CARE HOMES FOR OLDER PEOPLE
South Moor Lodge Care Home South Moor Road Walkeringham Doncaster South Yorkshire DN10 4JD Lead Inspector
Joanna Carrington Unannounced Inspection 4th January 2006 10:00 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.V274301.R01.S.doc Version 5.1 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.V274301.R01.S.doc Version 5.1 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.V274301.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users shall be within categories of OP (13) or MD (1) Date of last inspection 28/09/05 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.V274301.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over four hours on 4th January 2005. This was the home’s second statutory unannounced inspection for this inspection / financial year. The purpose of this inspection was to follow up the four requirements set at the last inspection and to inspect the remaining key standards that must be assessed over the one-year period. Therefore, this report must be read in conjunction with the previous report. The main method of inspection was called ‘case tracking’ which meant selecting three residents and tracking the support they receive through discussion with them and staff, checking of relevant care records and observation of care practice. Altogether two residents, two members of staff and one relative were spoken with. A partial tour of the premises also took place in order to inspect environmental standards. The manager was available for discussion and feedback throughout the inspection. What the service does well:
Examples of good practice were observed throughout the inspection. Staff were observed interacting with residents in a respectful manner. There was a warm friendly atmosphere in the lounge area where residents were relaxing watching television. The environment is clean, homely and well-maintained and visiting family and friends are made welcome. There are a range of activities on offer to residents and there also opportunities to go out on trips to places of interest, tea dances and down to the pub. Residents and relatives confirmed that there is always a choice with these things and residents can choose when they wish to be alone or in the company of others. There are regular residents meetings where residents can air their concerns, which are then acted on. The home also has a system for monitoring and reviewing quality, which seeks the views of residents and their representatives. The health care needs of residents are met with good access to nearby doctors. South Moor Lodge Care Home DS0000008788.V274301.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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.V274301.R01.S.doc Version 5.1 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.V274301.R01.S.doc Version 5.1 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): 2 The contract still requires further development to ensure that residents know the terms and conditions of their stay at the home. EVIDENCE: At the last inspection a requirement was set to include the individual resident’s accommodation details within the contract. This is now outstanding. In addition to this the contract needs to specify more clearly what services are included within the fee and what services require additional payments as this was not clear. All residents case tracked have a copy of their signed contract on their file. South Moor Lodge Care Home DS0000008788.V274301.R01.S.doc Version 5.1 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 and 10 Residents are treated with dignity and respect and there are clear arrangements in place for meeting the needs of residents, including safe systems for administration of medication. However, details on care plans must correlate with the outcomes of individuals’ risk assessments to ensure that the safe level of support is given. EVIDENCE: All of the residents spoken with said that staff treat them with dignity and respect. Staff were observed interacting with residents meaningfully and a member of staff was seen knocking on a resident’s bedroom door and waiting for permission before entering. One resident spoken with explained how she was able to keep the same doctor she had before she moved to the home and that access to a doctor is very good. She confirmed that staff are always sensitive to her needs and caring when she is feeling unwell. Medication stocks and administration records were looked at and all was in order; no errors found. There was evidence on the care plans seen that these are reviewed monthly and a relative confirmed that she is involved and consulted over care plans. The outcomes of risk assessments do not always correlate with care plans, for example a risk assessment concluded a resident requires one person to assist
South Moor Lodge Care Home DS0000008788.V274301.R01.S.doc Version 5.1 Page 10 with going to the toilet while the care plan suggested that this resident is fully independent when going to the toilet. South Moor Lodge Care Home DS0000008788.V274301.R01.S.doc Version 5.1 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): 12, 13 and 14 Residents are able to maintain contact with family and friends and are helped to exercise control over their lives, which includes with choices in respect to a range of activities available and with access to the local community. EVIDENCE: A relative spoken with said that she is always made to feel welcome whenever she visits. Bedrooms seen show that residents can bring their own furniture and possessions with them when they move to the home and a resident spoken with confirmed that she handles her own financial affairs, with the help of her daughter, which is her wish. Daily records state what activities residents have chosen to participate in such as bingo, quizzes and music and movement. Residents spoken with talked about trips out to the theatre, Clumber Park and tea dances at Retford Hall. A party was held for residents and their friends and relatives over Christmas, which everyone spoken with said they enjoyed. South Moor Lodge Care Home DS0000008788.V274301.R01.S.doc Version 5.1 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 There is an appropriate complaints procedure but this must be used to record all concerns and complaints regarding the home. EVIDENCE: Residents and a relative spoken with are all aware of the complaints procedure and how to make a complaint. Currently there are no records of complaints under the Complaints Procedure. The minutes of residents meeting do however evidence that residents do air their complaints and that any subsequent action taken is discussed at these meetings and recorded in the minutes. As well as recording in the minutes, all concerns or complaints regardless of their seriousness, should be recorded under the Complaints Procedure as this is a central place and enables the process of reviewing complaints and subsequently identifying ways of developing the service. South Moor Lodge Care Home DS0000008788.V274301.R01.S.doc Version 5.1 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 and 26 The home is kept clean and is well maintained and homely throughout. Residents’ bedrooms are comfortable and personalised to suit individuals tastes. EVIDENCE: On a tour of the premises it was apparent that the home is kept clean and hygienic. Furnishings are domestic in style and the home is nicely decorated. Bedrooms seen were all very different with residents’ own furniture and other chosen items such as photos, ornaments and pictures. South Moor Lodge Care Home DS0000008788.V274301.R01.S.doc Version 5.1 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): X None of these standards were assessed on this occasion. EVIDENCE: South Moor Lodge Care Home DS0000008788.V274301.R01.S.doc Version 5.1 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): 33, 35, 37 and 38 The views of residents are obtained for the purposes of quality monitoring and there has been an improvement with the notification of incidents to the Commission. Further written records will help to ensure that residents’ finances are safeguarded. Fire safety practice has improved and predominantly the health and safety of residents is protected. EVIDENCE: Quality Assurance Questionnaires are sent out to both residents and their representatives annually. This questionnaire covers different aspects of the home including friendliness of staff, meals, laundry facilities and quality of care. Comments then inform any changes and developments to the service. Notifications to the Commission in accordance with Regulation 37 of the Care Home Regulations are now being done. This is necessary so that the home can be effectively regulated.
South Moor Lodge Care Home DS0000008788.V274301.R01.S.doc Version 5.1 Page 16 The manager retains the money of some residents while other residents keep money in their own lockable facility or family members look after it on residents’ behalf. Residents’ money kept by the home is held securely with necessary signatures and receipts etc. In addition to this, where residents may present with some confusion or mistrust and subsequently require support then this is a need for which there must be a care plan specifying the arrangements for how residents are enabled to save, access and spend their money. The home has recently had an inspection from the Fire Authority. No issues were identified. The fire log shows that all necessary fire safety tests and instructions are being carried out. The testing and servicing of electrical and gas systems are all up to date. In accordance with Health and Safety legislation, for residents with bed rails a detailed risk assessment must be carried out which checks that they are installed safely and are appropriate to meeting the needs of individual residents. South Moor Lodge Care Home DS0000008788.V274301.R01.S.doc Version 5.1 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 X 2 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 4 X X X X 4 X 4 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X 3 2 South Moor Lodge Care Home DS0000008788.V274301.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? yes 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 contracts to privately funded residents include details of the room provided. (This is an outstanding requirement from the previous inspection, initial timescale 02/11/05 not met) In accordance with Schedule 4 of the Care Home Regulations ensure that the contract specifies what services are included in the fees and what services are not covered for by those charges but require additional payments. Ensure care plans are detailed enough to explain the exact level of support required (correlating with the home’s written risk assessment). Ensure all informal and formal concerns and complaints are recorded under the Complaints Procedure. Ensure individual risk assessments are carried out for the appropriate and safe use of bedrails. Timescale for action 28/02/06 2 OP2 5 28/02/06 3 OP7 15 31/03/06 4 OP16 22 31/01/06 5 OP38 13 31/01/06 South Moor Lodge Care Home DS0000008788.V274301.R01.S.doc Version 5.1 Page 19 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 OP35 Good Practice Recommendations Develop care plans for specifying the support residents require with managing their finances. South Moor Lodge Care Home DS0000008788.V274301.R01.S.doc Version 5.1 Page 20 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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