Inspection on 10/05/07 for Sovereign Lodge

This inspection was carried out on 10th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sovereign Lodge 22/05/09

Sovereign Lodge 23/08/06

Sovereign Lodge 02/11/05

Sovereign Lodge 12/04/05

Sovereign Lodge 13/09/04

Sovereign Lodge 22/06/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Sovereign Lodge Newbiggin Lane Westerhope Newcastle Upon Tyne Tyne & Wear NE5 1NA Lead Inspector Mary Blake Key Unannounced Inspection 09:30 10 and 11th May 2007 th 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 Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sovereign Lodge Address Newbiggin Lane Westerhope Newcastle Upon Tyne Tyne & Wear NE5 1NA 0191 2714029 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 Jennifer Houghton Marion Lydia Redhead Care Home 48 Category(ies) of Old age, not falling within any other category registration, with number (48) of places Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may take up to five service users aged between 55 and 65 years of age at any one time. 23rd August 2006 Date of last inspection Brief Description of the Service: Sovereign Lodge is a modern, purpose built residential home. It has 46 single bedrooms, all bar two of which have en-suite facilities. Most accommodation is on the ground floor. The home has 5 lounges and 2 dining rooms. There is a pleasant garden with seating. It is situated in Westerhope, a suburb of Newcastle upon Tyne, and is quite close to local shops. It is on a bus route. The current fees are £355 to £425 per week. The service user guide and inspection report were available at the entrance. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over two days and involved one inspector. All of the key standards have been assessed during these visits and from other information provided to the Commission. Twelve residents and eight staff (carers and ancillary) were spoken to. Others were chatted to briefly. Eight relatives were spoken to during the visits. Three resident, nine relative and two supporting professional questionnaires were received. These were generally very positive. The regional managers of the company were available during this inspection. Four care plans, training records and records for medication were examined. Staff files, recruitment records and health and safety documentation were looked at. What the service does well: Residents and their families explained a comprehensive admission process; this includes a gradual introduction to the home and a detailed pre-admission assessment. They felt that this helps new residents adjust and settle into living in the home. The care plans are detailed, comprehensive and regularly review this gives guidance to staff on how to meet the individual needs of residents. The home has strong links with supporting health professionals, which will give good health support to residents. Arrangements for residents to maintain contact with their family and friends are good. Visitors confirmed that they are always made welcome and kept informed and involved. The residents live in an environment that is clean, comfortable, well decorated and furnished to a good standard. The domestic and laundry staff provides an efficient and organised service giving residents a clean and pleasant home and well laundered clothes. The staff have a good understanding of residents individual needs. The residents and relatives were complimentary about the staff. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 6 Staff recruitment records were clear and concise and contained all relevant information. The vetting process helps protect residents. Residents live in a home that is well run and well managed. What has improved since the last inspection? What they could do better: To further develop systems to involve residents and their supporters in the running of the home. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 8 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 Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home undertakes a detailed pre admission assessment and liaises with the residents and family prior to admission. Satisfactory pre-admission assessments are undertaken and developed further in the care plan. The home is not registered for and therefore does not provide intermediate care. EVIDENCE: Assessments and detailed information to ensure that the home can meet the needs of the prospective resident are obtained prior to admission. The Registered Manager is involved in the decisions. Pre admission assessments are obtained from other professionals such as social workers, psychiatrists and previous care providers. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 10 Residents and their families explained a comprehensive admission process; this includes a gradual introduction to the home and a detailed pre-admission assessment. A recent admission to the home said she was able to visit and meet staff and felt that she and her family were involved throughout. They felt that this helps new residents adjust and settle into living in the home. Residents and relatives commented “Informed by staff” “Also notice boards have all the information” “My family visited and inspected other homes before deciding on this one” “We talked it over and all of us came to the conclusion that this was the right place for me” “don’t think you know till you are in the home” “Very good home” “On entering home warm friendly feel”. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and social care needs of residents are being met and the involvement of the residents and their family/supporter has improved. Residents are protected by the homes policies and procedures for dealing with medicines. Residents feel they are treated with respect and their right to privacy is upheld. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 12 EVIDENCE: Four care plans were examined. These were very well completed, clear and concise. The assessment tools such as pressure care, nutrition, moving and handling, mental health and dependency are completed consistently. Periodic evaluations are consistent. There is now involvement of residents and their families. Residents and relatives commented “ Very happy with the home and general care” “They listen to what you have to say and act in a positive manner” “Any concerns regarding my mother are quickly and efficiently resolved” “If my mother is ill could be checked better” “Always informed of any problems health or otherwise” “They never hesitate to have the doctor out” “This is very reassuring for relatives” “The needs of the residents are all well catered for” “Any problem they advise immediately and keep you informed of the situation” “if one is feeling unwell and would like to see a doctor a senior staff will arrange it for you” “good personal care” “I am very happy with the care in the home and would be willing to discuss this further if required”. Contact with social and health professionals is good and there were a number of professional visitors throughout the days including GP, District Nurse and Podiatrist. Professional questionnaires generally positive “provides appropriate support to residents family and encourages involvement in social activities” “need improvement in communications between service providers and commissioning staff” “on visiting a resident, kept waiting too long before care staff arrive to assist in enquiries”. The manager has taken steps to improve the care planning arrangements. Training is planned and records reviewed. There was evidence in the care plans of auditing by management. The medicines in the home are well managed and safely disposed. The treatment room was tidy. The controlled drugs were audited and were satisfactory. Visitors and residents feel that they are treated well and their privacy is respected “Very good” “They care for mam very well” “I find the staff helpful, caring and discreet”. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s social needs are being addressed and are documented. Residents maintain contact with family/friends/representatives and the local community as they wish. Residents are helped to exercise choice and control over their lives Residents receive a choice from a wholesome, appealing; balanced diet and dining arrangements were well organised. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 14 EVIDENCE: The home has an activities co-ordinator who is very committed and enthusiastic. A good rapport between residents and the activities person was observed. Residents were enjoying listening to music and having a pamper session. Relatives and residents commented “The programme of entertainment/activities is considerably less than promised but activities arranged have been appreciated” “Yes, very good” “ I like to pamper her on a daily basis” “She has her hair done twice a week at the hairdressers” “Staff do the residents nails” “Most of the time the activities appeal to me and I do take part in them, otherwise I can decline if I think they are not to my choice” “Good social activities for the residents” “The lady residents love the banter from staff”. Visitors were observed to come and go throughout the day. Staff have a good rapport with relatives. Relatives felt positive about the staff and being made welcome when they visit. Residents handle their finances for as long as they can. People are able and encouraged to bring their own possessions and keepsakes from home and this was evident in resident’s bedrooms. There is evidence of improvement of the involvement of residents or relatives in their care plans. Arrangements for residents to maintain contact with their family and friends and the local community are suited to each individual’s needs and vary accordingly. Comments “does not apply as I visit every day” “I visit my mother six days a week plus other family members visit “ “they have many activities involving family and friends. Christmas Fayre, Christmas Party. Easter Hat Parade. All who wished made Easter bonnets. Keep fit sessions (Outside agency) Weekly” “Monthly entertainment with family and friends invited” “Church Services every month”. The residents are encouraged to go to places in the local area and families are encouraged and supported to take residents out and about. Residents and relatives did comment about the trips “The minibus does not accommodate wheelchairs so outings are not possible” “Mini bus staff took all that were willing to go out on the bus (Newbiggin by the Sea, Whitley Bay, Corbridge)”. The residents’ bedrooms were personalised reflecting individual choices and preferences. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 15 Residents have visitors at any time and are able to use their own rooms, the small lounges or the larger, busier lounges to receive them. Relatives were very positive about the welcome they receive and the good communication between the home and families. Relatives commented; “Residents have total freedom” “Some choose to stay in their room all the time. Even having meals served for them”. The home now has the menu displayed visibly and the display board at the entrance gives more details of the meals for the day. Residents are asked for their choice for lunch and tea daily, which is recorded and given to the kitchen staff. The food being served was well presented, hot and well cooked. A number of residents expressed their satisfaction with the improvements to the dining arrangements, the quality and choice of the food served and that they no longer have long waits. However one resident questionnaire stated “Some days the meals are fine, but other times they are almost cold, this applies especially to the Sunday lunch, it would help a lot if the plates were hot” Others stated “good food” “good dining arrangements with bright tablecloths changed every day” “Cook and staff offer a good choice and variety of meals”. Staff served the food and drinks to residents acknowledging their needs. Many residents had individual pots of tea and coffee providing more choice and independence. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives and friends are confident that their complaints will be listened to, and acted upon. Residents are protected from abuse and all staff have be trained and this further protects residents EVIDENCE: The home has a complaints policy and staff are clear about the procedure to deal with complaints. Residents and visitors said that they knew who to talk to if they were unhappy and had confidence that these would be dealt with. The company also has a high profile within the home. The complaints record was available for inspection. Relatives commented “To date there have been few problems and the minor problems encountered have been addressed by management” “Responds rapidly to problems” “There were a few handling problems initially but management acted rapidly to address these” “Never needed to” “Only minor problems always very quickly dealt with”. The home has a Protection of Vulnerable Adults (POVA) procedure, which complies with the Department of Health ‘No Secrets’ Guidance. The staff in the home have received POVA training and this helps protect residents safety. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a safe well-maintained environment. Residents live in safe, comfortable bedrooms with their own possessions around them. The home is clean, pleasant and hygienic. EVIDENCE: The communal areas of the home are well decorated maintained and clean. A number of resident’s bedrooms were seen these were personalised. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 18 Those parts of the home that were seen were clean and hygienic with no obvious smells or odours. There was good domestic and laundry support with residents complimentary about the cleanliness of the home and laundering of their clothes. Comments received “The cleanliness of all areas are kept immaculate” “Everything is perfect” “Cleanliness and laundry - especially good” “The domestic staff are very good in keeping the home clean but sometimes there is an unpleasant smell along the corridors of stale tobacco smoke, and other things” “The home is always kept very clean”. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are met by the number and skill mix of staff and are protected by the homes recruitment policy and practices. The staff team are trained and appeared competent to do their jobs. EVIDENCE: Staffing rota and observation during the days indicated that the home is well staffed. One senior and two carers operate on each side of the home during the day and one senior and three carers are on duty during the night. The Registered Manager is supernumerary. There has been a low turnover of staff in the past year. Good ancillary support was in place. Relatives commented; “Most friendly staff and helpful in all ways” “Well looked after at night” “Some staff are better than others” “I am not qualified to comment on the staff skills. In my opinion they care very well for my mother which is most reassuring” “I am confident that she will be well looked after in their care”. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 20 Residents commented; “There are times when the staff are over busy and they cannot always attend to your needs immediately” “Most of the staff are very good” “they will listen to what I say” “there are times when it isnt always possible not enough staff when toilet buzzer goes off” “Need women carers for days, as they dont want men”. Three staff recruitment files, across all grades, were inspected and were satisfactory. Training files examined clearly detailed what training staff had completed for induction, foundation, mandatory and NVQ training. The Registered Manager had addressed the shortfalls in mandatory training and the inspector was able to clarify who had obtained National Vocational Qualification in Care level 2 or above and this information confirms that more than 50 of staff has completed this training. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home, which is well run and managed by a competent person. The home is run in the best interests of residents. Staff are now appropriately supervised. The health, safety and welfare of residents and staff are protected. EVIDENCE: Sovereign Lodge has a new manager, Marion Redhead, who has completed her application to become registered for this home. Mrs Redhead has previous experience as a Registered Manager within the company, is qualified to Registered Managers Award and is in the process of completing her level 4 NVQ in Care. Mrs Redhead is only responsible for Sovereign Lodge. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 22 Relatives commented “Marion, Senior staff and carers are always friendly and approachable which I feel is very important” “Impression so far is of a very well managed care home” “The manager is usually available to listen to you” “The manager has an open door and will certainly listen to any complaints”. Good quality assurance arrangements are in place. “I have just had talk with new manager and am satisfied with the care she gets at this moment” “they constantly strive to improve things important to me”. The Company representative completes monthly visits and reports. It was evident that the homes line manager is well known to residents, family and staff and she knows them personally. Relative and staff meetings have recommenced and questionnaires are undertaken for residents, relatives and supporting professionals. Regular staff meetings are held for all grades. The external Administration Manager, Pharmacist and Property management, periodically undertake quality audits. Internal quality systems include maintenance; care plan, medication and staff file audits. Random/sample visits are undertaken as well statutory regulations 26 visits. The Operations Manager is reviewing policy and procedures. Staff supervision on a 1:1 basis has been re-established. The maintenance and servicing records are in place. The Fire Log book had up to date emergency lighting and alarm panel checks records. Level of in-house fire instruction for staff was progressing well. A health and safety committee meet to review and promote good practice. Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 23 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 4 X X 3 X 3 Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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 Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Sovereign Lodge DS0000000456.V338144.R01.S.doc Version 5.2 Page 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!