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Inspection on 30/03/09 for South Moor Lodge Care Home

Also see our care home review for South Moor Lodge Care Home for more information

This inspection was carried out on 30th March 2009.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

People in the home live in a well-maintained environment, which is clean and warm. Staff are supervised and trained to meet their needs. There is a registered manager in place who is liked and respected by everyone at the home. People feel listened to and taken seriously by the staff at the home and people told us that they felt safe and cared for. People are given opportunities to take part in activities and offered suitable choices at mealtimes.

What has improved since the last inspection?

Staff now receive the training they need to support and maintain the safety of people who use the service. Handwritten medication records are now signed to ensure they are correct and minimise the risk of people using the service getting incorrect medication.

What the care home could do better:

People must receive assessments prior to moving to the home that cover all aspects of their daily lives to ensure that the carers are able to meet their needs. People must have their health and care needs properly recorded and a care plan drawn up that describes the support they require to manage their needs safely. People who enter the home on respite must have their medication recorded correctly to prevent errors in administration of medication.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: South Moor Lodge Care Home South Moor Road Walkeringham Doncaster South Yorkshire DN10 4JD     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Susan Lewis     Date: 3 0 0 3 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 26 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 26 Information about the care home Name of care home: Address: South Moor Lodge Care Home South Moor Road Walkeringham Doncaster South Yorkshire DN10 4JD 01427891204 01427891504 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Mrs Christine Mary Clayton,Mr Frank Clayton care home 40 Type of registration: Number of places registered: Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users who can be accommodated is: 40 The registered providers may provide the following categories of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home fall within the following categories: Old Age, not falling within any other category - Code OP Dementia - Code DE Date of last inspection Brief description of the care home South Moor Lodge is a residential home providing personal care to 40 older people and those who may suffer from Dementia. The home has a very a large paved courtyard. There is garden furniture in this area and a barbecue the manager told us this area Care Homes for Older People Page 4 of 26 Over 65 0 40 40 0 Brief description of the care home was used for barbecues and fetes. There was a large metal gate that when closed made the area secure. 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. The range of fees are: 361 pounds to 425 pounds per week. Care Homes for Older People Page 5 of 26 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star this means that people who use the service experience adequate quality outcomes. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views on the service provided. This process considers the providers capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. A review of all the information we have received about the home was considered in planning this visit including the Annual Quality Assurance Assessment (AQAA), and this Care Homes for Older People Page 6 of 26 helped decide what areas were looked at. The main method of inspection used was called case tracking which involved selecting the care plans of 3 people and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Members of staff, people who use the service and their relatives were spoken with. A partial tour was undertaken by the regulation inspector, which included looking at peoples bedrooms and communal areas of the home. We carried out our last Key Inspection 12th March 2008. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 8 of 26 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 9 of 26 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are assessed prior to moving to the service but the information obtained is not always sufficient to ensure needs can be fully met. Intermediate care is not provided in this service. Evidence: The Pre inspection information sent to us by the manager of the service told us that they had improved the pre admission assessment. The new forms were seen in the care plans of the most recently admitted people the information obtained was still short of what is needed to ensure people can be assured that their needs are fully met. People who live in the home tell us that they have enough information about the home to make a decision about living there. Care Homes for Older People Page 10 of 26 Evidence: Relatives spoken with said that mostly the staff provide the care their loved one needs to feel well cared for in the home. We saw training records and spoke to staff. Staff receive training to enable them to meet the needs of people living in the home, such as dementia training and moving and handling so they can safely assist people who have reduced mobility. A requirement was set at the last inspection to ensure that residents receive and assessment in line with standard 3.3. Although work has been done to try to achieve this it is not yet fully met. Care Homes for Older People Page 11 of 26 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents health and personal care needs are not always addressed in a way that is consistent. Evidence: For the purpose of this inspection three care plans were looked at to see if people were receiving the care and support they needed. Information received before the inspection showed that the manager had updated the care plans and created more robust information to promote peoples dignity. Two of the plans looked at were for people who had only recently moved to the home. Although there was information for each person the plans varied in quality and were not filled out in a consistent manner. One plan did not provide any information on how to provide care during the day yet the night care plan was very detailed and it was clear what the persons needs were and how staff were to meet them. This could mean the person does not receive the care they need at all times. Care Homes for Older People Page 12 of 26 Evidence: People who use the service were spoken with and all were positive about the care they received and how kind the staff were. The staff are lovely and I cant fault them. I like the staff they are very good to me. The staff are very kind and you can have fun with them. Relatives spoken with were mostly positive about the care their loved one received. All the staff seem friendly and you can have a laugh with them. The staff always make me feel welcome. The staff seem friendly and caring we are always made to feel welcome. I dont think staff are very caring. Daily records showed that doctors and other health care professionals were consulted when people were unwell and they showed that families were contacted if a person was ill. Where residents had pressure care needs although these were mentioned in the assessments and district nurses visited to provide treatment there was no information in care plans of what action staff needed to follow in order to minimise risk. This could potentially lead to people not receiving the care they need if cared for by staff unfamiliar with them. There was a requirement left at the last inspection to ensure that care plans were developed that identified all the needs of the person in sufficient detail to enable staff to provide comprehensive care. Although there is evidence that some work has been done to achieve this, the requirement is not fully met. All plans viewed identified where a person was at risk and what action needed to be taken to minimise the risk. A requirement was set at the last inspection regarding risk assessments and evidence seen shows that this has been met. People said that they received their medication on time, however when we examined the medication records errors were found in the recording of medication brought into Care Homes for Older People Page 13 of 26 Evidence: the home for people on respite care. This may place those people at risk of not receiving the medication that is prescribed to them. The audit system that had been set up after the last inspection had not picked this up and is therefore not robust enough. This was discussed with the provider and the manager who understood how the error had occurred and made efforts to remedy the situation before the end of the inspection. A requirement was made at the last inspection to ensure that all handwritten medication records must be signed and witnessed and medication policies must be updated, evidence was seen during the inspection that this has been completed. It was clear through out the inspection from observation and from what residents told us that their privacy and dignity was respected by staff. Care Homes for Older People Page 14 of 26 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are involved in meaningful daytime activities of their own choice according to their interests, needs and capabilities. Evidence: Information about what activities are available as well as forthcoming events for people to take part in is displayed throughout the home. People spoken with said they could take part in the activities but if they chose not to this was respected. During the day we noticed that some people who had dementia were wandering about the home and from discussion with other people who lived at the home this caused them distress. The manager is in the process of creating a sensory room to provide a diversion and a place for people with dementia to go if they are unsettled. People we spoke with as part of the case tracking said that they liked the meals although one person said that they didnt feel meals were not always up to scratch. A relative also commented that they did not think that pizza was a suitable tea time meal for older people. People were able to choose where they ate within the home, whether it was in one of Care Homes for Older People Page 15 of 26 Evidence: the spacious dining areas or their bedroom. The meal observed was traditional and nutritious. The cook was spoken with and was able to demonstrate how she provided meals for people who had specialist dietary needs such as diabetes ensuring everyone had their nutritional needs met. Care Homes for Older People Page 16 of 26 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People involved with the service say they are happy with the service provided, feel safe and well supported. However improvements are needed to make sure the service learns from complaints and maintains improvement. Evidence: Information received prior to the inspection showed that the home had received only one complaint and this was dealt with by the provider within 28 days. The manager only records formal complaints but not more minor concerns such as my tea is too milky. We discussed the importance of recording all concerns with the manager as this creates a log of all issues raised by people who use the service and can prevent a concern becoming a serious complaint at a later date. People told us they felt listened too and that when they did complain they were taken seriously, however small issues did tend to recur and this caused some frustration. Staff have access to safe guarding policies and training records show that staff have received training recently and are due to do more in the next few months. People who use the service told us they felt safe and well cared for by staff. Care Homes for Older People Page 17 of 26 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. Evidence: Information received before the inspection told us that they continue to renew and redecorate areas of the home as required. The home was seen to be clean and well decorated through out and provided people who use the service with a pleasant place to live. Those bedrooms seen as part of case tracking were spacious and well maintained. People who use the service said that the home was always clean and fresh. Staff files showed that staff have received infection control training and there have been no outbreaks of preventable infection reported to us. Care Homes for Older People Page 18 of 26 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Recruitment procedures are robust and protect residents from people who may abuse them. Staff training ensures that people who use the service receive consistent and good outcomes. Evidence: The staff rota was inspected to check there are enough staff on duty employed in their various roles to meet the dependency needs of the residents. The staff and the relatives said the number of staff seem appropriate to support people with their needs. People living at the service also said that there were enough staff on duty. One person commented If I call them they come quickly. From information received prior to the inspection it was clear that the service has achieved the target of 50 of staff trained to National Vocational Qualification (NVQ) Level 2 to ensure a suitably qualified workforce. The evidence on staff files indicates that a great deal of training has been provided since the last key inspection. The manager has now created a training matrix and can easily see what training has taken place and what needs to take place. This ensures Care Homes for Older People Page 19 of 26 Evidence: that staff always have up to date training to support peoples needs. The staff files were inspected to make sure that they had all of the information and documentation to ensure that residents are properly protected from people who may harm or abuse them. The files were very well kept and contained all of the information and documents needed by Law in order to safeguard vulnerable people. Care Homes for Older People Page 20 of 26 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager is a caring and approachable person, however some of the systems in place are not robust enough to ensure consistent practice. Evidence: The manager has over 18 years of experience in care services, she is registered with us and as such is assessed as having the necessary qualifications and experience to be competent to run the home. Evidence was seen in training records, care plans and medication records that the manager has tried to address the outstanding requirements from the last inspection. The manager has now recruited more staff and is able to spend more time in administration hours than at the last inspection and is able to show that things are beginning to slowly improve. A requirement was made at the last inspection to ensure that there was sufficient staff on duty to meet the needs of people who use the service and enable the manager to Care Homes for Older People Page 21 of 26 Evidence: take responsibility for fulfilling her duties. This is now met. People who use the service spoke positively about the manager and visitors generally felt the home was well managed as did the staff. One comment received was The service looks well run and staff seem caring and friendly. The manager ensures that pre inspection information requested by us is filled out to a good standard and carries out quality monitoring to improve the standard of care within the home. Evidence was seen in staff files of improvements in training for all staff as well as the manager particularly in areas of medication, safe guarding and infection control. A requirement was made at the last inspection to ensure records required by regulation are maintained up to date and accurate. The manager has done a lot of work in this area and has nearly completed the task the only area outstanding is ensuring care plans are accurate. There are still short falls in care planning as detailed in standard seven and eight and they are not completed in a consistent way to ensure that staff are fully aware of the needs of all residents. The manager sends in notification of incidents and deaths to us to let us know what is happening in the home between inspections. The arrangements in respect of residents finances were checked to ensure their interests are being protected. The records did not tally with the amounts held on the premises even though they had been signed to say they did. The manager was able to sort out the problem and it was an accounting error, there was no money missing for people who use the service. The records of Health and Safety servicing and checks were inspected to ensure that residents are properly protected. These were all up to date and well recorded. The staff have all completed their statutory training courses and they confirmed that their health and safety is promoted and protected by the provision of training and equipment. Care Homes for Older People Page 22 of 26 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 23 of 26 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 Pre admission assessments 27/04/2009 must be carried out on all people and provide sufficient information about their needs. This ensures that people who move to the home can be confident that all their needs can be met by staff. 2 7 15 Care plans must be created for all aspects of the persons care This is to ensure that people who use the service can have all their care needs met. 27/04/2009 3 8 17 Where people have 27/04/2009 incidences of pressure ulcers care plans must reflect the care and support they are receiving. Care Homes for Older People Page 24 of 26 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action This is to ensure that people who use the service receive the support they need to minimise any risk. 4 35 17 Financial records kept for people who use the service must be kept accurately. This is to ensure that people who use the service can be confident that they are free from financial abuse. 5 37 17 Records required by regulation must be maintained up to date and accurate. Complete Care Plans This is to ensure people who use the service are assured that their needs are met. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 27/04/2009 27/04/2009 1 16 All complaints no matter how small they seem should be recorded to enable the manager to quality audit the service effectively. Care Homes for Older People Page 25 of 26 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 26 of 26 - 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!