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 October 2006 9:40 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.V308674.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.V308674.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.V308674.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. 5th January 2006 2. Date of last inspection Brief Description of the Service: South Moor Lodge is a residential home for older people. The home has been extended since the last inspection to accommodate 29 residents. 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. South Moor Lodge Care Home DS0000008788.V308674.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 hours on the 20th October 2006. Since the last inspection a new wing of the home has been opened providing bedrooms, lounge and dining facilities small kitchen area and laundry facilities. During the previous two days before the inspection 16 residents had been transferred from another home to South moor Lodge. Several staff had transferred with the residents on a temporary or permanent basis. Records examined included, staff rotes, fire safety records, training records, staff personal files residents contracts, files, risk assessments, health and safety records. What the service does well: What has improved since the last inspection? What they could do better:
Since the increase in registration the Statement of Purpose and service user guide needs to be further developed to reflect the change to the service. To ensure staffs are clear on the care needs and action to be taken in the provision of personal care to residents, specific details of support and action needs to be recorded in individual in care plans. For the safety and well being of the residents risk assessments on resident’s medical conditions and mobility need to be developed, maintained and reviewed. To comply with record keeping requirements for the recording of the administration of Controlled drugs the registered person must ensure that two staff signatures are obtained when Controlled medication is administered. South Moor Lodge Care Home DS0000008788.V308674.R01.S.doc Version 5.2 Page 6 Staff reported and residents confirmed that all residents are offered a choice at mealtimes. Records of choices offered and details of the food provided needs to be recorded. To comply with legal requirements and National Minimum Standards the registered person must ensure that the rota includes details of all staff working at the home during the day and night and in what capacity. For the protection of residents before new staff commence work at the home up to date satisfactory CRB checks and two references must be obtained A system of obtaining the views of the resident, relatives and professionals be sought to ensure the aims, objectives and statement of purpose is met. Monthly visits (Regulation 26 visits) by a responsible person or their representative to ensure the home is being well run and records checked need to be developed and copies made available to the Commission. 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.V308674.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.V308674.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 poor. This judgement has been made using available evidence including a visit to this service Full assessments have not been carried out on new residents to the home. EVIDENCE: The statement of purpose and service user guide does not reflect the number of beds and the accommodation provided at the home. Assessments on new resident’s admitted to the home had not been completed. Records of existing residents included local authority assessments and assessments by the registered manager. The home does not provide intermediate care. South Moor Lodge Care Home DS0000008788.V308674.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 poor. This judgement has been made using available evidence including a visit to this service. Care plans do not set out in detail service users assessed health and personal care needs and action to be taken by staff. Risks assessments on medical conditions are not completed to ensure the safety of residents. Medication recording practices do not comply with legislation. EVIDENCE: Care plans viewed on recently admitted residents did not include specific details of action to be taken by staff to meet personal needs. One resident’s personal file seen contained no information on needs and preferences. Plans seen stated staff to ‘assist’ with no information on residents individual preferences or ‘how’ staff are to provide care to meet personal needs. Records viewed of a resident with limited mobility contained no evidence of how staffs are to transfer the resident or prevent pressure sores developing. South Moor Lodge Care Home DS0000008788.V308674.R01.S.doc Version 5.2 Page 10 One resident with an identified medical condition that would require action to be taken by staff in the event of a change in condition was not risk assessed and no evidence of action staff should take was seen. Staffs spoken with were well aware of the needs of the residents. Residents complimented staff on the care they receive. At the time of the inspection two medication systems were in place for the existing and transferred residents. Both systems comply with the legislation and National Minimum Standards. Staff spoken with reported they had attended medication training. One Controlled medication record seen contained only one staff signature. Residents spoken with commented that all staff treat them with respect and dignity. The inspector observed interaction with residents was appropriate and pleasant. All residents observed looked well care for and appropriately dressed for the weather conditions and environment. South Moor Lodge Care Home DS0000008788.V308674.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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s routines and lifestyle in the home are flexible and varied to suit resident’s expectations. EVIDENCE: Residents spoken with said that the home had a very pleasant atmosphere and met all their needs. A relative spoken with on the day of inspection commented that their relative had been waiting for a vacancy at the home and they had settled well. Advertisements for activities for the following month were displayed at the entrance to the home. On the day of inspection the main meal was prepared in the main kitchen. Residents spoken with commented on the good standard of food and they stated that they were offered choices at mealtimes. No records of food choices provided were evidenced. South Moor Lodge Care Home DS0000008788.V308674.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 poor. This judgement has been made using available evidence including a visit to this service. Residents feel listened to. The home does adequately protect the residents. EVIDENCE: Residents spoken with said they felt able raise concerns with staff and that their comments were listened to. The last record of complaint was February 2006. Evidence of concerns raised by residents are recorded in the staff message book, records of action were evidenced. The staff files and staff spoken with confirmed they had attended training on abuse. However the home has not complied with the recruitment policy, procedures and legislation for the commencement of staff with the new residents to ensure the protection of residents. (See Standard 29) South Moor Lodge Care Home DS0000008788.V308674.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. Residents live in a safe and well maintained environment. EVIDENCE: An extension to the home has been completed since the last inspection. The accommodation now comprises of two wings. The extension has two floors the top floor includes bedrooms and a quiet lounge area, the ground floor includes bedrooms, lounge and dining area and a small secure kitchen. The standard of decor and furnishing is high. All communal rooms are well personalised and residents are welcome to bring personal effects. The bathing facilities comply with the national Minimum standards and all bedrooms have en –suite facilities. The home is clean and systems are in place to prevent infection. The laundry area is well organised and has excellent laundry facilities. South Moor Lodge Care Home DS0000008788.V308674.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 adequate. This judgement has been made using available evidence including a visit to this service. The number and skill mix of staff working at the home meets residents’ needs. The recruitment policy and procedures have not been followed to protect the residents EVIDENCE: On the day of inspection the staffing rota did not reflect the number of staff working at the home nor their roles and responsibilities. Staffing levels on the day of inspection met the residents’ needs. Staff spoken with who have transferred from the other home confirmed that they had attended training to meet the needs of the residents. Staff files seen evidenced attendance on training and National Vocational Qualifications. The staff files seen evidenced Criminal Record Bureau Checks for the transferred staff from their previous employment. However the new employees working the home had obtained only one reference and no Criminal Record Bureau (CRB) or Prevention of Vulnerable Adult (POVA) check. Existing staff files evidenced all satisfactory checks and references had been obtained before staff commenced work at the home. Training records seen evidenced induction training to meet resident needs and National Vocational Qualifications (NVQ). South Moor Lodge Care Home DS0000008788.V308674.R01.S.doc Version 5.2 Page 15 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is experienced in the management of a care home. Records relating to the provision of care are not accurate and not maintained up to date. Recruitment policies are not followed. EVIDENCE: The manager has several years experience in the management of the home. A team leader has recently been appointed but no evidence of a their job description was seen. Staff’s spoken with were clear on their roles and responsibilities. New staff working at the home reported that the staff worked as a team and they enjoyed coming to work. Staff reported since the increase in residents the need for assistance with administrative tasks has been identified.
South Moor Lodge Care Home DS0000008788.V308674.R01.S.doc Version 5.2 Page 16 No written evidence of a quality monitoring system or monthly visits by the registered provider or their representative to interview residents, inspect the premises, its record of events and records of complaints and provide written report on the conduct of the care home were seen. The manager reported that residents meeting were held but no records were seen. During the inspection a number of relatives were observed visiting residents at the home. Relatives spoken with commented they are kept informed about their relatives and events at the home. Residents’ personal finances were not checked on this visit. The home has comprehensive health and safety policies and procedures, staff spoken with were well aware of safe practices. Maintenance checks are done regularly and documented. Repairs are carried out without delay. South Moor Lodge Care Home DS0000008788.V308674.R01.S.doc Version 5.2 Page 17 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 2 X 2 X X N/A 4 X X X X X X
4 HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X N/A X X 3 South Moor Lodge Care Home DS0000008788.V308674.R01.S.doc Version 5.2 Page 18 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 OP2 Regulation 5 Requirement The registered person must ensure that the statement of purpose and service user guide accurately reflects the services provided at the home. 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. Immediate requirement issued 20/10/06) The registered person must ensure that risk assessments on residents medical conditions are completed Immediate requirement issued 20/10/06) The registered person must ensure that risk assessments on residents mobility are completed (Immediate requirement issued 20/10/06) The registered person must ensure that two staff signatures are obtained when administering Controlled Drugs The registered person must ensure that records of residents choice of food is recorded
DS0000008788.V308674.R01.S.doc Timescale for action 04/12/06 2. OP7 15 08/11/06 3. OP8 13 (4) (c) 08/11/06 4. OP8 13 (4) (c) 04/11/06 5. OP9 13 2 17(1)(a) Sch 3 (i) 17 (1) (a) Sch 3(m) 04/11/06 6. OP15 04/12/06 South Moor Lodge Care Home Version 5.2 Page 19 7. OP16 22 7. OP27 17 (2) Sch 4 7 19 (1) 8. OP29 9. 10. OP29 OP29 17 (2) Sch 4 (e) 19(1) 11. OP33 24 12. OP37 26 The registered person must ensure that all complaints are investigated and the outcome recorded The registered person must ensure that a copy of the staff rota worked by day and night and in what capacity is recorded The registered person must ensure that satisfactory Criminal record Bureau or Protection of Vulnerable Adult checks and two references are obtained prior to staff commencing work at the home. (Immediate requirement issued 20/10/06) The registered person develops a job description for the team leader The registered person must ensure that satisfactory Criminal record Bureau or Protection of Vulnerable Adult checks and two references are obtained prior to volunteers working at the home The registered person must develop and maintain quality assurance system to review, improve the quality of care at the home The registered person or their representative must visit the home ion 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. 04/12/06 04/12/06 08/11/06 04/12/06 04/12/06 04/12/06 04/12/06 South Moor Lodge Care Home DS0000008788.V308674.R01.S.doc Version 5.2 Page 20 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 OP37 Good Practice Recommendations It is recommended that consideration is given to the home having administrative support South Moor Lodge Care Home DS0000008788.V308674.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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