Inspection on 20/02/07 for South Moor Lodge Care Home

This inspection was carried out on 20th February 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

South Moor Lodge Care Home 30/03/09

South Moor Lodge Care Home 12/03/08

South Moor Lodge Care Home 20/10/06

South Moor Lodge Care Home 05/01/06

South Moor Lodge Care Home 28/09/05

South Moor Lodge Care Home 22/03/05

South Moor Lodge Care Home 23/11/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE South Moor Lodge Care Home South Moor Road Walkeringham Doncaster South Yorkshire DN10 4JD Lead Inspector Judith Avill Key Unannounced Inspection 20th February 2007 10.45 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 Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 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 Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service South Moor Lodge Care Home Address South Moor Road Walkeringham Doncaster South Yorkshire DN10 4JD 01427 891204 01427 891504 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) Mrs Christine Mary Clayton Mr Frank Clayton Ms Roseanne Livermore Care Home 29 Category(ies) of Dementia - over 65 years of age (8), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (29) South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Mrs Christine Mary Clayton and Mr Frank Clayton are registered to provide accommodation and personal care at South Moor Lodge care home for service users of both sexes whose primary needs fall within the following categories: Old age, not falling into any other category (OP) 29. Dementia over 65 years of age (DE(E)) 8. Mental Disorder, excluding Learning Disorder or Dementia (MD) 1. The maximum number of service users to be accommodated at South Moor Lodge care Home is 29. 20th October 2006 2. Date of last inspection Brief Description of the Service: South Moor Lodge is a residential home providing personal care to 29 older people. At the time of inspection a further extension is being built. Mr and Mrs Clayton who are active in all parts of service provision own the home. Mrs Clayton works as carer at the home in the home and Mr Clayton is closely involved in the building and maintenance of the home. The home is an adapted cottage style house set in extensive grounds. All service users have single bedrooms with en-suite facilities sited on two floors with access by stairs, a stair lift and a lift. Some of the ground floor rooms have patio doors onto the garden. The patio area at the front of the building is secure and there is a car park to the front of the building. At the time of inspection the registered provider quoted the fees as £370.00 per week. South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This second unannounced key inspection took place over approximately 5 hours on the 20th February 2007 including during lunch. The main method of inspection was checking requirements issued from the last key inspection on 20th October 2006 and tracking the care three residents receive through checking records and discussion with them. The registered manager Roseanne Livermore, Mrs. Clayton one of the registered providers and three members of staff and two visitors were also spoken with. The inspector looked at records of health and safety checks, medication, resident’s finances and complaints. Lunch was also observed being prepared Staff were observed undertaking their duties throughout the visit. What the service does well: What has improved since the last inspection? What they could do better: Care staff spoken with were well aware of resident’s individual needs. To ensure that new staff are aware of the needs of residents needs the manager South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 6 needs to ensure that all care plans and risk assessments provide detailed information of ‘how ‘ care and support is to be provided. The rota provided evidenced that the home had no domestic staff at weekends and four care staff on duty during the day. Whilst the manager reported that the home are trying to recruit weekend staff and staff spoken with said that the manager, deputy or the provider provide adequate staffing levels need to be available to meet the residents needs and maintain the standard of hygiene in the home .. To ensure staffing levels are met at weekends for the safety and well being of residents and staff the registered person must make robust attempts to recruit extra weekend staff. 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. The summary of this inspection report can be made available in other formats on request. South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 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 Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 &6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The manager undertakes an assessment of prospective residents before providing care needs can be met. EVIDENCE: The service user guide does not contain up to date information about the number of rooms provided at the home but details the standard of accommodation. The registered manager reported that a new service user guide and statement of purpose will be developed when the new extension is completed and agreed by the Commission. Three residents files seen contained evidence of a pre assessment and information had been gathered on their personal information, preferences healthcare needs and assistance required. Staff spoken with said the manager and deputy told them about new residents before their admission. Intermediate care is not provided at the home South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Due to shortfalls in records of care plans and risk assessment documentation resident’s needs are at risk of not being met. The homes policies, procedures and practices for the storage and administration of medication help to safeguard residents. Residents are treated with respect. EVIDENCE: Two residents care plans viewed contained comprehensive information about preferences interests and health care needs. However one care plan seen contained no risk assessment for smoking or how the individual resident and other residents living at the homes safety was managed. One record stated that a resident required assistance with washing and dressing but no detail of how staff assist the resident was seen. The manager and staff spoken with were well aware of the individual residents needs and strategies for managing behaviour. Care plans have improved since the last inspection but some need to be more detailed to ensure any new staff follow good practice. Records of District Nurse and general practitioner visits were well maintained. Relatives spoken with commended the staff on the good standard of care and that their relatives health and care needs were met. South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 10 During the inspection the inspector observed interactions between the residents and staff. The staff responded in a kind and respectful manner. Staffs spoken with were aware of some behaviour of some residents to each other was challenging and said they had managing strategies for the behaviour. Medication is secure and staff reported they have been trained in the administration of medication. Records of medication were checked and were satisfactory on the day of inspection. South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 &15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from a range of appropriate activities provided at the home. Routines at the home are flexible and residents have the opportunity to follow their own lifestyle. Residents have a varied and nutritious diet, which promotes good health. EVIDENCE: Residents spoken with said they were able to get up when they wished and they can have a ‘lie in ‘ if they wish. They stated and staff confirmed that they like it here and the staff were kind helpful and they could spend the day as they wished . Relatives spoken with commented that the staff and manager and owner were helpful and they could visit when they wished and were always made welcome. The manager said that one of the residents had regular visits from their minister in accordance with their wishes. Kitchen staff were observed preparing lunch and preparations were being made for pancakes for the residents. The food being prepared was fresh and looked appetising. Records of food provided for residents were seen. Residents commented that they get plenty to eat and drink and the food is varied and well cooked. South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s complaints are taken seriously and acted upon. Residents are safeguarded by the homes adult protection policy. EVIDENCE: The record of complaints was inspected. One complaint has been received regarding care since the last inspection. This complaint has not been resolved at the time of inspection. Records seen were well maintained. Resident’s and relatives spoken with said they would talk to the manager, owner or staff if they had any concerns. Residents spoken with said they felt able raise concerns with staff and that their comments were listened to. The staff files seen and staff spoken with said they were aware of the action to be taken in the event of an allegation and said they would report any bad practice to the manager without delay. They were aware of their obligations to protect the residents. Since the last inspection the home has complied with the recruitment policy, procedures and legislation for the commencement of staff to ensure the protection and safety of residents. South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service The home has a high standard of furnishings and is very well maintained and offers comfortable accommodation to the residents who live there. EVIDENCE: The home is well maintained clean and offers a comfortable accommodation to the residents. The standard of furnishings and decorations are to a high standard. There are four lounge areas, which provide the residents with choices about where to sit and with whom. Residents commented they enjoy the views of the garden from their rooms. Bedrooms viewed were well maintained and personalised. The garden was well maintained and has a variety of garden furniture. The residents spoken with said they like the home and feel happy there. South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing levels mix meet the needs of the residents living at the home. The recruitment procedures ensure the protection and safety of residents. Staff receive training to ensure they are competent to provide care to residents. EVIDENCE: On the day of inspection there were four care staff, the deputy, registered manager two domestics and a cook on duty. The provider was also in attendance at the home. The rota stated and staff confirmed that there is no domestic staff on duty at weekends. The registered manager reported that she is trying to recruit weekend staff. The staff spoken with said that the manager, deputy or the provider are available for staff cover at weekend. Three staff were observed being attentive to residents, offering them drinks and assistance with personal care. Residents and relatives said the staff are were kind and caring The inspector checked three staff records and evidenced references, Criminal Record Bureau checks and records of training. One member of staff had not attended moving and handling training but reported that she was supervised at all times to ensure she follows safe practice. The manager and member of staff confirmed training had been arranged. Two staff spoken with confirmed South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 15 they had attended National Vocational Qualification training and had obtained their certificates. The manager reported she is working with Direct Skills Council (a training provider) for the development of a package of training for all staff at the home. South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33, 35 37 &38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from the management of the home supervised and supportedstaff. The home has a system in place to gain the views of residents and relatives. Appropriate systems are in place for the safe keeping of resident’s finances. EVIDENCE: Residents have their needs assessed, met and evidence gathered indicates that the home is well run with the interests of the residents at heart of the operation of the home. Residents spoken with said they are happy living at the home. The manager reported that the home has a process of sending South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 17 questionnaires to obtain the views of residents and their relatives. The Inspector did not evidence the responses on this inspection. The required monthly visits by a nominated person are not recorded. It was agreed that the Commission send an example of the format to home for their use. The staff commented that the provider is willing to provide anything to ensure the resident’s needs are met. They stated the managers are very available, supportive and have great affection for the residents. Staff spoken with during the visit to the home had a warm caring attitude to the residents and said they were happy working at the home. Residents finances checked were accurate and maintained up to date. The home has satisfactory policies and procedures in place. Sampling of records seen on the day showed that the health and safety and servicing of equipment records were completed and up to date. South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 2 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 3 3 South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 19 Are there any outstanding requirements from the last inspection? YES South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 20 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 OP7 Regulation 15 Requirement The Registered person must ensure that care plans are developed and identify all the needs of the service users in sufficient detail to enable staff to provide comprehensive care. The registered person must ensure that risk assessments on all identified risks are completed to ensure staff are aware of action to be taken The registered person or their representative must visit the home on a monthly basis to interview in private residents and staff working at the home as appears necessary in order to form an opinion of the standard of care at the home. Inspect the premises, record of event and record of complaints and prepare a written report on the conduct of the home. Provide a copy of the report to; the Commission, registered manager and the partners. Timescale for action 23/04/07 2. OP8 13 (4) (c) 23/04/07 3 OP37 26 23/04/07 South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 21 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 OP27 Good Practice Recommendations The registered manager actively seeks extra weekend staff to ensure the needs of the residents are met at all times and the home is maintained in a clean and hygienic state Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 South Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 22 Textphone: 0845 015 2255 or 0191 233 3588 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 Moor Lodge Care Home DS0000008788.V330510.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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