This inspection was carried out on 28th September 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
CARE HOMES FOR OLDER PEOPLE
South View Lodge 92 Station Road Hesketh Bank Lancashire PR4 6SQ Lead Inspector
Della Lovell Unannounced Inspection 28 September 2005 09:30 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 View Lodge DS0000005906.V254547.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 View Lodge DS0000005906.V254547.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service South View Lodge Address 92 Station Road Hesketh Bank Lancashire PR4 6SQ 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) 01772 812566 Bideaway Homes (2) Limited (Mr Thomas Wilson Blane) Ms Susan Barbara Ball Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places South View Lodge DS0000005906.V254547.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 8th March 2005 Brief Description of the Service: South View Lodge is a residential care home providing 24-hour personal care and accommodation for 30 older people. South View Lodge is owned by Bideaway Homes Limited. South View Lodge is situated in a semi-rural location close to the village of Hesketh Bank, West Lancashire. It has car parking available and has extensive grounds to the front side and rear of the home. There is a patio area and an ornamental fishpond. South View Lodge provides all ground floor accommodation with all but one of the rooms offering single occupancy. Six rooms have the benefit of an en-suite. There are three lounge areas throughout the house, one of which has been sub-divided to create small alcoves and a conservatory. There is one main dining area, central to the house. South View Lodge DS0000005906.V254547.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day in September 2005. The management team in the home are committed to raising standards. The inspection involved discussion with the people who lived and worked at the home, examination of records and a tour of the home. What the service does well: What has improved since the last inspection? What they could do better:
The home would benefit from some refurbishment and redecorating. The furniture is becoming a little shabby and carpets worn. Service users said that they are comfortable and were quite satisfied with the homes environment. However the inspector noted that some bedroom furniture was in need of replacement. The registered person should ensure that the areas in need of South View Lodge DS0000005906.V254547.R01.S.doc Version 5.0 Page 6 attention are firstly identified and a priority list developed, a programme of refurbishment and decoration should be put into place. 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 View Lodge DS0000005906.V254547.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 View Lodge DS0000005906.V254547.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 home had a thorough assessment procedure in place to ensure that service users needs are met. EVIDENCE: The home had a comprehensive care needs assessment in place. Individual records are kept for each service user. Observation of three new service users files showed that all new service users are admitted only on the basis of a full assessment and for individuals referred through social services the registered manager had obtained a local authority assessment. The home ensures that information relating to any medical history is fully recorded and transferred on to the homes care plan. One-service user told the inspector that she had the opportunity to stay at the home on a short-term basis to see if she liked it before making the decision to stay permanently. All service users spoken too said that they felt the home was meeting their needs. South View Lodge DS0000005906.V254547.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 and 8 Each service user had an individual care plan, which provided comprehensive information and detail to ensure that service users health, personal and social care needs are fully met. EVIDENCE: Each service user had a comprehensive plan of care, which sets out in detail the action that is needed to be taken by the care staff to meet each identified need. Each service user had a daily record sheet, which recorded the care given and any significant events. Care plans were all reviewed each month and service users and their relatives had the opportunity to be involved in the process. The files of three service users were viewed in detail as part of the inspection process. Each service users file contained a clear history, which had been taken from the initial assessment and charts to monitor and record any health care intervention. These records were up to date and provided detailed information. All service users health care needs were being met and a concise record was kept for all entitlements to NHS services.
South View Lodge DS0000005906.V254547.R01.S.doc Version 5.0 Page 10 Two service users files contain specific health information relating to a condition which required special cross infection measures to be in place. Procedures and instructions for staff were clearly in place and additional information and guidance was available in the service users files. South View Lodge DS0000005906.V254547.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): These standards were not assessed at this inspection. EVIDENCE: South View Lodge DS0000005906.V254547.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 and 18 The home had a complaints procedure, which ensures that all complaints would be acknowledged and investigated. The home had robust procedures in place to safe guard service users from abuse and harm. EVIDENCE: The home had a policy and procedure in place for the Protection of Vulnerable Adults and all new staff are made aware of this information through the home induction training programme. Staff spoken to were able to confirm that they had received training and were able to explain the correct procedure they would follow to protect service users. The home had not received any complaints since the last inspection. A complaints policy and procedure was in place and was made available to all service users and relatives in the homes statement of purpose. A copy of this was seen in the entrance of the home. One service user told the inspector they had no complaints but knew who they could speak to if they had any concerns. South View Lodge DS0000005906.V254547.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 The premises was clean and tidy which ensured service users live in a comfortable environment. However improvements were needed to ensure continued comfort and safety of service users. EVIDENCE: On the day of the visit the home was kept clean and tidy. Service users said they were comfortable in the home and had all they wanted. One service user said that her bedroom was always kept nice by the staff. Since the last inspection a small number of bedrooms had been decorated. However the home would benefit from a planned programme of refurbishment and decoration. The inspector noted the following; • Carpets in both the communal area and bedrooms were worn. • Doors and woodwork were chipped and marked in areas. • The dining room chairs were worn and stained and some of the lounge chairs looked old. • One set of drawers in a service users bedroom was broken and some of the bedroom furniture was in need of replacement.
South View Lodge DS0000005906.V254547.R01.S.doc Version 5.0 Page 14 The bathroom, which was being re-fitted on the last inspection, still needed finishing. The registered person should develop a clear programme of refurbishment for Southview Lodge. Not all pipe work in the home is guarded and should be risk assessed and action taken to minimise any risks to service users. The grounds were pleasant but there were parts around the home that had collected some litter and dead leaves. • South View Lodge DS0000005906.V254547.R01.S.doc Version 5.0 Page 15 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 and 30 The policies and procedure for the recruitment of staff are robust and provide safeguards for the protection of service users. Staff at the home are provided with training to ensure they are competent to do the job. EVIDENCE: The home had a robust recruitment procedure in place, which ensured the Protection of Vulnerable Adults. Personnel files showed that a thorough recruitment and selection process had taken place and all new staff had undertaken induction training. The home takes staff training seriously. There was a comprehensive training matrix in the home, which clearly showed what training had been undertaken and automatically highlights when training will need to be updated. Certificates were seen on the staff files and the staff files where kept in good order. Staff were provided with mandatory training and other more specialised training which equipped them with the necessary skills to carry out their role confidently and competently. Staff said that they felt well supported and that training was accessible. Since the last inspection more staff had completed the NVQ Level 2 qualification, which took the home over the 50 requirement. The remaining staff were working towards the qualification. Staffing levels in the home were sufficient for the number of service users living in the home. Staff spoken too said that they felt they had enough staff on duty to meet the needs of the current service users. South View Lodge DS0000005906.V254547.R01.S.doc Version 5.0 Page 16 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 36 Service users live in a home that is well managed and staff are appropriately supervised to ensure they are competent to do the job. EVIDENCE: The home is run and managed by a team of managers. The responsible individual has overall management responsibility and works in the home on a day-to-day basis supporting the registered manager with senior decisions. The registered manager has many years experience and is currently working towards the Registered Managers Award and takes responsibility for ensuring care plans are up dated and reviewed and supports care staff on day to day matters. The home has an excellent system in place for one to one supervision sessions with staff and this is well documented on each staff members file. The homes supervision sessions feeds into the annual staff appraisal. The management team work along side staff to ensure that direct care practises are monitored and the training manager mentors staff through NVQ modules. Staff in the home feel supported and morale was good.
South View Lodge DS0000005906.V254547.R01.S.doc Version 5.0 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 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X x STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X 3 X x South View Lodge DS0000005906.V254547.R01.S.doc Version 5.0 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 23(2)(o) 2 23(2)(b) 16(2)(c) 3 16(2) OP25 OP19 OP19 Standard Regulation Timescale for action The registered person must 30/12/05 ensure that the gardens and grounds are kept tidy and safe for service user access. The registered person must 30/12/05 ensure that the homes furnishings and fitments are replaced or repaired and are suitable for the stated purpose. The registered person must 30/12/05 ensure that all radiators are of low surface temperature or appropriately guarded. (Timescale 2004) of 30th December Requirement 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 View Lodge DS0000005906.V254547.R01.S.doc Version 5.0 Page 19 1 OP19 2 3 4 OP31 The registered person was advised to develop a planned programme to refurbishment and redecoration of the home. The registered provider should continue to put radiator guards in place and cover pipe-work. The registered provider should ensure that the services meet the Water Services (Water Fittings) Regulation 1999. The registered provider should ensure that the Registered Manager has the appropriate qualifications by 2005, and regularly updates knowledge. OP25 OP26 South View Lodge DS0000005906.V254547.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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