after by the staff and that the home ensures they have access to other health care services. One resident told the inspector that the activities co-ordinator always accompanies a resident to a doctor hospital appointment (with a taxi provided) if required. This was really appreciated. One resident who is unable to get out of bed was extremely well cared for and the inspector saw that all her needs were being fully met. Privacy and dignity are given a high priority and residents are treated with respect. All residents spoken to confirmed that they are always treated with privacy and dignity – staff always knock on doors before entering and speak to the residents in their preferred name. One resident said “they respect my privacy and dignity – I am a complete loner and the staff know that”. South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 Page 10 All residents have a private telephone installed in their rooms. One resident was observed having her mail delivered directly to her. No private rooms are shared. South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15 Residents’ activities and meals are both well managed and provide daily variation, choice and interest for people living in the home. EVIDENCE: The home provides 10 hours a week of activities and this can include group work but usually is done on a one to one individual basis. Some activities are structured and carried out on a regular basis, for example bingo, quizzes and church services. Other activities can include arts and crafts, outings or one to one communication with residents. A band regularly plays on the bandstand in the adjacent park. The activities organiser has worked at the home for many years and knows the residents very well. She takes a pride in her work and enjoys ‘having fun’ with the residents. One resident referred to her as ‘a friend’. Residents confirmed they are happy with the activities on offer at the home. Some are able to visit the local town, facilities and park unaccompanied due to their close proximity. Relatives and residents confirmed that they are always made welcome at the home at any time and are routinely offered drinks. There are several communal and private areas that can offer privacy when visiting if desired. South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 Page 12 Residents confirmed that they are free to do as they choose. Comments included “I can come and go as I please”, “there are no rules and I go in and out as often as I like” and “there are no restrictions”. Residents praised the standard of the meals provided. Some comments on the day included “lovely” and “very nice”. Residents particularly liked having breakfast served in their bedroom and one said “it is the best meal of the day”. Those wishing cooked breakfasts attend the dining room. Residents are given a choice of menu and an alternative always found. Residents are encouraged to have their lunchtime meal in the dining room, but this can be served in private rooms if a resident is unwell or requests it. Tea is a light meal and again served with a choice of food. The inspector enjoyed lunch with three residents and the food was praised as “always being homemade”. South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 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 standard(s) Not inspected on this occasion. EVIDENCE: No complaints were received during the inspection. Typical comments included “you can’t fault the place”. South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 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 standard(s) 19,20,21,22,23,24,25,26 Continuous investment and a continuous programme of modernisation improve this home to make it a safe, comfortable, clean and high quality environment for residents and visitors. EVIDENCE: The home is decorated to a high standard with quality fixtures and fittings. Residents’ private rooms are individually furnished and full of personalised and sentimental items. Rooms are centrally heated and individually controlled. The grounds to the front of the building are extremely attractive and immaculately attended with an abundance of flowering rose trees and glorious hanging basket displays. Residents confirmed their enjoyment at sitting in the various areas of the garden or the separate summer house. Communal areas are inviting, relaxed and very comfortable and residents told the inspector of their personal favourite areas of the home. South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 Page 15 The home was very clean and free of any offensive odours. There is a sluicing facility on each floor. The home has a laundry service for sheets and towels which is collected/delivered once a week. Care staff undertake personal washing only and an outside laundry provides good facilities. The home has recently had a stainless steel new kitchen fitted with all modern facilities. The home employs two cooks who work opposite. Meals are planned on a three-week rota and a choice offered. The cook on duty knew resident’s likes and dislikes very well and had worked at the home for many years. She confirmed that as far as possible all food is homemade. Tea is prepared by the cook and served by the care assistants on duty. There are an adequate number of baths in the home. All bathrooms have recently undergone modernisation and refurbishment and include modern, assisted and suitable equipment. The home has CCTV cameras which are used for security purposes only on the main entry/exits of the building. South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 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 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) 27 Staff morale is high resulting in an enthusiastic workforce that works positively and inclusively with residents to improve their quality of life. Residents’ needs are properly met by the number and skill mix of the staff. EVIDENCE: Residents confirmed that there is always enough staff on duty to meet their needs quickly. The manager has the permission to increase the staffing numbers if the dependency level increases for example if a resident becomes unwell or a terminally ill resident is admitted. The home has a registered manager who has worked at the home for many years. She is responsible for the management/administration of the home. In the manager’s absence, a deputy officer in charge is on duty. The home employs a head of care who takes responsibility for the care practice on the day-to-day shifts. Both the manager and head of care have successfully completed the Level IV in care and the Registered Manager’s Award. Many of the staff have worked at the home for several years and the home enjoys high staff morale with little staff turnover. All staff spoken with genuinely enjoyed working at the home and caring for the residents. Dedicated domestic staff are employed and residents said the home is always clean. South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 Page 17 The home employs one person under the age of 18 but this person does not provide personal care. South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 Page 18 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) 31,32 Residents benefit from an organised and positively managed home, which seeks to involve residents and staff in its operation. EVIDENCE: The home has a structured line of responsibility that all staff and residents are aware of. Staff meetings are held every month and minutes produced. The manager also holds meetings with her deputies on a regular basis. Staff confirmed that they felt included and valued and were given training opportunities. One member of staff said they felt “privileged” to be able to work at the home and another said “it was brilliant”. Residents said they felt very safe and extremely well cared for. South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 3 9 x 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 4 4 x x x x x x South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 Page 20 NO 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 Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations South Lodge (Susan Day Home) D54-D06 S22159 South Lodge V228455 210705 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Exeter Office, 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. 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