CARE HOMES FOR OLDER PEOPLE
South Moor Lodge Care Home South Moor Road Walkeringham Doncaster South Yorkshire DN10 4JD Lead Inspector
Judith Avill Unannounced Inspection 28th September 2005 10:25 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.V255579.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 Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service South Moor Lodge Care Home Address South Moor Road Walkeringham Doncaster South Yorkshire DN10 4JD 01427 891204 01427891504 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 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Old age, not falling within any of places other category (13) South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users shall be within categories of OP (13) or MD (1) Date of last inspection 21/3/05 Brief Description of the Service: South Moor Lodge is a residential home for 13 older people. At the time of inspection the home was being extended. 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 and a stair lift. Some of the ground floor rooms have patio doors onto the garden. Service users spoken to commented on the homely atmosphere, high standard of food, commitment of staff and how they are helped with maintaining their independence. The home has good links with the village community and has regular planned activity sessions. South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was the first of two inspections of South Moor Lodge Care Home. The inspection took place between 10.25 and 1.25 pm on the 28th September 2005. Records examined included, staff rotes, fire safety records, training records, staff personal files residents contracts, files, risk assessments, health and safety records. During the inspection residents spoken to by the inspector commented on the high standard of the care provided, quality of food and staff commitment. At the time of the inspection building work was ongoing to develop further accommodation for residents. The commission had received plans and a site visit will be undertaken on the completion of the work. . What the service does well: What has improved since the last inspection?
Further work has been undertaken on the extension to the home. On the day of inspection a patio area was seen laid outside each residents room. Residents meetings are held on a regular basis and agreements and decisions are recorded. South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 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 Moor Lodge Care Home DS0000008788.V255579.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 Moor Lodge Care Home DS0000008788.V255579.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 The contract for privately funded residents needs to be further developed. Prospective residents are assessed prior to their admission to the home. EVIDENCE: The contract for privately funded residents does not include details of the accommodation to be provided. Local authority staff or the homes assessment is completed prior to the admission of prospective residents. The homes assessment process includes all areas of need, preferences and plan of daily living. South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8 9&10 Healthcare needs are attended to but has limited information in identifying individual preferences, personal health care needs and the procedures for staff to follow. Record keeping was consistent and up to date. Medication records are well maintained. EVIDENCE: Resident’s records viewed included care plans, daily records medication records and risk assessments. From care plans viewed details of specific action to be taken by staff were not recorded to meet individual service users needs. Records for monitoring weight are maintained where residents were able to use the homes weighing scales. Staff’s spoken with were aware of the needs of service users. Service users spoken with complimented staff on the care they receive. Residents, relative involvement is recorded in care plans and reviews. Systems for ordering, receipt and disposal of medicines are well documented. Controlled drugs checked were accurate. South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 Page 10 South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 The residents receive a balanced diet EVIDENCE: The meal provided looked appealing and well presented. Residents commented that the food was well prepared and they had various options if they did not want the main choice. Records of food provided and environmental checks were maintained. The kitchen was clean and well organised. South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Complaints records are maintained. Staff report concerns to the staff, manager or provider. EVIDENCE: No records of complaints since the last inspection were recorded. Complaint information is displayed in the entrance and Statement of Purpose. The manager and provider work closely with staff in the provision of care. Dates for Adult Protection training are planned. Recruitment records seen contained records of checks on staff. South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 & 26 The home is clean, accessible, safe and well maintained. Furnishings and equipment in individual bedrooms meet the assessed needs. EVIDENCE: The home is maintained to a high standard. Resident’s bedrooms visited were well personalised, clean and had a high standard of furnishing and decor. The garden was well maintained. Residents commented on how they had enjoyed sitting in the garden during the summer. South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29 &30 Staffing levels meet the assessed needs of the residents accommodated at the home. Residents are protected by the homes recruitment practices. EVIDENCE: The rota provided included details of the hours worked by the manager and staff. During discussion the manager stated that she is reverting to the previous format for recording the rota. Staff files viewed evidenced that recruitment policies and procedures are followed and all checks and references are obtained prior to employment. Training records are well maintained. Details of planned and refresher training were seen. Supervision records were in place and maintained up to date. South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 37& 38 Fire records are not maintained up to date. not completed. Regulation 37 notifications were EVIDENCE: Residents said they were settled at the home and felt safe and well cared for by the staff. Records of weekly fire tests were not maintained up to date, other Health and Safety checks were well maintained. The Regulation 37 notification for events /incidents at the home had not been recorded and forwarded to the Commission. The Inspector provided a copy of the form. South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 Page 16 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 2 3 X X n/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X 4 X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X 2 2 South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 Page 17 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 Timescale for action 02/11/05 2 OP7 15 3 OP37 17 4 OP38 17,23 The registered person must ensure that contracts to privately funded residents include details of the room provided. The Registered person must 02/11/05 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 28/09/05 ensure that Regulation 37 forms are completed and forwarded to the Commission. An immediate requirement was issued in the day of inspection The registered person must 28/09/05 ensure that the weekly fire test are carried out and accurately recorded. An immediate requirement was issued in the day of inspection South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 Page 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations South Moor Lodge Care Home DS0000008788.V255579.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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